Academy of Neurologic Physical Therapists

https://www.neuropt.org/

     I am always sending my patients with some sort of nerve pain to seek the advice of a physical therapist specially trained in nerve pain. It took years to find out that these physical therapists had a national organization. Even though I find the website a bit confusing, any physical therapy office in your town may have an associate member. Ask the office if any of their providers are members of ANPT, or at least have a sub speciality in nerves. 

     When dealing with acute or chronic problems, I find that some many patients have a primary or secondary nerve problem. A chronic problem can develop nerve hypersensitivity needing nerve treatments, or an acute injury may be to the nerve primarily. There are easy problems like tarsal tunnel and Morton's neuroma which need nerve attention in treatment, but there are more subtle problems like chronic achilles pain or heel pain that are produced by the local nerve. 

     I always teach that there are 3 sources of any pain issue: mechanical, inflammation, or neuropathic. It is the neuropathic pain that does not respond to as well to mechanical and anti-inflammatory treatments and may need some nerve TLC. 

Great Article on Nerve Pain and Making the Diagnosis in Athletes

I have just starting treating a patient with 2 years of pain unable to get anywhere in treatment. She sent me this article this morning that I read from a physical therapist on nerve pain. I would have to say I agree with so much of this article, and although I am not sure yet if it applies totally to my patient, is a good discussion of the 3rd source of pain in my patient. The 3 sources of pain, each demanding separate treatments at times, are: mechanical sources (like your foot pronates too much or your hip muscles are not strong enough), inflammatory (where swelling in the tissues causes pain from injury or systemic causes), and finally nerve pain (which can be local like Morton's neuroma, referred pain from the spine, or combination of local and up-the-chain problems). 

The one aspect not discussed, and also may apply to my patient, is nerve overload with chronic symptoms. This basically means that there was a mechanical injury, that even with complete heeling, can leave you with nerve hypersensitivity, which now months later is the reason that you do not feel any better. This nerve hypersensivity can also need nerve treatments over mechanical ones. 

So, as I try to sort this all out for my patient, the body will continue giving us clues which can help if we listen. Rich 

https://www.irunfar.com/2017/08/six-signs-that-your-running-injury-is-nerve-pain.html/amp

Foot Nerve Pain: Email Advice

Good afternoon,

I recently read a blog of yours pertaining to a sesamoid injury. Her questions and your answers were exactly what I am going through. It brought me to tears to finally read someone discussing my EXACT symptoms that I have been dealing with for 4.5 months. I have a few questions and some information of what I have done/currently doing.

1. I stepped on glass back in March. A small shard of glass entered my toe and came out perfectly in contact within a couple of hours. I hit a nerve in my toe apparently (or so I think) as I had immediate pain in my toe that was not in the area that the glass had entered. Due to Covid it took a while for me to get in to a doctor. For 2.5 weeks I taped my toe and walked on the ball of my foot or outside of my foot and lifted my big toe constantly. All of this was done by walking barefoot on my hardwood floors. 

2. I continued to have a change in gait for many weeks to come and continued to walk on the hardwood floors putting additional pressure on my ball of foot by lifting my toe. 

3. I have seen a total of 6 doctors, I go to PT 2x per week for ultrasound and ASTYM and strengthening, and I also do virtual meetings with Caroline Jordan out in California. I have had a few xrays done as well as an MRI. The MRI only showed some inflammation directly above the sesamoid bones.

Dr. Blake's comment: For my reader's sake, Caroline Jordan worked with another great podiatrist, Dr. Arlene Hoffman, also in San Francisco, and chronicled her healing and exercise program for a sesamoid injury. Here is a link to one of the YouTube videos.

https://youtu.be/KnB9dlXPKjw

 

4. I had lots of nerve pain initially with my injury. So much so that I wanted to always keep my foot elevated to help with the inflammation and keep any additional pressure off my nerves. I could barely walk into the other room or have a sheet touch my foot:

5. I now wear a Hoka bondi outside and Fresh Foam More shoes indoors. I only go barefoot in the shower. I have nerve like pain only in my sesamoid area (poking, pinching, burning) and into my big toe sometimes as well but less often then months prior. I do get a small bubble in the webbed area between my first and second toe as well as in my second joint in my big toe. My foot is sensitive to the temperate changes in the shower. I really don’t look forward to showering for this reason. I’m using ice about 10 mins a day. I take turmeric, liquid fish oil, and vitamin D supplement (after reading your blog).  I will soon be getting custom orthotics made. 

What exercises or stretches should I be doing?

