Hi all,
I'll go down a slightly different pathway to everyone else, though CP did
mention slump which is along the same line of thought. Looking at his
history, the biomechanically based tissue management(orthotics, splints etc)
plan has been quite comprehensive. There is a strong indication this may not
be the key to further management, though mechanical passive and active
movement of the tissue may yet prove effective.
My initial thought with anyone presenting with bilteral long term (9 year)
syndromes is DRG damage, cord injury, or central sensitisation. Without
knowing the patient we can guess the problem desrcibed by Simon is one of
altered peripheral and central sensitivity. In cases of combined long term
peripheral and central sensitivity it is not uncommon to find normal NCV
tests and MRI evaluation. This is because the pain processing regions are
not located in the areas of pain presentation - they are located in the
brain. NCV tests are also very unreliable depending on which individual part
of the nerve is tested. Hang with me here....
In Simon's case the initial injury in the tissue to one side is probable(if
no central cord damage), however after so many years the tissue response
rate is such that it should have healed or started to have responded by now.
If there was a unilateral injury then many neural processes may have
occurred to produce contralateral pain presentation. Nerves can undergo
phenotype changes and produce a whole bunch of nasty neuromodulators which
may produce a dorsal horn change. Some research is suggesting this may cause
a change in the neural stimulation to create pain, ie: fibres which are
predominantly used to determine light touch and small movements now have
lower activation thresholds and will be perceived as pain stimuli.  So as in
this case sheets, socks, stimuli from  walking etc.
My suggestion would be to send this getleman to a manual therapist who has a
background in chronic pain management and is commonly managing people with
central sensitisation based syndromes. There is no short term management if
this is the case, only long term...but after 9 years any help would be
appreciated.
Regards
Daryl M. P.


>From: "Erin Ward, D.P.M." <[log in to unmask]>
>Reply-To: A group for the academic discussion of current issues in podiatry
>              <[log in to unmask]>
>To: [log in to unmask]
>Subject: Re: heel pain
>Date: Sat, 5 Jun 2004 08:16:46 EDT
>
>Simon and Kevin
>
>Simon:
>Start with the simple and least costly and work to the more complicated and
>more costly. Good luck with the patient.
>
>Kevin:
>The material cost is about $0.25 and Tc99 bone scans must be extremely
>cheap
>in California.  I'll send my Tc99 patients to Sacramento.   Anyway, we are
>getting away from helpful info to Simon.
>
>Take care
>Erin
>
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