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Ed--entrapped nerve therapy

Posted by wallyh on 9/17/01 at 08:07 (060677)

Ed,

Your suggestion about 4% alchol solution, 2-5 traetments into the area of the medial calcaneal nerve sounds good. Now, you said that this is a purely sensory nerve and this would 'deaden' it. Is this treatment primarily for relief from pain or can it be curative?

Thanks,
Wally

Re: Ed--entrapped nerve therapy

Pauline on 9/17/01 at 10:04 (060692)

Hi Dr. Ed.
Add my question on to Wally's. If this treatment is curative and does kill the nerve, how much (length from where to where?) of the nerve is dead and how much numbness in the foot or leg results? Which parts become numb? Is this tried before surgery? Is it possible to have a 1/2 killed nerve?

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 12:43 (060723)

Hi Wally

Before you have any shots for therapy did anyone do a diagnostic shot, or nerve conduction studies to make sure which nerves where entrapped?
Usually a neurologist, or a physiatrist would do the nerve testing. A pod could do a diagnostic shot with lidocain, etc.

I had similiar symptoms to you, and also had a positive squeeze test done, and the podiatrist said I probably have nerve entrapment. He wanted to do diagnostic shots with a mild anesthesia to determine which nerve was involved, but said if I was having any nerve conduction test to not have the shots, because they could affect the results.

I had the nerve conduction studies done, and it turned out that I had entrapment of the lateral plantar nerve, and one of it's brances, (baxters nerve.) This is considered Tarsal Tunnel if either the Posterial tibial nerve, or one one the brances are entrapped

I would think before you had any type of invasive nerve procedure like alcohol shots to deaden the nerve, it would be a good idea to find out what nerves are really entrapped. Also, it seems dangerous to me to kill nerves in that area, and other problems like numbness, atrohpy, etc. could result.

If it turns out that any of the nerves are entrapped I would think it would be better to try to reduce the inflammation around the nerves with a conservative approach, rather than deaden the nerve itself. I would think the nerves are needed to keep the muscles alive in your foot, etc. Once
the inflammation is reduced the nerve will start to function better. If demylination has taken place, then the nerve will have to heal also.

You could try things like Vioxx, icing the tarsal tunnel area, mild non steroid, or steroid injections, myofascial release, etc. I have had much of the inflammation reduced by a procedure called Active release technique (ART), meds, and acupunture. Also if the nerve is hypersensative, it's good to start taking meds like neurontin, and possibly nortripyline to calm the nerves down in addition to the vioxx. This will help with the pain, and also keep the nerves from becoming hypersensative, and having a chronic pain syndrome develop. What's important is to reduce the inflammation surrounding the nerve!

Maybe I'm wrong, and I hope Dr. Davis doesn't take offense, but it seems like killing the nerve is very invasive, and should be a last resort to take. Especially when you don't know which nerves are involved for sure. I would think killing a nerve may cause other problems. I know this is done with neuromas, but I've never heard this done in the tarsal tunnel area.

Donna

Re: Ed--entrapped nerve therapy

wallyh on 9/17/01 at 13:25 (060733)

Donna..Thanks for all the info. I have taken Vioxx and have had two shots of coritsone into the center of the heel. I've worn orthotics for a few months. I really want to avoid surgery. I have had relief and am taking a very conservate approach. It's been about five months now. The people I work for and the insurance company are breathing down my neck. I have as much trouble dealing with them as do my heel!! I go to see my podiatrist tomorrow, whom they are pressuring also. Wish me luck as he has to make a report. I am looking for ways to extend the home care I am doing (which I believe is sufficient) because I know if I return to work at this stage will probably re-injure myself...all my good work down the drain. I have followed all the regimens described in the book and even lost 25 lbs. It's just that this is a Worker's Compensation Case and right now I am a deficit to everyone financially. Throwing a lawyer into the mix will complicate things as it appears that the Commmission is on my side, so I am depending on my doctor to stretch this thing out for me, but to do so he may have to prescribe some therapy besides rest, taping, icing, weight loss etc.

Wally

Re: Walley --entrapped nerve therapy

Donna SL on 9/17/01 at 14:24 (060740)

Hi Wally

The shots in the center of the heel wouldn't help if they didn't target the area of entrapment. The entrapped nerves can cause pain symptoms in the heel, because they supply feeling to that area, especially the Baxter's nerve which is a branch off the lateral plantar nerve. The area your doctor squeezed is usally one of the areas where the entrapment occurs, and that may be a good area to target an injection, but more of the nerves may be involved.

Unfortuntly this is not an easy condition to cure quickley with conservative methods , but it can be done. The inflammation didn't occur overnight. It took a while to occur, and it can take just as long to get rid of it. A good multi-care approach is very important. You need to be very careful with cortisone in the TT area also, or too much cortisone in general.

