12.12.2013

Medicine for nerve pain in arm joints

Baxter’s neuropathy is entrapment of a local nerve under the heel by the plantar fascia. Have you ever wondered why there are so any recommendations and treatments for plantar fasciosis?
You’ve probably come to the realization that a lot more goes into the diagnosis and treatment of plantar fasciosis than you once thought. Can I ask: The onset of my foot symptoms coincided with a new and intensive treatment regime for CFS which included huge doses of B12 and magnesium by injection, as well as a slew of other dietary supplements. BTW my primary point of pain seems to be atypical as it is more up the back of the heal rather than the bottom (although the sole of the foot is somewhat painful as well). If you manage this site and have a question about why the site is not available, please contact us directly. This entry was posted in Anatomy, Ortho, Rheumatology and tagged MSK, physical exam, rotator cuff by Ali. CopyrightUse these images to learn, but if you want to use them on your own website please credit me! DisclaimerAll of the information on this website is purely for educational purposes and has not been peer-reviewed.
Out come the summer athletes, weekend warriors and even the average folk that spend time cutting the grass or gardening.
A 2013 study in the medical journal,┬áSkeletal Radiology, found degenerative changes via diagnostic ultrasound in the plantar fascia at various areas of the foot including the insertion (heel) and non insertional sites (other attachment points on the foot). Heel spurs are worse when walking on the heels, during heel strike and at the end of the days. Three areas that can refer pain into the heel include the tarsal tunnel (posterior tibial nerve), Baxter’s nerve, and the low back (4, 5). The nerve supplies the muscles of the little toe; therefore, entrapment affects little toe motion (4). The low back must be ruled out first otherwise a patient could go weeks to months of care and never get at the true culprit for why they have heel pain. We see stress fractures of the heel typically with runners, triathletes, and in impact sports (basketball, volleyball, dance, cheerleading, poms, etc.).


The application here is that multiple different paths all lead to the same end result of plantar fasciosis.
Blanket, one size fits all recommendations usually don’t work well for this condition.
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For example, a recent post we found had recommendations for ice, Motrin, and stretching for a woman in her mid 30’s with a 4-5 month history of bilateral (both sided) plantar fasciosis that had not seen a medical or allied health provider.
Often, the first step in identification is a comprehensive exam followed by X-rays comparing right to left.
Please find a medical or allied health provider (medical doctor, osteopath, chiropractor, podiatrist, physical therapist, athletic trainer, body worker, etc.) that understands these concepts. The pain gets worse with a transition from sitting to standing and during the first several steps that a patient walks.
Patients typically don’t inherit mechanics from their parents nor do they get their faulty mechanics from their brother. Heel spurs tend to hurt at the end of the day as opposed to plantar fasciosis which hurts after periods of rest including first thing in the morning. Second, ┬árecommendations call for a comprehensive blood work with the addition of an autoimmune panel. Stress fractures present with progressively worsening pain with increased activity and with activity on harder surfaces. Patients develop their mechanics during the development process (sitting up-turning over-crawling-standing-walking), with lifestyle based factors (our American sedentary based lifestyle) or from repetitive postures and positions assumed.
The posterior tibial nerve can be stretched, compressed or entrapped leading to referred pain in the heel that is not due to plantar fasciosis. Plantar fasciosis and stress fractures have the location of pain as similar, but stress fractures differ in the the intensity of pain combined with the reports of worse with increased activity and hard surfaces. Typically, conservative treatments (no drugs – no surgery options) are the best and first line treatments (5, 6, 7, 8, 9).
A simple test to screen for stress fractures is to squeeze the heel between the thumb and index finger comparing side to side for increased pain.


A bone scan for a stress fracture should be considered if the history matches up plus there is a difference side to side with the heel squeeze test. Biopsies performed at the time of surgery combined with diagnostic ultrasound studies show long standing degenerative changes to the tissues of the plantar fascia WITHOUT INFLAMMATION.
Heel spurs despite looking rather sinister on X-rays may not even be a source of pain; so, seeing one on an X-ray is not a definitive reason to surgically remove the spur, inject the area with cortisone, nor recommend other aggressive treatment options. Posterior tibial neuritis (inflammation of the nerve) or tarsal tunnel syndrome is worse with standing, walking, weight bearing and repetitive use. We can also recommend supplementation along with dietary changes to reduce local and systemic inflammation. The recommendation for anti inflammatory medication (Motrin, Advil, Aleve, Aspirin, Celebrex, Viox, Indomethacin, Toradol, oral steroids, etc.), steroid injections, and even ice may not be the best treatments for degenerative conditions. These treatments attempt to limit inflammation; however, inflammation is not the real culprit.
Actually, we may want to induce inflammation and induce more blood flow to the area to jump start the healing process.
Fourth, a 1-2 week trial of care of ice, Motrin, and rest is probably not enough to reduce the pain from a mechanical problem as long standing as this one. Maybe, the treatment should focus on the pathway to get to plantar fasciosis rather than treating the plantar fasciosis itself. Treatments that induce inflammation and blood flow to the area include deep tissue massage, Graston, Active Release Techniques, shock wave therapy, dry needling, acupuncture, heat, laser therapy, and PRP injections). Plantar fasciosis is described as dull, aching pain at rest that turns to sharp and stabbing pain when transitioning up and walking the first couple steps.
The key is finding someone who understands that a one size fits all approach doesn’t help the patient.




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