the singing podiatrist.com

the foot stuff

chronic pain

Foot pain can take a long long time to heal. Many foot injuries require months of proper treatment - usually rest from weightbearing, sometimes orthotics and shoe change, sometimes physiotherapy or massage. Try not to be discouraged. If you're not healing as quickly as you think you should, consider getting a second opinion, but most definitely speak to the person who is treating you and express your frustration. Certainly don't "jump around" from practitioner to practitioner looking for a "cure". Alleviating foot pain may require a step-wise approach - you need to find someone you trust and follow recommendations that are made. At least that way you will find out what doesn't work. Some people end up getting relief with natural treatment approaches, and sometimes time is the only healer. If you truly think that you have an injury that will not heal you might consider asking your doctor for a referral to a pain clinic. The condition listed below is rare but can be a cause of chronic pain in some people.

chronic regional pain syndrome (CRPS)

"... a rare condition, but absolutely essential that it be recognized as early as possible"

Definition

This is a chronic pain condition that results after an injury (usually minor) or surgery. It used to be called RSD - reflex sympathetic dystrophy, but it is now known that the "sympathetic" nervous system is not the only area involved so the name has been changed. If you have had a minor injury like an ankle sprain or a routine surgery and your foot has become extremely hypersensitive and either swollen, cold, hot, or red, you may have this condition. It is extremely rare however, and most of the symptoms listed below can also be caused by other conditions.

Past history of a minor injury or surgery that results in prolonged and severe pain. The pain is way out of proportion to what it should be for the seriousness of the injury - eg. most foot and ankle sprains and injuries will heal and pain will decrease within the first 2 to 3 months (unless you reinjure it). With CRPS the pain seems to get worse over time. Also, the pain will usually spread beyond the original area of injury - eg. an initial ankle sprain will start to hurt in the toes and all over the foot.

Pain is burning, dull, aching, throbbing and/or piercing and may be very sensitive to pressure from sheets or even a breeze. Pain is usually aggravated by cold, touch, movement and emotional stress. Early on the pain is mild and as it progresses the severity increases.

Skin is usually cold, mottled (purplish) and may be swollen. It could also be hot and red at times.

Possible muscle spasms and tremors or bruising.

Generally speaking, you may start to feel like you're going crazy - you are resting from the injury or surgery and the pain is getting worse. It seems to be there all the time and is particularly bad at night (when you have less distractions). Noone understands how much pain you're in and your life has really been put on hold.

What You Should Do

If you think you may have this condition in your foot, see your local podiatrist, family doctor or physio. Surgeons and neurologists are generally aware of this condition. Your local physiotherapist can help immensely - they must be familiar with the specifics of how to treat this condition. In larger centres there will be pain clinics (some are not covered under medical). The longer you wait and fool around with treatments like icing (very bad), elevation (not extremely helpful), rest (will not alleviate this condition), anti-inflammatories (Advil, Ibuprofen) the less likely the problem will go away. Some people progress slowly and sometimes it does resolve on its own. But, if you've had this pain for more than a few months and it is accompanied by the unusual symptoms listed above, find someone who knows how to diagnose and treat CRPS.

In Vancouver, St. Paul's Hospital has a clinic dedicated to treating CRPS. The waiting list is long to see the pain doctors, but you can get in to see the physios who are specially trained to deal with this condition (and often they can alleviate your symptoms before you even need to see a doctor).

What Your Practitioner May Do

Take an x-ray and/or bone scan. These tests can identify CRPS in some cases and identify fractures or other conditions that may be causing your pain rather than CRPS. A test used in the past to diagnosis this condition was a sympathetic nerve block (needle into the sympathetic nerve centre in the back). This test is no longer considered to be useful for diagnosing this condition.

Refer you for physiotherapy (in the early stages) - St. Paul's Hospital in Vancouver is a good place to go. There may be other centres that I'm not aware of. Any pain clinic would also be appropriate - but the wait may be too long or the cost too high.

Prescribe medications. Generally, anti-inflammatories will not work. Sometimes oral steroids in early cases will help. Sleeping medication may be helpful if sleep is disturbed. There are some specific medications that may help - however, these must be prescribed by a knowledgeable physician. Most people do not respond to pain medication (codeine, etc)

First and foremost: These exercises should be done on the recommendation of a physio or physician who has assessed you and designed a specific treatment plan. Everyone with this condition is different. All the exercises listed below may not be appropriate for everyone.

NO COLD !!! Do not apply ice, even when the part is burning hot. A fan is okay to use. Do your best to keep a cold foot warm (hot water soaks (not if you're diabetic), massage, fluffy socks).

For night pain or burning - try doing your exercises, light walking or hot water soaks - perhaps meditation?

Massage of the area or surrounding area to improve blood flow and to interrupt the pain signals. You could try a heat rub (anything with menthol) Don't do anything that increases the pain.

Active range of motion exercises. Start sitting. Curl your toes up and down, move the ankle through figure 8's. Stretch the ankle/foot in all directions (within your pain level). Pump the foot up and down. Do this for several minutes every hour and increase the duration if tolerated.

Standing exercises: Stand in barefeet. Go up on your toes while holding onto a chair. Go up on your heels. Put your weight on the inside and outside of your foot. But REMEMBER - don't do anything that makes the foot/ankle hurt more. If you accidently flare it up, remember to do less next time. You may have to start very very very slowly.

Next you can add theraband (obtain from a physiotherapist). You can do a variety of exercises using the resistance of a rubber band. Now you are starting to strengthen the foot/ankle (which has probably been held immobile or protected for many months).

Water exercises: If you cannot walk without pain - try walking in a warm pool (wear your shoes if you like). Just do whatever you can to get your feet moving again. Walk forwards, backwards, sideways and go up on your toes. NO bouncing!! Now you can take a whirlpool and if it doesn't hurt, put the jets on or near the sore area.

Walking: If you have been immobile because of the pain, try walking very slowly in supportive shoes and maybe only a few steps the first time. See what your body has to say about it - if the pain level doesn't increase, walk longer the next time. Perhaps start with 2 minutes per hour and increase accordingly.

Modalities: These would be provided by your physiotherapist - Paraffin baths, ultrasound, whirlpool and TENS are most often used. Home TENS is also an option. TENS must be prescribed and supervised closely by a trained practitioner.

Avoid using assistive devices (braces, walkers, canes, wheelchair) unless necessary to allow weightbearing. Initially after some injuries or surgeries you will be using assistive devices appropriately. How do you know when this has become counter-productive. It may be hard to tell whether you should walk on a foot that has been excruciatingly painful or it's better to use a wheelchair. It is so important to attempt to normalize your gait (walking) as soon as possible once CRPS has been diagnosed (even if it is suspected). Generally, let your body be your guide - if activity makes your pain worse, you probably shouldn't do it. The only exception is if the exercises are done under supervision using pain control methods (TENS, medications, injections).

Relaxation: Please don't underestimate the importance of removing stress from your life when you're trying to heal a condition like this. You must stop doing doing doing - find the support you need to look after yourself. Take lots of deep breaths, especially when you feel the pain (please don't hyperventilate) and find someone you can talk to about the pain (someone who believes you and can listen well).

Final note

The information I've presented here is very detailed and is intended to be a guide only. In some communities you may not be able to find a practitioner who is experienced with CRPS. Diagnosis and treatment of this condition is continually changing because it is not completely understood. Referral to a pain clinic, physician or physiotherapist experienced with CRPS is essential.