Do you have a lot of pain in the heels? I had terrible pain all over my heels, especially the rims, and it took a long time before someone figured out it was nerve entrapment. Also the rest of my feet didn't feel so great either. It seems like whomever diagnosed you knew what they were doing. Now it's important to treat the area properly, and more agressively.

I don't know if you tried this, but if you haven't already you should try neuropathic drugs like neurontin, nortriptyline, etc. to help calm the nerves down, and reduce pain, and help them from developing a chronic pain syndrome. These drugs can be taken in addition to anti-inflammatories.

I just put this article on the tarsal tunnel area of the board, but this may help you understand why I recommend the neurontin, and other treaments. It's a little complicated, but full of excellent info.

http://www.helpforpain.com/articles/understand-neuropathic-pain/understanding.htm

It's also important to have an MRI to make sure there isn't some type of mass pressing on the area. This is probably unlikely, and hopefully once the inflammation is reduced around the nerves you should be ok, but an MRI should be done.

Donna

Re: Walley --entrapped nerve therapy

wallyh on 9/17/01 at 14:32 (060741)

had the mri too. Came back negative.
Thanks again, wally

Re: Walley --entrapped nerve therapy

Donna SL on 9/17/01 at 14:46 (060746)

Hi Wally

That's good. My MRI was negative too. Now it's important to have nerve conduction velocity testing, and an emg done. This may, or may not be positive. It depends if any demyelination has occurred to the nerves which would produce slowing on the testing results. Even if the test are negative you probably still have nerve entrapment which hopefully hasn't caused any damage to the nerves yet. Entrapment, and which nerves are involved can then hopefully be confirmed with diagnostic shots, but you should still proceed with the nerve testing first.

Also highly unlikely, and the inflammation is probably local, but radiculopathy should be ruled out also. This can be done when you are having the NCV/emg testing done on your feet/tts area.

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 15:15 (060752)

Wally and Donna:

The type of shots I have described have virtually no danger of atrophy.
Treating the area of pain generally has advantages to systemic treatment.
Vioxx is a good drug but tends to have little effect on nerve pain. The medial calcaneal nerve is extremely difficult to get an accurate NCV reading on due to its small size---The test would have little value.

Local treatment of the nerve is, depending on your perspective, really less invasive than taking a lot of oral medications, all of which have systemic effects.

Placing some lidocaine around the nerve for diagnostic purposes is a good idea.

The medial calcaneal nerve is a branch off the post. tibial nerve, so the procedure would not actually be done in the tarsal tunnel area. The area of potential numbness is very small and inconsequential to most.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 16:22 (060763)

Hi Dr. Davis,

I still think it would be a good idea to try to isolate what nerves are really involved before giving a shot randomly, and get a proper diagnosis. It may not be the medial calcaneal nerve at all, and other nerves may be involved. Also, maybe I'm wrong, but the way you described deadening the nerve with a chemical neurolysis sounded very invasive, and seems like it could possibly detroy the nerve rather the remove inflammation surrounding the nerve, and cause many long term problems. If the inflammation isn't removed somehow, how would this solve the problem long term? Did you actually mean reduce the inflammation around the nerve with the alcohol solution which would not touch, or harm the nerve itself?

If the actual nerve itself was destroyed who knows what problems down the road could occur? I have spoken to other doctors who have different opinions on using alcohol injections, and feel they are not that gentle of a solution, and are much more of an invasive approach that should not be used unless absolutely necessary. Again these are only opinions.

If it is determined which nerves are entrapped then injections could be considered. If you are only trying to destroy inflammation around the nerve, would alcohol injections still be the treatment of choice over cortisone? Do either of these have the potential of destoying the nerve?

I also understand the area of entrapment may be in one of the branches off the posterior tibial nerve, as was my case, and not in the actual tarsal tunnel area, and that's where the shot should be targeted. I still had a diagnosis of tarsal tunnel though. But it is important to try to determine what possible nerves are really involved first. Not everything shows on NCV test. Even though only the lateral plantar nerves, and the branches showed entrapment on testing, I had the entire area treated, and had acupuncture, and ART in the actual tarsal tunnel area too, which provided additional relief.

As far as meds, it's important to take the inflammation down in as many ways as possible to protect the nerve from further damage. As you know one shot may not do the trick, and many different steps may be needed to reduce the inflammation, and a multi-step approach is really necessary.

I'm very interested in different opinions on shots, and what works best. My symptoms have improved dramatically from conservative treatments, but I don't consider myself totally cured yet. This may be due to demyelination that occured in my nerves, and hopefully they just need to heal. If this isn't the case, and there is still some deep remaining inflammation, and this isn't a %100 resolved soon, I would consider some type of shots also.

Donna

Re: Ed--entrapped nerve therapy

wallyh on 9/17/01 at 17:24 (060773)

Ed,

Thanks a lot again. I feel more well-equipped for the visit to my doctor tomorrow.