Dr. Blake's comment: The treatment should be nerve focused. Nerve love motion, ice 5 minutes only, and warm compresses more. Nerves therefore love neural flossing or simple range of motion of the toe and ankle, but no prolonged stretches. Nerves do not like pressure, so make sure that the orthotics off weight the area. Nerves love massage, if it is non painful, so use Neuro Eze or Neuro One to massage 3-4 times a day. Both over the counter products. 

https://youtu.be/g94F8g_jzGg

Is nerve pain normal with sesamoiditis?

Dr. Blake's comment: The nerves are superhighways to your brain, that is why they unconsciously force us into mega protection mode. You injured the nerve twice that runs from your toe to your sesamoid (same nerve I suspect). First, you traumatized with glass, and secondly, you traumatized it by either holding your big toe in the air, or walking on the nerve under the sesamoid. Luckily you should have been walking slow enough not to injure the sesamoid badly (alittle maybe??)

Are there any sandals that are okay to wear for short periods of time?

Dr. Blake's comment: Oofos sandals would be my best bet now due to the softness. 

I know healing time periods vary, but does there seem to be an average amount of time?

Dr. Blake's comment: The mantra I use is "Look at a nerve funny, and it hurts for nine months". You are 5 months along, and you are improving. The reason you wrote (I read between lines sometimes) is that you do not want to have a setback and start over again. 

What can I do for the nerve pain in the mean time as I heal?

Dr. Blake's comment: Start with the above, and when they are all in place, you can add other nerve treatments if your symptoms warrant: flossing, massage with topical, warm or ice, off weight with orthotics or gel pads, soft sandals, and no prolonged pressure or stretching. Keep me in the loop, and I will try to answer. Rich 

Thank you so very much for posting! This has been one of the most emotional times in my life and have felt quite alone until coming across blogs posted by kind people such as yourself. 

Kind regards

Foot Nerve Pain: Where does it come from?

Hi Dr. Blake,

I have enjoyed reading your blog and felt inclined to send in a question regarding my foot pain.

Background:

I developed a lot of pain right under my big toe in my left foot (not in the ball of the foot, but the underside of the toe itself) about a year and a half ago. The pain had first started cropping up with rock climbing and got progressively worse over time. I got a cortisone shot from a podiatrist that did not help at all and I could barely walk (was in a boot/using a knee scooter) for several months. I ended up having 2 more cortisone shots in that toe over the course of the next year (the 2nd two shots did help, they were from a different doctor than the first time and spaced 4 months apart). I had improved to the point that I was able to do my day to day activities, but still could only walk for about 10 minutes at a time without causing a flare up of pain. 

Dr. Blake's comment: Do you know what he was injecting? Ligament, joint, nerve?

At the one year mark, my right big toe started experiencing the same symptoms and the bulk of the pain simply switched over to my right foot. My left toe stopped bothering me and my right toe became the problem.

Dr. Blake's comment: The only explanation was a nerve problem from your back. The position of your toe in rock climbing put to much tension on the local nerve. This same nerve, typically originating from L3/L4 or L4/L5 nerve roots in the back, was painful due to double crush. This means the nerve is being irritated at the foot and back combined. A slight change in your spine would make the symptoms jump to the other foot. That can could be from limping or protecting for a year, or a primary back problem. 

I limped around and tried to manage it with anti-inflamatories for 3 months before deciding to get a cortisone shot in my right big toe. As soon as I got the shot, I had a TON of pain in the ball of my foot closer to my 3rd and 4th toes (probably an inch below the base of my toes). The doctor I was seeing at the time diagnosed it as a morton's neuroma.

Dr. Blake's comment: Cortisone is for inflammation, which many times there is none. Cortisone if injected into the nerve, a superhighway in your foot and leg, can cause pain in many nerves. Morton's neuromas take many years to develop. 

The big toe pain either went away from the cortisone shot or was masked temporarily, and this new pain in the ball of my foot became the main problem. It pretty much made it so that I could not walk for more than 1-2 minutes here and there to get around my house. It also became painful to drive. I felt some relief by using a metatarsal pad to offload the area, but was still in pain. After 2 months, the big toe pain started returning and it would just depend on the day what would hurt more, the toe or the ball of my foot. My guess is that whatever help the cortisone was giving had worn off. 

Dr. Blake's comment: Yes, but cortisone is not a predictable way of helping nerve pain, so please limit. 

I began seeing a new doctor who ordered an MRI. The MRI showed a "stress reaction" in my big toe, but did not show much for the ball of the foot problem. My new doctor advised me to take a vitamin D supplement and to immobilize the toe for a month in a walking boot. After the month was up, my big toe felt a lot better, but I still had pain in the ball of my foot. 

Dr. Blake's comment: It is hard to know if the boot helped the stress reaction, or just not moving the toe helped you not to irritate the nerve. Did you ever have an MRI of the left? 

