Foot Neuropathy

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Refuse to suffer with foot neuropathy. Watch this presentation to learn more and to see there are really solutions to this severe condition.

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Foot Neuropathy

  1. 1. <ul><li>Dr. Michael E. Graham </li></ul><ul><li>Podiatric Physician and Surgeon of the Foot and Ankle </li></ul><ul><li>Fellow, American College of Foot and Ankle Surgeons, </li></ul><ul><li>Fellow, International Peripheral Nerve Surgeons, </li></ul><ul><li>Diplomat, American Board of Podiatric Surgery. </li></ul><ul><li>Private Practice, Birmingham and Shelby Township, Michigan </li></ul>
  2. 2. New Hope for Peripheral Neuropathy
  3. 3. What is Neuropathy? <ul><li>Neuro - something doing with the nervous system </li></ul><ul><li>- pathy - there is a problem </li></ul><ul><li>A very generic term meaning that something is wrong with the nervous system </li></ul>
  4. 4. What is Peripheral Neuropathy? <ul><li>Problem with a nerve outside of the spine </li></ul><ul><li>Usually a problem in the hands/feet </li></ul><ul><li>A very non-descriptive term </li></ul><ul><li>Leaves the patient and doctor guessing as to what is the problem. </li></ul>
  5. 5. Nerve Anatomy
  6. 8. What do I feel? <ul><li>Pain </li></ul><ul><li>Numbness </li></ul><ul><li>Combination </li></ul>
  7. 9. Symptoms Depends on which nerve fibers are being affected
  8. 10. Symptoms of Foot/Ankle Involvement <ul><li>Typically starts as numbness/strange feeling under the toes or ball of the foot. </li></ul><ul><li>Usually occurs during walking/running </li></ul><ul><li>Subsides when the activity is stopped </li></ul><ul><li>Feeling that the sock is loose/wrinkled under the toes </li></ul>
  9. 11. Symptoms <ul><li>Foot is “awake” in the AM when first get out of bed. </li></ul><ul><li>As the day progresses the numbness starts. </li></ul><ul><li>After retiring for the night, feet “wake-up” </li></ul>
  10. 12. <ul><li>Feet are “awake” when first get out of bed </li></ul><ul><li>Go numb pretty quick </li></ul><ul><li>After going to bed, feet “wake-up” after 30 to 60 minutes-feel like bugs are crawling on the bottom of the feet </li></ul><ul><li>After a prolonged period of this, when the nerve “wake-up” they “wake-up” with a vengeance. </li></ul>
  11. 13. <ul><li>After a while the feet are extremely sensitive. </li></ul><ul><li>Toes are very cold during the day and are on “fire” at night </li></ul><ul><li>Can’t stand the touch of their sheets to touch their feet. </li></ul><ul><li>Eventually, the feet are numb all the time </li></ul>
  12. 14. <ul><li>Numbness starts in the toes </li></ul><ul><li>Slowly works it way to the arch of the foot </li></ul><ul><li>Loss of sensation to the heel </li></ul><ul><li>Starts to then travel up the lower leg </li></ul>
  13. 15. Typical Patient Background <ul><li>Active lifestyle- lots of walking/standing </li></ul><ul><li>May or may not be a diabetic </li></ul><ul><li>May or may not have had chemotherapy/radiation </li></ul><ul><li>Usually have a lower than normal arch, or high arched foot. </li></ul>
  14. 16. What kind of damage is occurring to the nerve <ul><li>There are signs of vascular damage </li></ul><ul><li>There is damage of/to the nerve </li></ul><ul><li>Enlargement of the nerve </li></ul><ul><li>Shrinkage of the nerve </li></ul><ul><li>Nerve death-discontinuity of the nerve </li></ul>
  15. 18. Nerve Anatomy Posterior Tibial Nerve 1 st Area of Damage 2 nd Area of Damage