Wally

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 19:12 (060791)

Donna:

You are making a lot of assumptions without really being familiar with the treatment process.

Shot are never given 'randomly' as you state. Obviously, we are not and cannot provide an exam over the internet. The doctor who provides the exam can by examination, isolate exactly which nerve is the problem. Another way to confirm that is to selectively block the nerve in question with lidocaine.

Inflammation in an area exists for a reason. If the cause of the inflammation can be isolated, then it can be treated. It is unlikely that an oral anti-inflammatory would do it though. A small amount of 'cortisone' can be injected around the area to relieve any local inflammation, if necessary.

If the nerve was 'destroyed' as you say, then the only problem down the road is a small area of numbness. Again, it is a small sensory nerve. This procedure would not be utilized for TTS. Secondly, it is not necessary to completely destroy the nerve in order to desensitize it. Third, very few would consider such a shot to be an invasive procedure (any breaking of the skin could be considered invasive, if you wish). Finally NCV testing has a very small possiblity of providing accurate information on the medial calcaneal nerves.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 20:46 (060809)

Dr. Davis,

With all due respect It seems that you were making assumptions that it was only the medial calcaneal nerve that was entrapped, and suggesting a chemical neurolysis of that specific nerve as stated in your prior post, without suggestion of further investigation. As I mentioned before, I had a positive squeeze test too, yet many other nerves were involved. One definition of neurolysis is disintegration of nerve tissue. Another is surgical separation of adhesions from a nerve fiber. Also exhaustion of the nerve by execss stimulation is another definition. My question is would the chemical neurolysis destroy the nerve, or just remove the surrounding inflammation if alcohol was used? Would cortisone have the same effect?

If you are referring to all nerves off the posterior tib as the medial calcaneal nerves that is one thing, but the medial calcaneal nerve is actually only one of several nerves in that area that only supplies feeling to the skin of the calcaneous. This nerve would not cause the severe heel/foot pain that is often felt, so what would be the purpose of only targeting this nerve? There is also the medial, and lateral plantar nerves, and the associated branches, among many other nerves in the foot.

That's why I had recommended test like NCV testing, or diagnostic shots to determine which nerves are involved. Why not at least try to have a NCV test to determine the extent of the entrapment, or if any damage has occured. Once anti-inflammatory meds are injected this would make any testing more difficult by affecting the results.

When the podiatrist at the pod school diagnosed me manually his first recommendation was that if I decided to get the associated nerve testing done then do that first, and if it comes back negative, then the next step would be to do only diagnostic testing with injections to determine for sure what nerves were involved. Then we would take it from there. He also didn't think anything would show on NCV test, but it did.

I think it is really difficult to make a predictions, or guarantees on little, or no complications on any nerve injury that could possibly result after a chemical nerve neurolysis, and if your definition of nerve neuroloysis includes disintegration of that nerve, it should be avoided, unless absolutely necessary. Even if a small bit of numbness resulted why should that risk be taken before other methods are tried?

Also, I still stick with the multi-care approach including meds, etc.. I have nothing against shots if that is the only alternative. But, if a couple of shots was all that it took, then why are so many people not getting permanent resolution of their pain from these shots, and many of them resorting to surgery, or continuous suffering?

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 21:24 (060813)

Donna:

Sorry, but I must again state that what the doctors can do here is to provide information based on what treatments are effective for specific situations, specific problems. We cannot diagnose and treat people we have never seen over the internet. That is not the intent of this site and not the intent of our posts. I have never made the assumption that 'only the medial calcaneal nerve' was entrapped. I provided a potential treatment for a potential diagnosis--that is all. A 'squeeze' test is only one of many things a doctor would do in an exam. We are not formulating a diagnosis based on that test nor do we offer diagnoses, over the internet, based on the very limited information that is provided to us. I, as well as other doctors posting on this site are trying to provide information as to how diagnoses are arrived at but we cannot provide a specific diagnosis for questioners. We encourage questioners to obtain a complete and appropriate exam from qualified practitioners.

If the medial calcaneal nerve is indeed a problem in a patient, then it can cause considerable heel pain and targeting it can potentially cure that pain. Where do you get the information to support your statement that 'this nerve would not cause the severe heel/foot pain that is often felt?' A thorough exam can determine if the problem is caused by the medial calcaneal nerve, other nerves or some other cause. There is absolutely no reason to target nerves which have no contribution to the problem.

Why do you insist on recommending a test that is highly unlikely to provide an accurate result. I think people sometimes refer to that as 'unecessary testing.' You cannot compare the medial and lateral plantar nerves to the medial calcaneal nerve.

