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08/19/2013    Michael M. Rosenblatt, DPM

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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