Is it Tendinitis or Nerve Pain: Email Response

Hi Dr. Blake,

I hope you're well.  

I am wondering how to know if the pain in my foot/ankle/lower leg is coming from the FHL, FDL, or Tibialis Posterior? They all seem to have the same location and trigger points from the muscle are also close together. I would like to do self-massage to release whatever is trapped/tight if possible.

Some history:

Two and half years ago, I injured my FHL tendon where it meets my sesamoid (imaging showed inflammation and swelling of the 1st metatarsal, fracture of sesamoids ruled out) on my right foot.  I developed nerve pain as a result (in right foot and leg, and mirror nerve pain in left foot and leg), as well as piriformis syndrome in my right glute from the gait changes.  Tendon eventually healed, but different kinds of nerve pain/patterns and piriformis muscle pain remained, sometimes mild sometimes more severe.  Additional imaging ruled out lower back/SIJ issues.  

Two months ago, I developed an intense tension in my right foot, very close to my Achilles tendon, between my Achilles tendon and ankle bone on the inside of the leg, when walking.  Tension would feel like somebody was pulling my heel back whenever I tried to take a step forward as if one of the tendons/ligaments was too short and bouncing back each time.  Pain could not be reproduced by pressing the area of the pain, just when stepping forward. The pain only appeared when I put on my shoes and took a step when at home in flip-flops I could walk pain-free. The pain came and went for about 10 days, then disappeared. 
 Dr. Blake's comment: This is classic neural tension from the piriformis or low back typically. Glad it resolved. Tendinitis would not of so quickly. 

A week ago I started feeling pain in my right foot, starting from the bottom just in front of the heel (between heel and arch) and shooting upwards towards the back of my ankle bone on the inside of my leg.  Not a nerve pain feeling, but a tension again, less severe than two months ago, different spot (but nearby), and sometimes starts tingling slightly when I press on it.  Tried rolling foot on a tennis ball at the point of pain and felt tingling on the bottom of the foot towards big toe (similar to pain from FHL injury 2.5 years ago but much less intense). Did not continue rolling on the ball.  Being familiar with trigger points, I press my lower leg up from the ankle (on inside of leg) to calf and get some referred pain into my foot between the heel and arch.  Pain is felt when swimming, walking, and stretching body when waking up (tension/soreness) and when not moving (dull throbbing ache).
Dr. Blake's comment: Again, this is neural tension. The tingly, shooting sensation, does not like prolonged pressure, are classic for nerve generated symptoms. 

Any ideas of which tendon this could be and suggestions of how to release whatever is pulling on the tendon would be much appreciated! I would rather not go to doctors and physiotherapists all over again, but would not want to leave this if it might get worse.  I got used to the residual/chronic nerve pain and piriformis muscle pain but would not want to start shifting gait again.  

Dr Blake's comment: Nerve generated pain can be numbness only, pain only, and a whole range of abnormal symptoms. These again seem more like nerve so neural flossing, Neuro-Eze, lidoderm patches, active range of motion (not resistance or pressure), perhaps a sciatic nerve program from a chiropractic to avoid irritating the nerve (you can do that seating, lying, lifting,etc. ) I would go in that direction. 

Thank you,

Neural Tension Introduction Video

This nice video begins a discussion about neural tension. Neural tension can produce pain syndromes, and its treatment in minimizing neural tension can dramatically ease pain. We all know that when we lift something heavy we need to bend our knees. The bending of the knees takes tension off the sciatic nerve running in the back of the knee, thus less neural tension. At the ankle, limiting the total amount of flexion also takes tension off the sciatic nerve called the tarsal tunnel, also producing less neural tension. Hyper-extending our knees can over stretch the sciatic nerve, producing abnormal neural tension and resultant nerve symptoms. So much that goes into gait evaluation and sport technique evaluation comes from concepts of avoiding too much neural tension and the development of pain syndromes. Over pronation of the ankle, over stretches the sciatic nerve, leading to neural tension in the foot, ankle, and above (podiatrist's bread and butter!!).

Plie in Ballet would cause neural tension in the ankle due to the extreme flexion except for the knee being bent which relaxes the sciatic nerve. The spine should also be in neutral position at this point putting no tension on the nervous system.