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

     

Double Crush: Back to Foot Connection

Dr. Blake,

I found your blog and need some advice if you have a minute.

I have pretty bad lumbar back problems. MRI has shown lots of problems from L3 down to S1. I was referred to a pain doc for 3 rounds of steroid shots. She took new pictures and said it was time for me to see a surgeon.

At the same time I have numbness in my feet. Bad in the right. Swelling/pain in ankle, etc. Went to foot doc and was diagnosed with tarsal tunnel and neuroma. Have this in both feet, bad in right, left is manageable. He said my shoes were to narrow causing the neuroma and my high arches were falling causing the tarsal tunnel.

Basically, I'm a mess and in pain all the time. Lower back and ankles/feet. Hard to stand for very long.

I was googling and found "Double Crush" which links the lower back problems and the tarsal tunnel problems.

I need advice because I don't know how to proceed. I've tried everything, shoes, expensive orthotics, compression socks, stretching, exercises, chiropractic, massage, and others. I was prescribed shoes, orthotics, compression socks by foot doc. I was prescribed drugs (They want me to take Lyrica) by the neuro sergeon. 

I'm frustrated and frightened because I'm just turning 50 and I concerned this is only getting worse. I don't know if I should see another foot doc or another back doc or what to do. I need my foot doc to talk to my back doc and discuss this problem together because my reading indicates they are related.

I'm also confused on the orthotics because some of my research shows, yes do them, other reading indicates they may be causing some of the problem and I need to go natural. I believe there is a connection and my alignment from my feet up to my back is out of wack and I don't know were to turn.

Any advice?

Frustrated and in Pain from San Antonio, TX

Dr Blake's response:

     Thank you so very much for your email. Lower Back irritation to the nerves that go to the foot are unfortunately very common. I am a biomechanics expert. I need to see if I am dealing with a musculo-skeletal problem, or a neurological one, since the treatments may vary at times.

     You want to try to avoid foot surgery, if suggested for neuroma or tarsal tunnel, until the low back component has been worked on considerably. But, you still need to treat the foot locally.
Golden Rule of Foot: Treat the Low Back Nerve Component First to see what the Role in the Foot Pain.

     You are so right to want a team approach. Typically, this is a physiatrist, who can work with the medicine/epidural side, but knows what the podiatrist is doing, and what the neurosurgeon has to offer.

     You are in a nervous system overload right now. You should maximize support to the foot and low back (orthotics, foot strengthening/taping, core strengthening, back braces), and ways to minimize nervous irritability (oral meds, topical meds, warm soaks, neural flossing,etc.). I never recommend avoiding medications in this scenario, since you have to get the nervous system calmed down, and it can take a long while, getting the medications right. 

     Definitely, the role of orthotic devices to stabilize your lower extremity, and lifts if you have a short leg, are a no-brainer to me. Find out who makes the best orthotics in your area. Have your doc prescribe a Standing AP Pelvic Xray to document the leg length difference standing (I have some posts in my blog on this). Treatment of a short leg is Back Pain 101 to me. Most definitely recommend surgery for the back if the nerve injury is causing weakness in your legs, but waiting a month or two to get orthotics that make your feet function symmetrically and lifts for any short leg make help considerably. 

     I sure hope this helps somewhat. Rich

     

Neuropathy or Referred Pain from the Low Back: Email Advice

Hi Dr. Blake,

I have a few symptoms that I will be telling my doctor about at my annual physical in two months. In the meantime, I thought I would ask you about them.

For about a year or so, I have a hard time with walking around the house barefoot. It is especially difficult first thing out of bed. Recently I have been having numbness in the corner of my right big toe. I thought this was just and old ingrown toenail thing acting up again, but it seems to be more than that. I have pain in my arches-just below the ball of my foot. I bought some arch inserts from Germany, and now have to put them into almost any shoe I wear, except my dansko clogs.

Dr Blake's comment: I have linked this with my video on foot nerve pain and it's relationship to the back. You can see how the corner of the big toe is related the L4 Disc as well as the pain in the ball of the foot into the arches.

Sometimes I imagine I get relief after stretching my hamstrings. I have one of those green stretch nylon ropes with loop holes I got after rehabbing from my knee surgery(right knee)  I got a little freaked out tonight after standing in a rite aid store. There I was getting dental floss and the auto message over the loud speaker was warning customers of their possible undiagnosed diabetic neuropathy. They listed off some sensations that sounded like a few of my symptoms.  Of course, walking home, I kept thinking.."what if this is something I have?" I don't have diabetes, that I am aware of anyway?

My questions are:

Why would the upper left corner of my big toe feel numb and burning on and off? Not just at the toenail, but under it on a callous pad and at side of toe bone.

