Flare Up Pain Post Examination: Nerve Related?

Dr. Blake,

I hope you're well. I have spent some time reading through you blog as well as various reviews. It seems you are a leading expert in sessamoid injuries. My story is I'm a 35 year old competitive runner. I never had sessamoid issues until recently. I went for a hike/run in the mountains and had the indicative stiff toe shortly thereafter. I was able to get around well and saw improvement through the week. I tested my foot 7 days later and had mild soreness after the run. Although I was able to walk without issue I was unable to run and wanted to rule out any sort of fracture. I went to see a sports medicine doctor three days after the light run. Before the doctor came in a resident physician on rotation examined me twisting my foot in various positions as well as pushing my big toe up to the highest point my body would allow. The pain was not immediately debilitating but on the way home from the hospital I began to feel pain on the top of my first metatarsal as well as pain in the ball of my foot for the first time. The pain got progressively worse over the next 24 hours.

Dr. Blake's comment: Sorry for that. I have inadvertently done that to a few patients over the years. Residents do not have experience yet, actually you are their experience. I was a resident once so I feel for you. It normally lasts a day or so. 

 I wasn't able to sleep that night and was unable to walk or weight bear the next day. It's been three weeks since that examination and I still cannot bear weight. I knew something was wrong and had an MRI done two days after my initial visit to the doctor. The MRI results did not show a sesamoid fracture just some metatarsal edema and "sesamoiditis". I have been taking prescription anti-inflammatory meds and limping around in a post op shoe putting my weight on the outside of the heal (i find the cam walker to be too uncomfortable). I use a scooter around the house. When I do limp in the post op shoe I try to put a ballet pad on my foot to offload some of the pressure from the sesamoid. I live in the Carolinas so literally across the country. Is it possible to schedule a remote consultation with you or do you only see patients in the office? I have been reading the horror stories and like most I have seen no improvement over the past month. I'd also like to have a second opinion since the doctor who initially diagnosed me as not having a fracture was the attending physician when I was injured by the resident.....which makes me question his familiarity with this injury. He recommended a graphite insert which I can't even imagine walking on anytime soon. 

Dr. Blake's comment: So sorry for your problem. I can review the xrays and MRI. You can have them mailed to Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. Look up my friend at the Barry University in Florida Dr. James Losito. He also may have a local recommendation. You need to get back in the removable boot with a cut out for the sesamoid. Some times I need 1/2 inch sesamoid accommodations to protect the sesamoid. Anti-inflammatories slow bone healing so try to change to ice and contrast bathing. With contrast bathing start with 1 minute hot and 1 minute cold for 10 minutes and see if it makes it feel better. I would rather you do that. This is very unusual to hurt like this after an examination, so if you forget about the diagnosis for awhile, the goal has to be weight bearing with 0-2 pain levels. Typically podiatrists are great at that, but if you have to also work with a pain specialist. The 3 sources of your pain are mechanical injury documented by the MRI, inflammation, and nerve hypersensitivity. So many patients with pain like this actually have nerve pain. If you float the sesamoid 1/2 inch off the ground and you still have major pain, then you have some nerve pain. And, nerve pain has to be treated differently than mechanical produced pain or inflammation produced pain. I hope this makes sense. Rich

http://www.aapsm.org/members-south.html I also love Pat Nunan in one of those Carolinas!!

Thanks

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