I am not making 'guarantees on little, or no complications on any nerve injury...' as you state. What we have to go by, is past treatment results and statistics and whether you like it or not, the treatment I have discussed is a highly successful modality with a very low complication rate when used appropriately.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 22:32 (060819)

Dr Davis,

I don't understand why you are so against diagnostic testing like NCV testing? What if the pain was from the Baxter's nerve for example instead of the medial calcaneal nerve? That would be missed with the other injection. What is they indeed did have TTS, or peripherial neuropathy instead of just one nerve involved? I had varying opinions until it was confirmed with these test. No one thought I had TTS until I had these test done. Just going ahead with some type of injection with a strong chemical before doing a full evaluation is like a shot gun approach. A physical exam is a good start, but if there are other methods to get a more definitive diagnosis why not do them? Again I know you are only making suggestions to this board, and have not examined the patient, but I see no recommendation of diagnostic testing, or shots in your initial post.

I am aware of many people who have had surgeries, ESWT for PF, tarsal tunnel surgery, etc, and a lot of these surgeries failed for one reason or another, and in many cases a proper diagnosis of the condition hadn't been made before these procedures were done. If more diagnostic test that you seem to think are so unnecessary were done, then a lot of pain and suffering could be avoided.

There is nothing wrong with suggesting successful treatments that you have tried, and I'm sure everyone appreciates your input immensely, but full diagnostic testing should be encouraged first before attempting any type of an invasive procedure.

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 23:12 (060821)

Donna:
I am writing things here but you are not reading what I am writing--you just keep repeating the same irrespective of what I am posting.

I never said that I was against NCV testing. It is something that may be of benefit provided the clinical signs warrant it. If the clinical signs demonstrate a neuritis, limited only to the medial calcaneal nerve, then NCV testing is not likely to be fruitful. We do not just do tests because a test happened to show your particular problem.

For the umpteenth and final time we are not recommending 'just going ahead with some injection of a strong chemical before doing a full evaluation.' I have stated repeatedly that a full exam needs to be done before moving forward with treatment, but you chose to ignore what I am posting.

My initial post discussed a hypothetical treatment for a potential problem. I never instructed anyone to move forward with any treatment without first obtaining a proper diagnosis. We do not have the time nor resources to provide a complete scenario for every possible situation. Obviously, you insist on holding me to that standard. I am not paid to provide such a service but am here to help people who pose specific questions about particular scenarios. Despite your claim of appreciation, your expectations of what I can do here is completely unrealistic.

At this point I will not respond to your posts. If you insist on entering into conversations on posts from other individuals I will refrain from further responses. If you insist on further distortions of the information I have provided here, I will withdraw from this site on a permanent basis unless Scott blocks your posts.
Ed

Re: Ed- -entrapped nerve therapy- every one should be able to give their opinion

Donna SL on 9/18/01 at 03:03 (060826)

Dr Davis

I don't really care if you respond to my post at this point, and don't feel it is necessary that you do so. It is quite obvious at this point that you have not taken the time to carefully read my post.

What I do know is that you have constantly been contradicting yourself throughout the last few threads on this issue of nerve entrapment, and have not welcomed any suggestions, or opinions from me. You only see any additional recommendations that I have made to others as a plot to distort your prior posts which is the furthest thing from my mind.

I will give some examples. In this very post you said you are not against NCV testing yet in the prior post #60813 you criticized me for
recommending a NCV test after I stated my opinion of why I thought they were important, and gave very specific reasons, in post # 's 60809,
60763, 60723, 60646 ,etc.

Another example was from a the post under 'nerve entrapment' #60214, where you make a suggestion that it may be the medial calcaneal nerve that is involved, and keep referring to that particular nerve in future post, and then in the post 'it looks like a medial calcaneal nerve' #60307 you suggest alcohol injections work well for that type of problem.

All I did was recommend that further diagnostic testing should be done to make sure other nerves weren't entrapped, and also make sure there were
no other problems that are not always obvious like peripheral neuropathy, TTS, radiculopathy, etc. In my case I did have a past radiculopathy, and existing TTS, and no one ever imagined that was possible before I was tested, and simple NCV/EMG showed this. Also as I stated before any prior anti-inflammatory injections prior to this testing could have distorted these test.

I know other doctors in the past on this board have always stressed the importance of thorough testing in these areas. Only after I mentioned further diagnostic testing did you endorse that on this particular thread. Also, I was just questioning the safety, and necessity of chemical neurolyosis of that nerve at this point, and the effects, and you took this very defensively.

You also have negated, and discouraged other treatments that have proved successful, and helpful to me, and maybe to others like medications that have been recommended to me by very highly respected practitioners.

As far as your point on me entering into conversations on post from other individuals I thought the purpose of this board was the free exchange of
information, and I don't think anyone would see that I have distorted your post in any way. I also have not challenged you, or put you down. I have only provided a counter opinion, and additional recommendations. I think I provided some very intensive, and helpful information. You have only been very defensive of almost every bit of information I have offered.

I don't think anyone should be discouraged, or threatened from offering their opinion, and help on this board.

Donna

Re: Ed- -entrapped nerve therapy- every one should be able to give their opinion

Carol C on 9/20/01 at 19:52 (061104)

Donna,
Just curious....What are your credentials for providing the information that you do. Your license is in what?