The new doctor diagnosed it as "metatarsalgia". He said it was possible that it could be a neuroma, but it was unclear from my symptoms. He gave me a steroid injection from the top of my foot down in the 3rd-4th webspace. This definitely helped and the ball of my foot feel much better. HOWEVER, I now have a similar pain in the ball of my left foot (sort of below 3rd and 4th toe or 4th-5th...hard to pinpoint). I again am unsure if this new pain is metatarsalgia, morton's neuroma or something else. It is worse some days than others. Offloading with a metatarsal pad helps. My doctor has prescribed 6-8 weeks of physical therapy so I am planning to try that next. 

Dr. Blake's comment: You are making me a little dizzy!! LOL Only irritable nerves behave like this. Has your back or any other part of your spine, up to your neck, been an issue in the past? 

My questions for you are: 

What advice do you have to finally kick this pain? I feel like I'm playing a game of whack a mole....when one problem improves another one always seems to pop up!

Dr. Blake's comment: The problem with this is probably not finding the true source of the nerve issues. All of the pain would have to be primarily from the low back or higher. That would make the foot nerves sensitive, and as you favor one problem you then set off the other side. At least, this is the most common cause. I do like the "mole game" analogy. Research in your area PTs that are in the national neurologic physical therapy association as these peripheral nerves are not so mysterious to them. I am glad the cortisone is calming things down locally. 

Do you think my ball of foot pain is morton's neuroma? 

Dr. Blake's comment: No! You can have morton's neuromas that have never bothered you, and normally never will, unless something like this happens. Morton's neuroma has a surgical side that I would avoid thinking about. Typically, it is merely a local neuritis that the cortisone great for. So, I would call this neuritis over neuroma from now on. Yes, I am opinionated!!

Nerve problems present 1/3 of the time as pain (you, unfortunately). 1/3 of the time as a mixture of pain and numbness. And, 1/3 of the time as numbness with funny feels of transient burning, bugs crawling around, tingling, vibration. The more pain involved, the more treatment, even though these scenarios present with the same pathology. Sad!

What do you think is the best way to heal the ball of foot pain that I have described?

Dr. Blake's comment: So, I would use 5 minute ice soaks, if tolerated, several times daily. I would get a pair of Hoka One One shoes or other stiff shoes that your toes do not bend alot. I would have the advice of a PT and Physiatrist about your back and peripheral nerve sensations. If someone agrees that you trust, then trying to calm the nerves down with topical medications like Neuro Eze, Lidoderm patches, TENS units, oral medications. Sometimes we are icing the back, and using warm water soaks for the foot. Find what predictably helps some, and stick with it for 3-6 months to slow down this roller coaster. The met pads seem to help for one so that should be part of your treatment. Come up with 5-7 times over the next month that have some positive affect. I hope this helps some. Rich 

Thanks so much!

How I Approach Problems: Plantar Fasciitis with Sudden Onset and No Obvious Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

           Plantar Fasciitis: Acute in Nature and without Swelling

Most heel pain is diagnosed as plantar fasciitis, and everyone knows the ice, stretch, and support protocol. But what if it is not plantar fasciitis. One subset of patients that I see have a sudden onset of pain (not plantar fasciitis), and without swelling that I can note on exam, and therefore fall into one of these 2 diagnoses.

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:

1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms)

Plantar fasciitis can morph into bursitis due to chronic low grade inflammation, but this is not the type we are discussing. The heel pain that is sudden with a plantar heel painful palpable mass, is called infra calcaneal (heel) bursitis.  There may or may not be a reason for the bursae to swell causing the pain that the patient will remember (like stepping on a rock barefoot at the beach). There is a bursal sac that is there when needed to protect bony prominences (like side of hip, front of knee, under the metatarsals), and only gets sore and swollen when irritated.

You can perhaps make the diagnosis with barefoot walking. Plantar fasciitis typically hurts the worse at push off, so walking on the toes may hurt. Heel bursitis hurts more when asked to walk on the heels alone (bursitis sufferers usually do not like this at all).

Heel neuritis can be local (Baxter's nerve entrapment) or referred pain from the tarsal tunnel or higher up (low back and even cervical issues). Like any peripheral nerve problem, you always have to think that it could be from higher up the chain (called Double Crush syndrome). In Double Crush, the nerve would be irritated at the heel (say a pes cavus foot with bony heel and no fat pad---the perfect storm), and is being irritated at the back, piriformis, behind the knee due to a baker's cyst, or in tight hamstrings or calves. What complicates this is that there is no test that confirms that the nerve is irritatable. Nerve tests like nerve conduction studies are looking for damaged nerves not excitable nerves.

 This photo may be alittle difficult, but it is of all the nerves on the bottom of your foot. Look at the nerves just under the heel bone. Any of these can get irritated locally or from a signal from higher.

