REFLARES OF PAIN: UNFAIR, BUT PART OF THE PROCESS

This is an email from a typical patient expressing her frustration over a recent reflare of her symptoms. The symptoms are in the front of her foot, and a recent MRI showed no sign of fractures or neuromas.

Hi Dr. Blake,

My foot has been flare up since Sunday after a yoga class, I have been using the contrast bath, but not too much ice though, according to the acupuncturist, she thinks that I need more blood circulation to improve the nerve problem. Icing is not a good option in Chinese medicine.

Last time (Thursday) I visited her, we had a very good acupuncture session, she attached electrodes to needles to provide continued stimulation (like the Stim unit). After the treatment, I felt good, walked without any nerve problem for a while.

Sunday morning I went to a yoga class, I felt OK during the walk from my home to the gym, but there were several standing poses in the yoga class that required strong foot position, then I felt a lot of nerve activities. After the class, I went home to apply a contrast bath, and it seems to quiet down a little.

But yesterday and today, I can feel the nerve problem all the time even when wearing my MBT shoes or sneakers (on a better day, I can almost feel normal in those shoes).

So now I'm applying ice, hoping it will not get any worse.

I forgot to ask you if you have a diagnosis report that I can bring with me when I visit my Physical Therapist and my Acupuncturist. I went to my PT office on Friday, but they were not sure if it's OK to treat me with massage and ultra-sound, so they asked to see the doctor or MRI report and maybe your recommendation for PT. 

Also I want to ask you if it's OK that my Acupuncturist massage my foot, in her opinion, she thinks there is scar tissues developed, so she wants to deep massage them to break down the scar tissues. 

I forgot to ask you if you have seen any possible fracture in my MRI? These two days, I started to feel "similar feelings" as when I had the stress fracture on my metatarsal two years ago. Am I starting to get paranoid or is it really a fracture? 

Can you see it from the MRI if there's any fracture line, since we did not looking for fracture but neuroma, is it possible the MRI might miss a fracture line?

I still have my immobilizer boot from two years ago, should I start to wear it, will that help to improve my condition?

Sorry to ask you tons of questions, I was feeling better last week and felt the condition might be improving, but now I feel the problem again, it really brings my spirit down again and my mind starts to go crazy a little........

Thank you very much in advance.

And here is my response:

 Thanks for the email and sorry about your flareup. Flareups are quite common, and you have may a few more until we get this under control. One of the secrets to not going insane is in quickly controlling the symptoms of a flareup. Definitely the boot and icing are wonderful to do right now. Wear your removable boot 24/7 for three days longer than you need. If it puts stress on your back, go to our sports shop and get an EvenUp for the other shoe. Ice for 10 minutes 3 to 4 times per day. 2 Advil 3 times per day for 5 days on, followed by a 2 day rest is appropriate. Since it is nerve pain, absolutely no deep massage at all. Accupuncture is great. PT is rarely helpful at this time. The MRI shows no fractures. When you know it has been irritated by the yoga, only ice for 48 hours. The contrast bathes may have heated it up too much. Hope this helps. Finished your orthotics today!! See you soon. Rich

Email Activity Followup: An Excellent Method in Helping to Treat Some Injuries

Joe had severely injured both feet several years ago. For 2 years he hardly walked, and this is when I first met him. He had injured his big toe joints and walked on the heels only of MBT shoes. It was a fantastic adaptation of this shoe. First thing I needed to do was to see if he could begin to walk on his full foot. This took many months to accomplish. It was also hard to wrap my fingers around his problem with our monthly followup visits. The monthly ups and downs of his pain levels based on what he did was hard to follow. So, March of this year, I had Joe email me a activity report based on the standard pain level . I will have a post just on the pain scale. It is based on a scale of pain from 0 to 10. As Joe began to walk, stand, bike, etc I wanted to follow his pain to understand it better. I told him we want to keep him in the 0-2 good pain area, but occasionally drifting to 3 or 4 is okay. Joe had kept his pain level between 0 and 1 for 2 years by not walking, but his muscles and bones were atrophing terribly. The golden rule of foot is if it takes 2 years to heal something, it will take 2 more years to rebuild the strength. I knew Joe and I had a long haul together. We had to do it right. This daily activity log with pain level during really keeps us honest and on the right course. EOD stands for End of Day. PL stands for Pain Level.

This is what Joe sends me and I respond only when I think necessary.


July 1 Walking 45 min Standing 40 min PL1-2 Biking 50 min PL1-2 EOD PL: 2-3

July 2 Walking 40 min Standing 25 min PL 1-2 Biking 25 min PL1-2 EOD PL: 3

July 3 Walking 15 min Standing 30 min PL: 1-2 EOD PL: 1-2

July 4 Walking 1 hr Standing 3.5 hrs PL: 2 Biking 45 min PL: 0-1 EOD PL: 3-4

Here I sent Joe an email to increase his icing and decrease his activity.
July 5 Walking 30 min Standing 1 hr PL: 2 Biking 45 min PL: 0-1 EOD PL: 3

July 6 Walking 25 min Standing 40 min PL: 1-2 Biking 35 min PL:0-1 EOD PL: 1-2

July 7 Birks Walk: 25 Standing: 35 PL: 1-2 Keens Walk: 5 Stand: 5 PL: 1 Biking 45 min PL: 0-1 EOD PL: 1-2

Joe has been walking in Birkenstock sandals without bending his foot to push off the ground. We are introducing Keen enclosed shoes as a step forward towards normalcy. Joe awaits some new tests to see how he is doing. I am ordering a new MRI (last one 6 months ago) and a bone scan. Yet, I think the activity and pain scale log may be giving us a great picture of how well he his doing.