Re: Ed--entrapped nerve therapy

Pauline on 9/17/01 at 10:04 (060692)

Hi Dr. Ed.
Add my question on to Wally's. If this treatment is curative and does kill the nerve, how much (length from where to where?) of the nerve is dead and how much numbness in the foot or leg results? Which parts become numb? Is this tried before surgery? Is it possible to have a 1/2 killed nerve?

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 12:43 (060723)

Hi Wally

Before you have any shots for therapy did anyone do a diagnostic shot, or nerve conduction studies to make sure which nerves where entrapped?
Usually a neurologist, or a physiatrist would do the nerve testing. A pod could do a diagnostic shot with lidocain, etc.

I had similiar symptoms to you, and also had a positive squeeze test done, and the podiatrist said I probably have nerve entrapment. He wanted to do diagnostic shots with a mild anesthesia to determine which nerve was involved, but said if I was having any nerve conduction test to not have the shots, because they could affect the results.

I had the nerve conduction studies done, and it turned out that I had entrapment of the lateral plantar nerve, and one of it's brances, (baxters nerve.) This is considered Tarsal Tunnel if either the Posterial tibial nerve, or one one the brances are entrapped

I would think before you had any type of invasive nerve procedure like alcohol shots to deaden the nerve, it would be a good idea to find out what nerves are really entrapped. Also, it seems dangerous to me to kill nerves in that area, and other problems like numbness, atrohpy, etc. could result.

If it turns out that any of the nerves are entrapped I would think it would be better to try to reduce the inflammation around the nerves with a conservative approach, rather than deaden the nerve itself. I would think the nerves are needed to keep the muscles alive in your foot, etc. Once
the inflammation is reduced the nerve will start to function better. If demylination has taken place, then the nerve will have to heal also.

You could try things like Vioxx, icing the tarsal tunnel area, mild non steroid, or steroid injections, myofascial release, etc. I have had much of the inflammation reduced by a procedure called Active release technique (ART), meds, and acupunture. Also if the nerve is hypersensative, it's good to start taking meds like neurontin, and possibly nortripyline to calm the nerves down in addition to the vioxx. This will help with the pain, and also keep the nerves from becoming hypersensative, and having a chronic pain syndrome develop. What's important is to reduce the inflammation surrounding the nerve!

Maybe I'm wrong, and I hope Dr. Davis doesn't take offense, but it seems like killing the nerve is very invasive, and should be a last resort to take. Especially when you don't know which nerves are involved for sure. I would think killing a nerve may cause other problems. I know this is done with neuromas, but I've never heard this done in the tarsal tunnel area.

Donna

Re: Ed--entrapped nerve therapy

wallyh on 9/17/01 at 13:25 (060733)

Donna..Thanks for all the info. I have taken Vioxx and have had two shots of coritsone into the center of the heel. I've worn orthotics for a few months. I really want to avoid surgery. I have had relief and am taking a very conservate approach. It's been about five months now. The people I work for and the insurance company are breathing down my neck. I have as much trouble dealing with them as do my heel!! I go to see my podiatrist tomorrow, whom they are pressuring also. Wish me luck as he has to make a report. I am looking for ways to extend the home care I am doing (which I believe is sufficient) because I know if I return to work at this stage will probably re-injure myself...all my good work down the drain. I have followed all the regimens described in the book and even lost 25 lbs. It's just that this is a Worker's Compensation Case and right now I am a deficit to everyone financially. Throwing a lawyer into the mix will complicate things as it appears that the Commmission is on my side, so I am depending on my doctor to stretch this thing out for me, but to do so he may have to prescribe some therapy besides rest, taping, icing, weight loss etc.

Wally

Re: Walley --entrapped nerve therapy

Donna SL on 9/17/01 at 14:24 (060740)

Hi Wally

The shots in the center of the heel wouldn't help if they didn't target the area of entrapment. The entrapped nerves can cause pain symptoms in the heel, because they supply feeling to that area, especially the Baxter's nerve which is a branch off the lateral plantar nerve. The area your doctor squeezed is usally one of the areas where the entrapment occurs, and that may be a good area to target an injection, but more of the nerves may be involved.

Unfortuntly this is not an easy condition to cure quickley with conservative methods , but it can be done. The inflammation didn't occur overnight. It took a while to occur, and it can take just as long to get rid of it. A good multi-care approach is very important. You need to be very careful with cortisone in the TT area also, or too much cortisone in general.

Do you have a lot of pain in the heels? I had terrible pain all over my heels, especially the rims, and it took a long time before someone figured out it was nerve entrapment. Also the rest of my feet didn't feel so great either. It seems like whomever diagnosed you knew what they were doing. Now it's important to treat the area properly, and more agressively.