So, when heel pain, initially diagnosed as plantar fasciitis is not getting better from plantar fascial treatment, you must start looking for another working diagnosis. When there is no obvious swelling, typically ruling out problems like plantar fascial tearing and heel stress fractures or bone bruises, you should look for heel bursitis and heel neuritis.

My next posts will go over the treatments for each separately.

Nerve Pain helped by Neuro One Topical

Neuro One is a topical that you can order through Amazon and other places. It has L-Arginine and Vitamin B-12. It is one of the medications, along with neural flossing, warm bathes or 5 min ice, non painful massage, metatarsal support, and foot mobilization, that I use routinely for foot nerve pain of any sort. This can include Morton's Neuromas, peripheral neuropathy, sciatica, etc. I advised this particular patient to reduce the Neuro One to once daily to see if we get the same great results. 

Hi Dr. Blake,

I hope that you and your family are keeping well! We are muddling along without too many problems.

You suggested that I check in by email right around now.

The only question that I have right now is whether you want me to change my NeuroOne routine.

I have been using it for about 14 weeks, twice a day, on my left foot.

The neuroma “pain” is diminished by about 50% on both feet since I starting using the NeuroOne in February. Now on both feet it’s in the 1-2 range, and the predominant sensation when I walk is something like having the ball of your foot brushed by a vegetable brush.

Also, I have stopped icing the balls of my feet at night. Now I just ice the boney ridges on the tops for 10 minutes in the evening, which is more relaxing than anything else.

I haven’t gotten up the courage to try any shoes other than my Chaco sandals. Sheltering in place (with daily walks between 90 and 120 minutes) doesn’t require any footwear more stylish then Chaco’s.

So, there you have it: the NeuroOne question, plus I’d be happy to hear any other suggestions or advice.

Thanks, and take care!

Nerve Pain in the foot: Email Advice

Dear Dr. Richard,

I am miserable an in need of urgent help.

I am a 37 year old female. I fractured my right foot (Jones fracture) on August 24 2018. I was put in a cam boot and after one month started initial weight bearing with the boot and then on the 8 week mark when the x-ray showed that the fracture has healed I was told to get out of the boot and start walking.

Several days after I started walking, I developed severe pain on the top of my foot (between the 3^rd and 4^th metatarsals) that made me limp badly and also on the ball of my foot that I could feel the most when walking barefoot. I went to see a foot and ankle specialist who suspected a stress fracture. He asked for an MRI and an ultrasound and both showed  no stress fractures. They also did not show any soft tissue issues, neuroma, etc. 

Dr. Blake's comment: This would appear then to be nerve irritation since it is never seen on x-ray, ultrasound, or MRI like bone or soft tissue injuries would be seen. 

The doctor gave me non steroidal anti-inflammatory (600 mg) one pill a day for 20 days and he asked me to rest my foot. This kind of got rid of the dorsal pain but the pain in the ball of my foot remains severe.

The pain cannot be felt if I touch my foot neither from the top or if I touch the ball. It is not there when I’m resting either but it shoots up when I walk or bear weight. It is the worst when I walk barefoot and when the foot spreads. 

I went to see the doctor again and he tested for neuroma but there was no click. He couldn’t figure out what it is but he says he suspects a soft tissue inflammation. He gave me two steroid shots in the areas shown in picture 1 below. He targeted those areas because this is where I thought the pain generates from. It has been a week and the shots did not help at all. I still have severe pain in my foot. Picture two below demonstrates where the general area of my pain is. And as mentioned, it is the worst when the foot spreads.

Please help I am very desperate as I have not really been walking since my fracture and I am becoming severely depressed. I was an active person before this and now I cannot even go to the toilet without having severe foot pain.

All the best,

Dr. Blake's comment: This has to be nerve irritation which will not show up on tests, but since nerves are super highways to the pain, they can give the most severe pain. Neuromas are long developing problems at the nerve, so I would not expect this to be one. You and your doctor need to find the nerve that is causing the pain with using only long acting local anesthetic, not cortisone at least until you find it. Then a treatment pain can be designed. See my post below on these diagnostic tests. You will be fine, so hang in there. You have ruled out major problems, so a local very painful pinched nerve should be the cause of this pain. Keep me in the loop. Rich

PS. The pain can be coming from above your foot also due to limping for awhile and upsetting the delicate balance of your body. See my video on foot pain from back causes. 

https://youtu.be/E0E60NpOSHg

http://www.drblakeshealingsole.com/2010/08/diagnostic-injections-pearl-oft.html

Resolution of Foot Nerve Pain: Email Advice

Rich,

You asked for 2-week feedback on my heel problem (https://www.drblakeshealingsole.com/2018/05/foot-pain-from-hamstring-stretch.html), but I had some delays waiting for Neuro-Eze and traveling over Memorial weekend, so here's my 3-week feedback on the neuropathy.