  16. 19. Why does this occur? <ul><li>There is chronic overstretching of the nerve </li></ul><ul><li>There is chronic compression of the nerve </li></ul><ul><li>There is chronic overstretching and compression of the nerve </li></ul>
  17. 20. The Problem Chronic Overstretching of the Nerve(s) Compression of the Nerve(s)
  18. 21. Nerve Damage Cycle <ul><li>When we walk with abnormal mechanics to the foot, this leads to an overstretching of the posterior tibial nerve. </li></ul><ul><li>When there is no motion to the foot, the nerves channels are open and nerve impulses are traveling through the nerves. </li></ul><ul><li>After a period of overstretching and compression the nerve fibers stop functions and there is decreased sensation to the nerves. </li></ul><ul><li>Once the overstretching/compression stop, the nerve will eventually recover and sensation will return to the foot. </li></ul><ul><li>As time goes on, however, damage is occurring to the nerves and they will take longer to recover until permanent damage occurs and the feet are always numb. </li></ul>
  19. 22. Degeneration of the Nerve
  20. 23. Carpal Tunnel Syndrome <ul><li>80% of cases have involvement of the wrists as well as the feet. </li></ul><ul><li>It is simply a chronic compression of the nerve. </li></ul><ul><li>The nerves are being strangled, they is why the scream and kick when possible to let us know that something is wrong. </li></ul>
  21. 24. Tarsal Tunnel Syndrome <ul><li>Tarsal Tunnel is the carpal tunnel of the foot. </li></ul><ul><li>Due to chronic compression of the nerves to the inner ankle </li></ul>
  22. 25. How do we diagnose this? <ul><li>Nerve Conduction Tests (NCV) </li></ul><ul><li>Eletromyograms (EMGs) </li></ul><ul><li>Test for diabetes </li></ul><ul><li>Tests for other medical conditions </li></ul>
  23. 26. <ul><li>Apply pressure to the tarsal tunnel- usually there is pain </li></ul><ul><li>Test vibratory sensors of the foot (VPT) </li></ul><ul><li>Radiographs </li></ul><ul><li>Gait analysis </li></ul>
  24. 27. Treatment of Neuropathy <ul><li>Usually told “We don’t know why you have it!” </li></ul><ul><li>We can give you pills to try to help (meanwhile it just gets worse), pills are expensive, usually just take off the “edge” </li></ul><ul><li>Keep coming back for more testing </li></ul><ul><li>You will most likely become a diabetic if not already diagnosed (not true) </li></ul>
  25. 28. Current Forms of Treatment <ul><li>Biannual testing </li></ul><ul><li>Extra depth shoes </li></ul><ul><li>NSAIDS </li></ul><ul><li>Pain pills </li></ul><ul><li>Nerve Pills </li></ul><ul><li>Psychiatry </li></ul><ul><li>Wheelchair/walker </li></ul><ul><li>Shows increased nerve damage </li></ul><ul><li>Prevent ulceration </li></ul><ul><li>Do nothing </li></ul><ul><li>Barely take off the edge </li></ul><ul><li>See next slide </li></ul><ul><li>Loosing battle </li></ul><ul><li>Syndrome X- further decrease in activity </li></ul>
  26. 29. What is the New Hope? <ul><li>Decompression of the compressed nerves </li></ul><ul><li>Carpal tunnel release in the wrist, tarsal tunnel release in the foot </li></ul>
  27. 30. This photo is like a nerve being damaged by the overlying tissues. The damage starts superficially and continues within the nerve. The goal is to release the tissues damaging the nerve. Thank goodness nerves can repair themselves if given a chance, unlike this fallen tree. The longer the tissues destroy the nerves the more damage is done to the nerve.