I don't know if you tried this, but if you haven't already you should try neuropathic drugs like neurontin, nortriptyline, etc. to help calm the nerves down, and reduce pain, and help them from developing a chronic pain syndrome. These drugs can be taken in addition to anti-inflammatories.

I just put this article on the tarsal tunnel area of the board, but this may help you understand why I recommend the neurontin, and other treaments. It's a little complicated, but full of excellent info.

http://www.helpforpain.com/articles/understand-neuropathic-pain/understanding.htm

It's also important to have an MRI to make sure there isn't some type of mass pressing on the area. This is probably unlikely, and hopefully once the inflammation is reduced around the nerves you should be ok, but an MRI should be done.

Donna

Re: Walley --entrapped nerve therapy

wallyh on 9/17/01 at 14:32 (060741)

had the mri too. Came back negative.
Thanks again, wally

Re: Walley --entrapped nerve therapy

Donna SL on 9/17/01 at 14:46 (060746)

Hi Wally

That's good. My MRI was negative too. Now it's important to have nerve conduction velocity testing, and an emg done. This may, or may not be positive. It depends if any demyelination has occurred to the nerves which would produce slowing on the testing results. Even if the test are negative you probably still have nerve entrapment which hopefully hasn't caused any damage to the nerves yet. Entrapment, and which nerves are involved can then hopefully be confirmed with diagnostic shots, but you should still proceed with the nerve testing first.

Also highly unlikely, and the inflammation is probably local, but radiculopathy should be ruled out also. This can be done when you are having the NCV/emg testing done on your feet/tts area.

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 15:15 (060752)

Wally and Donna:

The type of shots I have described have virtually no danger of atrophy.
Treating the area of pain generally has advantages to systemic treatment.
Vioxx is a good drug but tends to have little effect on nerve pain. The medial calcaneal nerve is extremely difficult to get an accurate NCV reading on due to its small size---The test would have little value.

Local treatment of the nerve is, depending on your perspective, really less invasive than taking a lot of oral medications, all of which have systemic effects.

Placing some lidocaine around the nerve for diagnostic purposes is a good idea.

The medial calcaneal nerve is a branch off the post. tibial nerve, so the procedure would not actually be done in the tarsal tunnel area. The area of potential numbness is very small and inconsequential to most.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 16:22 (060763)

Hi Dr. Davis,

I still think it would be a good idea to try to isolate what nerves are really involved before giving a shot randomly, and get a proper diagnosis. It may not be the medial calcaneal nerve at all, and other nerves may be involved. Also, maybe I'm wrong, but the way you described deadening the nerve with a chemical neurolysis sounded very invasive, and seems like it could possibly detroy the nerve rather the remove inflammation surrounding the nerve, and cause many long term problems. If the inflammation isn't removed somehow, how would this solve the problem long term? Did you actually mean reduce the inflammation around the nerve with the alcohol solution which would not touch, or harm the nerve itself?

If the actual nerve itself was destroyed who knows what problems down the road could occur? I have spoken to other doctors who have different opinions on using alcohol injections, and feel they are not that gentle of a solution, and are much more of an invasive approach that should not be used unless absolutely necessary. Again these are only opinions.

If it is determined which nerves are entrapped then injections could be considered. If you are only trying to destroy inflammation around the nerve, would alcohol injections still be the treatment of choice over cortisone? Do either of these have the potential of destoying the nerve?

I also understand the area of entrapment may be in one of the branches off the posterior tibial nerve, as was my case, and not in the actual tarsal tunnel area, and that's where the shot should be targeted. I still had a diagnosis of tarsal tunnel though. But it is important to try to determine what possible nerves are really involved first. Not everything shows on NCV test. Even though only the lateral plantar nerves, and the branches showed entrapment on testing, I had the entire area treated, and had acupuncture, and ART in the actual tarsal tunnel area too, which provided additional relief.

As far as meds, it's important to take the inflammation down in as many ways as possible to protect the nerve from further damage. As you know one shot may not do the trick, and many different steps may be needed to reduce the inflammation, and a multi-step approach is really necessary.

I'm very interested in different opinions on shots, and what works best. My symptoms have improved dramatically from conservative treatments, but I don't consider myself totally cured yet. This may be due to demyelination that occured in my nerves, and hopefully they just need to heal. If this isn't the case, and there is still some deep remaining inflammation, and this isn't a %100 resolved soon, I would consider some type of shots also.

Donna

Re: Ed--entrapped nerve therapy

wallyh on 9/17/01 at 17:24 (060773)

Ed,

Thanks a lot again. I feel more well-equipped for the visit to my doctor tomorrow.

Wally

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 19:12 (060791)

Donna:

You are making a lot of assumptions without really being familiar with the treatment process.

Shot are never given 'randomly' as you state. Obviously, we are not and cannot provide an exam over the internet. The doctor who provides the exam can by examination, isolate exactly which nerve is the problem. Another way to confirm that is to selectively block the nerve in question with lidocaine.