Why is it so painful to walk barefoot? As if I need the support of a shoe or else it feels like my bones crunch with each step. As though not enough muscle in my arche to hold myself up?
Dr Blake's comment: The video above should explain what nerve root in your back is probably effected. Pressure on a nerve can cause both abnormal sensations and abnormal muscle function (ie your muscles are not supported the bones and they complain mightily.) 

Should I be concerned about diabetic neuropathy?
Dr Blake's comment: This does not sound like neuropathy, but, in the early stages of development, the symptoms can be atypical. If you were in my office, I would send you to our back doc to check if this was coming off your back. 

How can you tell the diference between foot weakness symptoms  - foot neuropathy -- Morton's neuroma - plantar fascia pain ?

Also what type of doctor would I want to be seen by. Is this for a podiatrist or a neurologist?
Dr Blake's comment: Both a podiatrist to treat the local symptoms and a neurologist or physiatrist to evaluate and possibly treat the back. The MDs would definitely help in pinpointing the diagnosis better, but the lion's share of the treatment can be left with the podiatrist. Sure hope this helps. Rich

Thanks for your time.

Nerve Pain: Double Crush, Diabetic, Low Back??

Hi,




I have had severe sharp stabbing and burning left foot pain for some time now. I was tested twice for neuropathy and found I am showing signs of it. A slight increase shown in the last test from the first which was three years apart. I am a Diabetic, not on insulin but taking 1500 mg of Metformin/day. I also have sciatic problems but mostly in my right foot. I blew out my l5-s1 in 1991 and had surgery to fix it. 6 moths later I was at the GYM working out on a machine and felt my right foot go numb. I put up with it ever since. I have been to three different Doctors about my pain. One claims it’s my neuropathy, another says it’s my back injury, and the last doctor (and current one) says it is Tarsitis. He gave my a shot in my ankle which took the pain away. BUT, it came back after two weeks. He gave me another shot but it only lasted four days. The pain is getting worse, keeping me from sleeping. Ice dose not work anymore. The pain is on top of my foot and on it’s left side looking down at it. It is also into my small toes. Seems to travel from in front of my ankle to my toes and wraps around the left of the foot.

No body has done an x-ray or a MRI. I am taking Lyrica which at first I thought it was helping but now the pain is worse.

Any suggestions?

John in PA  (name changed)

Dr Blake's response:

    Thank you so very much for the email. I am sure that there are some versions of Diabetic neuropathy that present like this, but it is an unlikely presentation and therefore not my top pick. However, it is a perfect time to make sure that your diabetes is under control. What is your HbA1c? Make sure it is below 6. You need to get a handle on what your neurological exam tells us. Please review the videos next.





So, from your description, and the 2 videos you can be dealing with a localized nerve (superficial peroneal or sural) or the L5 and S1 nerve roots, or both called the double crush syndrome. See the link below.

http://www.drblakeshealingsole.com/search/label/Double%20Crush%20Syndrome

The injection you got was very diagnostic in identifying what nerve was involved, but it still does not tell you if all or some of the pain is coming from your back. Please follow these steps.

1. Develop quickly a pain free environment, since nerve pain can get out of control. I personally had to get both an epidural and a sympathetic block since I could not calm mine down in 2004. I am presently nursing another back injury, and trying to be much better. 
2. Get to a back doctor to do back xrays, MRI, and NCS/EMG. You deserve all these things because of the severity of your problem.
3. Typically with nerve pain you are on some topical medication and oral like Lyrica. So, for right now ask about a topical and build the Lyrica gradually to 150 mg twice daily. 
4. Work on your diabetes by getting the HbA1c and fasting blood glucose. 
5. Use crutches, removable boots, activity modification, etc to get out of pain ASAP. 

 I hope this helps your direction. Feel free to comment. Rich Blake

Foot Nerve Pain: Does It Always Start in the Foot?

Yes, it was my birthday on 1/9. 

My great Medical Assistant Shawanna surprised me with a cake. 

This Standing AP Pelvic Xray shows that the right hip is 6 mm or 1/4 inch short with compression of the right L4/5 disc which can lead to pain in the nerve's distribution in the foot. 

See how the marker at L4/5 disc shows right side compression with lean of the lumbar spine to the right. This patient has Morton's Neuroma pain in the right foot in the 3rd metatarsal area, consistent with L 4/5 nerve pain.

The same patient above has a collapsed metatarsal arch also leading to possible nerve irritation at the foot level. The yellow line from the bottom of the 5th metatarsal to the bottom of the sesamoids should be the lowest points in the metatarsal arch. See how the 3rd and 4th metatarsal heads fall below this plane in your Plantar Axial Foot Xray. This patient could easily be irritating the nerve at the back and at the foot causing a "double crush syndrome."