I was impressed with your question about low back and sciatica because I do have a recently collapsed disc L4-L5, and experienced sciatica for the first time in the LEFT hip and leg in April. That faded away in a few weeks, then the heel problem manifested in the RIGHT heel, triggering by stretching, but I assume it could also be due to the damaged lumbar disc and sciatic nerve.

I strictly limited my walking, switched from your permanent orthotics (thin foam) to your temporary orthotics (memory foam) for their rearward arch placement and heel cushioning, and followed your treatment instructions (neural flossing, Neuro-Eze, knee-bent lifting, warm water) rigorously for three weeks. Heel pain was gone after two weeks, but I continue to feel the occasional twinge when barefoot on a hard surface or inadvertently stretching the achilles.

After 3 weeks I switched back to permanent orthotics and have walked about 5 miles since, resulting in no pain but again, minor twinges in the heel. My feet seem to be missing the arch and cushioning of the memory foam orthotics, which really relieve pressure on the heel!

Questions at this point:

1. How long should I continue the neural flossing and Neuro-Eze, considering that pain has been gone for a week?

Dr. Blake's comment: Thank you for the wonderful feedback!! Once the nerve is irritated at the lumbar spine, or along the sciatic nerve, the abnormal sensations called dyskinesias can linger for quite awhile (meaning months and months). You sort of have to pay attention, but you sort of do not. I like the Neuro-Eze three times a day for two weeks longer than the pain, then one month at twice daily. The self-massage is probably as important at this stage as the medication itself. Consider the neuro-flossing through August 1st (almost 2 more months because that gets the basic problem of the sciatic nerve settled down). 

2. Do you see any issue with using the memory foam orthotics? Dr. Blake's comment: No, you can continue with the full-length Hannafords, unless it upsets some other problem. Sounds like it helps the heel the best, and that makes sense, between the heel cushion and the transfer of weight into the arch off the heel. 

3. In the short term, how much is this neuropathy likely to be affected by walking? Should I be really cautious about resuming activity? Dr. Blake's comment: Walking should be wonderful as each step is a rhythmical neural floss. Possibly the stress on your back may be worse up or down steep hills, but I am not sure. Just go easy on hills. 

4. What about stretching? When and how can I resume (cautious) back stretches, hamstring, calf, etc.? Dr. Blake's comment: This I would bring up to a physical therapist. I know when I herniated my disc, they were cautious about stretching for several months, but that was in the acute phase. It depends where most of the tension on the nerve is: sometimes calf, sometimes hamstring, sometimes piriformis, sometimes low back. Just know that prolonged stretch can trigger it for awhile, but it sounds like it is relaxing fine. You can do short 10 second stretches with less pull than normal first to see how you feel. I would wait until July probably. 

5. What about long-term? Is this sort of condition likely to recur, or to limit my activity permanently, without more aggressive treatment? Dr. Blake's comment: I would not expect any long-term disability. I play basketball several days a week but have some dyskinesias from time to time. Months and months can go by without issues. Make sure with your back issues that you are fully rehabbing your back on a daily basis. Hope this helps. Rich

Thanks again!

Nerve Pain: Email Advice

Dear Dr. Blake , Thank you so much for your blog I just wish that I had found it 7 months ago!. Can you please help me? I have been a labour and delivery nurse for 30 years. 12 hours days and nights on  my feet. Last year I broke 2 toes on my right foot and very stupidly continued to work . I could not wear a closed shoe so I foolishly wore flat shoes with no support and flip flops all summer.  7 months ago I started to wear my new supportive work shoes and a 7mm  lift. ( During the summer my osteopath diagnosed me with a 7mm leg length discrepancy as the cause of my lower SI joint pain). Within weeks I started to have pain under my 2nd Metatarsal on my left foot ( the foot I limped on for 4 months).

Dr Blake's comment: Is it also the foot with the lift? Very important because, if it is a heel lift it can transfer the weight to the metatarsals, and if it is full length it could be too stiff in that area. 

 I went to a podiatrist and he recommended a metatarsal pad. I tried to wear the metatarsal pad but it seemed to make things worse.

Dr Blake's comment: Met pads can make nerve pain in that area worse, and tendon pain worse, since those structures run back into your arch. Met pads normally help bone and joint pain unless too far forward. Did you try to move it around? 

 The pain soon was at the base of my 2nd and 3rd metatarsal . I went to physiotherapy and they diagnosed me with plantar fasciitis both feet ( no heal pain but pain under arches and below ball of feet worse on the left foot. Also they diagnosed me with possible capsulitis and neuroma. I ordered custom orthotics at this time. While waiting for the orthotics I continued to work. I started to experience intense burning and tingling shooting neuralgia. My feet were so painful the sheet could not touch them. 