Inflammation in an area exists for a reason. If the cause of the inflammation can be isolated, then it can be treated. It is unlikely that an oral anti-inflammatory would do it though. A small amount of 'cortisone' can be injected around the area to relieve any local inflammation, if necessary.

If the nerve was 'destroyed' as you say, then the only problem down the road is a small area of numbness. Again, it is a small sensory nerve. This procedure would not be utilized for TTS. Secondly, it is not necessary to completely destroy the nerve in order to desensitize it. Third, very few would consider such a shot to be an invasive procedure (any breaking of the skin could be considered invasive, if you wish). Finally NCV testing has a very small possiblity of providing accurate information on the medial calcaneal nerves.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 20:46 (060809)

Dr. Davis,

With all due respect It seems that you were making assumptions that it was only the medial calcaneal nerve that was entrapped, and suggesting a chemical neurolysis of that specific nerve as stated in your prior post, without suggestion of further investigation. As I mentioned before, I had a positive squeeze test too, yet many other nerves were involved. One definition of neurolysis is disintegration of nerve tissue. Another is surgical separation of adhesions from a nerve fiber. Also exhaustion of the nerve by execss stimulation is another definition. My question is would the chemical neurolysis destroy the nerve, or just remove the surrounding inflammation if alcohol was used? Would cortisone have the same effect?

If you are referring to all nerves off the posterior tib as the medial calcaneal nerves that is one thing, but the medial calcaneal nerve is actually only one of several nerves in that area that only supplies feeling to the skin of the calcaneous. This nerve would not cause the severe heel/foot pain that is often felt, so what would be the purpose of only targeting this nerve? There is also the medial, and lateral plantar nerves, and the associated branches, among many other nerves in the foot.

That's why I had recommended test like NCV testing, or diagnostic shots to determine which nerves are involved. Why not at least try to have a NCV test to determine the extent of the entrapment, or if any damage has occured. Once anti-inflammatory meds are injected this would make any testing more difficult by affecting the results.

When the podiatrist at the pod school diagnosed me manually his first recommendation was that if I decided to get the associated nerve testing done then do that first, and if it comes back negative, then the next step would be to do only diagnostic testing with injections to determine for sure what nerves were involved. Then we would take it from there. He also didn't think anything would show on NCV test, but it did.

I think it is really difficult to make a predictions, or guarantees on little, or no complications on any nerve injury that could possibly result after a chemical nerve neurolysis, and if your definition of nerve neuroloysis includes disintegration of that nerve, it should be avoided, unless absolutely necessary. Even if a small bit of numbness resulted why should that risk be taken before other methods are tried?

Also, I still stick with the multi-care approach including meds, etc.. I have nothing against shots if that is the only alternative. But, if a couple of shots was all that it took, then why are so many people not getting permanent resolution of their pain from these shots, and many of them resorting to surgery, or continuous suffering?

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 21:24 (060813)

Donna:

Sorry, but I must again state that what the doctors can do here is to provide information based on what treatments are effective for specific situations, specific problems. We cannot diagnose and treat people we have never seen over the internet. That is not the intent of this site and not the intent of our posts. I have never made the assumption that 'only the medial calcaneal nerve' was entrapped. I provided a potential treatment for a potential diagnosis--that is all. A 'squeeze' test is only one of many things a doctor would do in an exam. We are not formulating a diagnosis based on that test nor do we offer diagnoses, over the internet, based on the very limited information that is provided to us. I, as well as other doctors posting on this site are trying to provide information as to how diagnoses are arrived at but we cannot provide a specific diagnosis for questioners. We encourage questioners to obtain a complete and appropriate exam from qualified practitioners.

If the medial calcaneal nerve is indeed a problem in a patient, then it can cause considerable heel pain and targeting it can potentially cure that pain. Where do you get the information to support your statement that 'this nerve would not cause the severe heel/foot pain that is often felt?' A thorough exam can determine if the problem is caused by the medial calcaneal nerve, other nerves or some other cause. There is absolutely no reason to target nerves which have no contribution to the problem.

Why do you insist on recommending a test that is highly unlikely to provide an accurate result. I think people sometimes refer to that as 'unecessary testing.' You cannot compare the medial and lateral plantar nerves to the medial calcaneal nerve.

I am not making 'guarantees on little, or no complications on any nerve injury...' as you state. What we have to go by, is past treatment results and statistics and whether you like it or not, the treatment I have discussed is a highly successful modality with a very low complication rate when used appropriately.
Ed

Re: Ed--entrapped nerve therapy

Donna SL on 9/17/01 at 22:32 (060819)

Dr Davis,

I don't understand why you are so against diagnostic testing like NCV testing? What if the pain was from the Baxter's nerve for example instead of the medial calcaneal nerve? That would be missed with the other injection. What is they indeed did have TTS, or peripherial neuropathy instead of just one nerve involved? I had varying opinions until it was confirmed with these test. No one thought I had TTS until I had these test done. Just going ahead with some type of injection with a strong chemical before doing a full evaluation is like a shot gun approach. A physical exam is a good start, but if there are other methods to get a more definitive diagnosis why not do them? Again I know you are only making suggestions to this board, and have not examined the patient, but I see no recommendation of diagnostic testing, or shots in your initial post.