  28. 31. Surgical Decompression
  29. 32. Cross Over Effect <ul><li>This is real not imaginary. </li></ul><ul><li>The damaged nerves of one foot affect the opposite foot. </li></ul><ul><li>Scenarios: </li></ul><ul><ul><li>Good- </li></ul></ul><ul><ul><li>Bad- </li></ul></ul><ul><ul><li>Ugly- </li></ul></ul>
  30. 33. Cross Over Effect - Good <ul><li>By decompressing one foot not only is there is improvement on that side there is also improvement in the contra-lateral limb. </li></ul><ul><li>IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the nerves </li></ul>
  31. 34. Cross Over Effect - Bad <ul><li>Surgery to the foot yield minimal results with no change in the contra-lateral limb </li></ul><ul><li>The opposite limb is the dominate nerve pathology and once that side is also decompressed there should be an additional effect on both feet. </li></ul><ul><li>Must warn patients about this prior to surgery. </li></ul>
  32. 35. Cross Over Effect - Ugly <ul><li>Nerve decompressions are performed on both feet (one at a time) and no results are felt. </li></ul><ul><li>Don’t take the patient’s word for it. Must perform nerve testing prior to surgery and routinely post-op. </li></ul><ul><li>Their nerves may be so severely damaged that it was too late. </li></ul><ul><li>No matter how severe I will still attempt. </li></ul><ul><li>It just may takes years for the results to be felt. </li></ul>
  33. 36. Complications of Surgery <ul><li>Wound dehiscence </li></ul><ul><li>Scar tissue formation </li></ul><ul><li>Hematoma </li></ul><ul><li>Infection </li></ul><ul><li>Temporary increase in nerve symptoms </li></ul><ul><li>2% revision rate </li></ul>
  34. 37. Complications of: “ Supervised Neglect” Doing Nothing <ul><li>Increased Nerve Pain </li></ul><ul><li>Loss of Sensation </li></ul><ul><li>Ulceration </li></ul><ul><li>Bone infection </li></ul><ul><li>Amputation </li></ul><ul><li>Charcot’s Foot </li></ul><ul><li>Decreased Activity Level </li></ul><ul><li>Decreased metabolism </li></ul><ul><li>Increased Weight (obesity) </li></ul><ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Arterial Disease </li></ul>
  35. 38. What about the Hyperpronation?
  36. 39. Hyperpronation - The most common consistent finding/etiology of nerve compression syndrome.
  37. 40. The Correction-must internally straighten the foot.
  38. 41. Hyperpronation-the cure Abnormal/Before After/Restored Normal HyProCure
  39. 42. Abnormal Closure of the space
  40. 44. Post-Op Course <ul><li>3-5 days minimal walking </li></ul><ul><li>7-10 days increased walking-but still limited </li></ul><ul><li>2-3 weeks relatively normal walking </li></ul><ul><li>4-6 weeks no limitation, residual soreness </li></ul><ul><li>2-3 Months Running/Jogging </li></ul><ul><li>1 year fully recovered </li></ul>
  41. 45. What are the results <ul><li>It depends on: </li></ul><ul><li>how long has the symptoms has been present </li></ul><ul><li>How much nerve damage has been done </li></ul><ul><li>What other medical deformities are present </li></ul><ul><li>The health of the patient </li></ul><ul><li>Patient compliance </li></ul>
  42. 46. When will the results be felt? <ul><li>Usually the severe pain at night is instantly resolved </li></ul><ul><li>The return of feeling to the foot can take a very long time to return it ever. </li></ul><ul><li>If the nerve fibers are completely destroyed the feeling may never return </li></ul><ul><li>Other times there is instant feeling in the foot. </li></ul>
  43. 47. What are the Potential Complications? <ul><li>Delayed incision healing </li></ul><ul><li>Infection </li></ul><ul><li>No return of feeling </li></ul><ul><li>Further nerve damage </li></ul><ul><li>Scar tissue </li></ul>
  44. 48. What are the Potential Complications of Not Having these Procedures Performed <ul><li>Progression of the pain </li></ul><ul><li>Nerve disintegration </li></ul><ul><li>Complete numbness in the foot. </li></ul><ul><li>THEN at risk for </li></ul><ul><li>Ulceration and other severe bone deforming diseases, infection, loss of limb. </li></ul>
  45. 49. There is indeed New Hope For Peripheral Neuropathy <ul><li>It is not a mystery anymore </li></ul><ul><li>Medications only mask the symptoms, meanwhile, the nerve damage continues to occur </li></ul><ul><li>The sooner surgical decompression is performed, the sooner nerve healing can occur </li></ul><ul><li>The risks of not having the decompression/stent procedure far outweigh the risks of having the procedures performed. </li></ul>
  46. 50. thanks

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