Dr Blake's comment: The orthopedic problem had become neurologically over sensitive to protect itself. You now had the original problem, and nerve hypersensitivity, together. You have to take this very serious because it can lead to CRPS, so creating a consistent 0-2 pain level is crucial. 

I went back to the Podiatrist and he gave me a celestone cortisone injection between my 2nd and 3rd and 3rd and 4th metatarsal. After a couple weeks I started to get alot of relief in the burning and nerve pain the inflamation went down considerably. The cortisone allowed me to  receive physio therapy ( ultrasound and aggressive manipulation of my feet) I did all of the exercises I was given. 3 months later the symptoms returned with a vengence.
Dr Blake's comment: Unfortunately, it is common to have these long acting cortisone wear off and you need boosters. I tell my patients that they may need 3 total to address the nerve pain. While you are injecting a nerve, since it may wear off, consider oral nerve meds like Lyrica, topical Neuro-eze, neural flossing, ice pack 10 minutes twice daily. 

 I got another steriod injection this time Depro Medrol same locations.
Dr Blake's comment: Celestone is 6 mg per ml, whereas Depro is 20, 40 or 80 mg. It is very strong cortisone, as should not be used alot in the foot unless diluted. 

 After a very uncomfortable steriod flare 7 days later my foot started to settle down. I still suffer with the intense dull pain under my 2nd and 3rd metatarsal and my toes feel " out of joint" I can flex them but it feels swollen behind them and I cannot extend them without great ripping pain. I finally got an appointment with an orthopedic surgeon and he did xrays which showed no fractures, small heel spur. He diagnosed me with Tenosynovitis of the 2nd and 3rd metatarsals and plantar fasciitis . I agreed to PRP injections . I had a 2 week inflammatory response from those ( very painful) but my plantar fasciitis is 75% better  and the  Tenosynovitis is finnally settling down. I am icing several times a day. I was doing calf stretches but stretching irritated the tenosynovitis so I have stopped. The only advise I was given from this doctor was to rest and return in 5 weeks. I have been wearing a very flat firm slipper that my orthotic fits in I can't seem to wear my running shoes because they make my toes flex. It has been 3 weeks with very little ambulation in the day I am couch bound. I tried wearing a Budin Splint but it seamed to irritate the tenosynovitis on the toes. I plan to remain on the couch another 2 weeks then I see him again for the 2nd PRP injection if needed.

My questions are. 1) I think my orthotic is making it worse. When I walk I feel like I land right on the 2nd metarsal and when I tried a met pad it seem to cause the plantar ligament to pull on the capsule and the 2nd and 3rd metatarsals making the tenosynovitis worse. What do you recommend I wear on my feet? How long should I wait to try a met pad? How long should I wait to try the Budin splint again.
Dr Blake's comment: Orthotics are tricky for metatarsal issues since the end of the plastic is where you hurt. You can try a full length Sole (I prefer the red ones) with or without a loose fitting Budin Splint. Use a single loop Budin and open it up and place around the 2nd and 3rd toe, or the 3rd and 4th toes together. Yes, avoid met pads when there is nerve hypersensitivity. 

2) What types of shoes should I wear with this history.
Dr Blake's comment: Definitely try the Hoka One One Bondi or similiar to give you rocker. You may also need a Hike and Bike shoe for the rigidity right now.  How do you feel in a Danco clog, for cooking or short spurts?

3( Should I give up on the orthotic?. I pronate on both but much worse on my right foot . My arch is falling on the right. And the right foot is my good foot.
Dr Blake's comment: Give up on it right now, until we experiment with full length ones from Sole, Powersole, Lynco, etc. 

4) How long  should I remain off my foot? Should I completely immobalize my foot? How would you recommend I do this?
Dr Blake's comment: Nerves like warmth, motion, not prolonged stretching, non painful activities like walking. So, being immobilized is may help orthopedic injuries, the nerves hate it. I would have to know how you feel walking with crutches in a removable boot.

5)How will I know it is time to start restrengthening and returning to normal activities ie work?
Dr Blake's comment: Strengthening should be happening right now. This is usually organized by the PT. If you can not balance on one foot due to pain, you at least should be able to use a stationary bike with your weight in the heel for an hour a day. You should be doing a gym program for at least ankle strengthening, knee, hip, core, cardio, some upper extremity. Consider experiment with various beginner yoga poses or pilates exercises. Over the next month, every day find one exercise that does not hurt, and keep building.