I am aware of many people who have had surgeries, ESWT for PF, tarsal tunnel surgery, etc, and a lot of these surgeries failed for one reason or another, and in many cases a proper diagnosis of the condition hadn't been made before these procedures were done. If more diagnostic test that you seem to think are so unnecessary were done, then a lot of pain and suffering could be avoided.

There is nothing wrong with suggesting successful treatments that you have tried, and I'm sure everyone appreciates your input immensely, but full diagnostic testing should be encouraged first before attempting any type of an invasive procedure.

Donna

Re: Ed--entrapped nerve therapy

Ed Davis, DPM on 9/17/01 at 23:12 (060821)

Donna:
I am writing things here but you are not reading what I am writing--you just keep repeating the same irrespective of what I am posting.

I never said that I was against NCV testing. It is something that may be of benefit provided the clinical signs warrant it. If the clinical signs demonstrate a neuritis, limited only to the medial calcaneal nerve, then NCV testing is not likely to be fruitful. We do not just do tests because a test happened to show your particular problem.

For the umpteenth and final time we are not recommending 'just going ahead with some injection of a strong chemical before doing a full evaluation.' I have stated repeatedly that a full exam needs to be done before moving forward with treatment, but you chose to ignore what I am posting.

My initial post discussed a hypothetical treatment for a potential problem. I never instructed anyone to move forward with any treatment without first obtaining a proper diagnosis. We do not have the time nor resources to provide a complete scenario for every possible situation. Obviously, you insist on holding me to that standard. I am not paid to provide such a service but am here to help people who pose specific questions about particular scenarios. Despite your claim of appreciation, your expectations of what I can do here is completely unrealistic.

At this point I will not respond to your posts. If you insist on entering into conversations on posts from other individuals I will refrain from further responses. If you insist on further distortions of the information I have provided here, I will withdraw from this site on a permanent basis unless Scott blocks your posts.
Ed

Re: Ed- -entrapped nerve therapy- every one should be able to give their opinion

Donna SL on 9/18/01 at 03:03 (060826)

Dr Davis

I don't really care if you respond to my post at this point, and don't feel it is necessary that you do so. It is quite obvious at this point that you have not taken the time to carefully read my post.

What I do know is that you have constantly been contradicting yourself throughout the last few threads on this issue of nerve entrapment, and have not welcomed any suggestions, or opinions from me. You only see any additional recommendations that I have made to others as a plot to distort your prior posts which is the furthest thing from my mind.

I will give some examples. In this very post you said you are not against NCV testing yet in the prior post #60813 you criticized me for
recommending a NCV test after I stated my opinion of why I thought they were important, and gave very specific reasons, in post # 's 60809,
60763, 60723, 60646 ,etc.

Another example was from a the post under 'nerve entrapment' #60214, where you make a suggestion that it may be the medial calcaneal nerve that is involved, and keep referring to that particular nerve in future post, and then in the post 'it looks like a medial calcaneal nerve' #60307 you suggest alcohol injections work well for that type of problem.

All I did was recommend that further diagnostic testing should be done to make sure other nerves weren't entrapped, and also make sure there were
no other problems that are not always obvious like peripheral neuropathy, TTS, radiculopathy, etc. In my case I did have a past radiculopathy, and existing TTS, and no one ever imagined that was possible before I was tested, and simple NCV/EMG showed this. Also as I stated before any prior anti-inflammatory injections prior to this testing could have distorted these test.

I know other doctors in the past on this board have always stressed the importance of thorough testing in these areas. Only after I mentioned further diagnostic testing did you endorse that on this particular thread. Also, I was just questioning the safety, and necessity of chemical neurolyosis of that nerve at this point, and the effects, and you took this very defensively.

You also have negated, and discouraged other treatments that have proved successful, and helpful to me, and maybe to others like medications that have been recommended to me by very highly respected practitioners.

As far as your point on me entering into conversations on post from other individuals I thought the purpose of this board was the free exchange of
information, and I don't think anyone would see that I have distorted your post in any way. I also have not challenged you, or put you down. I have only provided a counter opinion, and additional recommendations. I think I provided some very intensive, and helpful information. You have only been very defensive of almost every bit of information I have offered.

I don't think anyone should be discouraged, or threatened from offering their opinion, and help on this board.

Donna

Re: Ed- -entrapped nerve therapy- every one should be able to give their opinion

Carol C on 9/20/01 at 19:52 (061104)

Donna,
Just curious....What are your credentials for providing the information that you do. Your license is in what?