Severe Heel Pain After Plantar Fasciotomy (Mark Aldrich, DPM)
Whenever you have a patient with severe localized pain, you might find benefit in looking for a cause that is not necessarily inflammation related, like nerve damage or a conduction defect. Patients like that benefit from nerve conduction studies which you can then have a physical medicine consultant read and consider. We always worry about treating these patients with any form of narcotic because they are highly likely to become acclimatized and possibly addicted to them. The irony of narcotic analgesic therapy for chronic pain is that the pain itself becomes how the addiction is expressed.
This is why some pain specialists use Tricyclic anti-depressants for such patients, which may help significantly reduce the amount of narcotics necessary. I myself have used this and present it to patients as a way to control the "depression aspects" of chronic pain. The actual purpose of the therapy is to reduce pain, not to treat depression, so I consider this a part of the DPM license. Sounds like circular reasoning, but patients need to understand the drug.
You can also look at hyperuricemia, alcoholism and even pedal manifestations of generalized disease processes, like lupus, severe obesity, etc. However they are less likely. If there is a diagnosed nerve conduction problem, you would refer the patient to a neurologist for a consult. They might try Neurontin. Alternatively you could also consider absolute alcohol injections into the site to try to "de-sensitize" the affected nerve, after you work up the patient and get consults.
The risks of using dilute absolute alcohol injection therapy exist, but are not Draconian. Obviously you would start out with a low dose. Even if there is no diagnosed nerve conduction defect by electro-diagnosis, it might still be considered. You would request a consult with another DPM on that issue and consider this possibility together. Without demonstrated conduction defect, the consultation is important, but does not rule out the possibility of that treatment.
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net
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