6) I'm sure the 7mm lift in my right shoe has changed the weight distribution between my feet and has probably caused the perfect storm. I have been wearing the lift for 7 months now and it has been the answer for the S.I. joint pain I have had for 7 years ( GONE !!!) Should I have new orthotics made with no lift? I could get a separate lift made and add height a bit at a time.
Dr Blake's comment: The relief of the SI pain is pretty striking and emphasizes the need for the lift. I am glad the lift is not on your injured side. I love orthotics and lifts separate, so you can experiment. If the lift is only a heel lift, try to take that off and use a 1/8th inch full length lift (spenco insert) for the next month on the one side to see what happens. Hope all this helps some. I do want to say that lifts under your foot on one side have a very dramatic effect on the base of the spine. If I was treating you, I would order an MRI of the injured foot, and a Standing AP Pelvic xray with your 7 mm lift and orthotics to see how the spine, hips, and SI joints look. How level are they?

Please help me I am desperate to return to work and my life I love walking. I have been limping for 12 months now!

Karen

Foundation for Peripheral Neuropathy

This look like a good source of information on peripheral nerves coming off the spinal cord. I look forward to explore over the next few weeks. 

Golden Rule of Foot: Look at a Nerve Wrong and it will hurt for 9 months!

https://www.foundationforpn.org/2016/11/09/foundation-for-peripheral-neuropathy-celebrates-10th-anniversary/

Lower Extremity Nerve Symptoms: Looking for more than one Source

https://youtu.be/_7qNgYNUrmw

This was a comment to my You Tube video which I see often dealing with neurological problems in the lower extremities. There can be 2 or 3 sources of this neural tension that in themselves are minor, but together cause major disabilities. The treatment stems from finding all the possible triggers like poor posture sitting, overpronation of feet, poor core strength with low back issues, piriformis syndrome, etc, etc. I have had patients where the 2nd source of nerve irritation was the neck area, and the foot symptoms would not resolve unless the neck was stabilized somehow.

Hi Doctor Blake, I have a buzzy sensation in the ball of my foot when I walk. It began 10 months ago when I was running long distance. I had a variety of symptoms and was unsure where the pain was originating. It resulted in me developing a strong limp because I was in so much pain. I have had electric shock type pains travelling up my left leg, numbness in the ball of my left foot, pins and needles in my calf, tightness in my hamstring and glute. I have also had varying degrees of back discomfort but not enough for the doctor to think it is sciatica. I can't pinpoint a painful point in my foot and foot specialists haven't been able to either, although it does feel buzzy after it has been manipulated. I have had a steroid/anti inflammatory injection that didn't do much for me. The best thing has been some orthotics that raise my arch taking the pressure of the ball of my foot. I get the buzzy feeling by tapping the tarsal tunnel by my ankle as you demonstrated. What does this mean? Thanks,

Dr Blake's comment:

Calmare Pain Therapy: Email Correspondance

Dear Dr. Rich,

Yes, I finally got through to Dr. Gutierrez and signed up for the treatment, starting Monday, March 21.  My symptoms were perhaps not typical; most people start with a lot of pain and it gradually reduces.  My neuropathy pains have always been intermittent and worse at night;  a major problem has been sensitivity of the soles of my feet.  So for the first treatment my pain level was zero  before treatment, but they did it anyway.  However, that same day I noticed a marked improvement in the sensitivity of the soles.  The second day I wore a pair of thin soled shoes and before the treatment walked around on rough ground including a gravel path, and it felt OK.  This was something I absolutely could not have done before.   Again zero pain at the start of the treatment, but I am sure the treatment was beneficial.  I don't know if Dr.Gutierrez though I was a hypocondriac, since I was supposed to have more pain.  I ended up having only 3 treatments;  I questioned  whether getting all 10 proposed treatments would be beneficial.  The shooting pains I had for the past year or more had been less lately and have not recurred.  Dr. Gutierrez agreed for me to stop after the 3rd session (and not have to pay for all 10) with the understanding that if pain returned I could "start over."

I am happy about the outcome and grateful to you for telling me about it.  The other symptom of neuropathy, which they call "compression" or feeling like the feet are overstuffed sausages, with difficulty  flexing the toes, is apparently not helped by this treatment.  And then there's the arthritis which is still active.  However,  any progress is welcome and I am now able to wear all my shoes, some of which I could not get my feet into a few months ago, and walk much more comfortably.

So, many thanks, and I hope Calmare gets full approval.

Best regards,

Foot Nerve Pain: You Tube Video Comment Reply

Hi Dr Blake, I have excruciating pain in between the 1st & 2nd metatarsal. (4 years ongoing). It only happens when I walk for long, try to run, carry heavy items or wear tight shoes. MRI scans showed nothing, XRays showed nothing. Could it be a neuroma? Massaging it helps alot. The cold also aggravates the pain. Anti inflammatory meds help as well as lyrica for nerves. My guess it is a pinched nerve or a neuroma.

Dr Blake's comment:

With the negative scan, this is typically an L4/L5 nerve root irriation or double crush syndrome. Neuromas are rare in this area. Look into neural flossing/gliding and topical NeuroEze. Have the nerves evaluated by a neurologist or physiatrist for radiculopathy. Definitely try to manipulate the weight bearing with Hapad Longitudinal Arch Pads and try restricting toe motion with toe separators, Budin Splints, spica taping. Ice Pack for 10 minutes twice daily for the next month to see if this is helpful. Hope this helps.

Foot Nerve Pain: Email Advice regarding origin from back

Hi there Dr Blake, 

    I have watched your 'Foot nerve pain -can it come from your back?' video about 100 times !! Thank you for sharing it - it is very useful. I am writing because I would be extremely grateful for your advice. 

    ​ I have had severe, non stop excruciating, burning pain in my right foot ( sole and arch - but mainly sole and more recently on front of ankle) for 8 months.. I have no back pain or leg pain - just the foot. It is really getting me down, curtailing my work, making me grumpy etc.. There is no structural problem with the foot (numerous MRIs are all clear) but a lumbar MRI shows a disc herniation at L5/S1 level. I have tried nerve blocks into the nerve which relieved the pain for a couple of hours but then it came back. The physician said the fact that the pain went away, albeit briefly, is is a strong indicator that the origin of the pain is in my back  But the surgeon hesitates to do a microdisctectomy as says he cannot guarantee that the herniation is the cause as I have no other radicular pain and no neuropathic symptoms ( numbness, problem with movement etc) . He basically said he can offer a 70% chance of the MD fixing it as opposed to 95% ( that is a BIG) difference .. It could also make it worse esp as I have a small scoliosis at the top which may be disturbed ... What to do ? I am going to see him again tomorrow . What questions should I ask ? I cannot bear the pain ( and cannot take meds as feel too spacey) . The surgeon is one of the best in the UK so he knows what he is talking about. In my (unprofessional view) as all possibilities of a mechanical problem in the foot have been excluded, it seems a logical option that the pain is emanating from the spine. Is it possible to have foot pain (and JUST foot pain) with no other symptoms in back, down leg etc ?? I would sooo appreciate your opinion on this. 

Thank you so much for your time - i really appreciate it.

Very best wishes,

Dr Blake's response:

     Thank you so very much for the email. Definitely I see so many patients with only pain at the end of the nerve, and nothing in the back, and no classic sciatica radiation. The art of all this. One of my friends came in 5 years ago for excruciating pain from an ingrown toenail. The problem was when I examined him he had no ingrown toenail. I told him it was probably a bulging disc. He said he had no back pain, and he definitely had a negative straight leg test. The back doctor reluctantly agreed to a lumbar MRI, not sure if the back was involved. The patient called me after the MRI stating that I had been wrong (a guy thing!!). He said that he did not have a bulging disc as I had thought, but his foot pain was caused by Stage 4 Prostate Cancer with impingement on the nerves in the low back. He has done great, and I am happy to have been part of his cure. It is one of the best examples I have on back problems causing only foot pain and nothing else. 

     It is all about nerve irritation coming from somewhere (even the neck primarily)  to hit those nerves. And, it could be "double crush", so I am glad you are ruling out the foot part. Unfortunately, you probably have no choice but to work on the low back (surgically or conservatively). Many disc herniations do not need surgery. Mine did not, but I spent 8 months in PT getting stronger, more flexible, and calming the nervous system down. My symptoms were L2/L3 in the thigh above the knee. But, they sound like yours. I was blessed that I did not have to walk on the pain, but I joked that I wanted to be the podiatrist for a nudist colony since the pants leg would hit the front of my leg and send level 10 pain. What joy!! And, I never had back pain. 

    When you get neuropathic symptoms, it is 1/3rd of the time only numbness/tingling, 1/3rd of the time only pain (you I think!!), and 1/3rd of the time a combination of numbness and pain. 

    I wish I could tell you how to proceed, but my gut level is you have to address the back. The neuropathic pain you are dealing with unfortunately can be a devil to turn off, even if the disc herniation is surgically treated or resolves on its own. I am assuming you are doing neural flossing, applying compounding creams three times daily or Neuro-eze, oral medications like Lyrica or Neurontin at least in the evening (as soon as you get home for good), warm compresses should be used, and a good low back treatment including postural dos and donots that they teach in every low back class. Bend those knees, etc. Look into Calmare pain therapy if it is offered in the UK for the peripheral nerve part. Ice your low back 3 times daily minimum for 30 minutes. The epidural you had gets at the inflammatory part of the herniated disc, but most of your pain is neuropathic. A sympathetic block may be very important combined with epidural. For sympathetic blocks, they need to hit 3 ganglions/levels for the best results.

     I sure hope this helps you somewhat. Greetings from across the pond. Rich