Foot/ Heel/ Ankle

FOOT NUMBNESS/ TINGLING/ WEAKNESS/ SWELLING

Foot numbness occurs when you lose the sensation on the foot. Foot numbness can be a temporary condition or may be due to any chronic condition like diabetes. The numbness of foot is a progressive disorder with foot losing more sense as time moves. Foot numbness affects the sense of touch and experience tingling, weakness and swelling in the area. With lose of foot sense, the patient may not be able to feel the ground and may lose his balance. The major cause of foot numbness is due to damage in the complex network of nerves that send and receives signals from the brain. A block, infection or compression in the nerves causes interruption in sending and receiving brain messages and experience numbness in the foot. These conditions can be caused from arthritis, excess alcohol consumption, and chronic disease conditions like diabetes or central nervous disorders.

The doctor performs a physical and clinical examination and may order an MRI scan to view the presence of an infection, compression or blockage in the nerves that are causing the symptoms and takes the medical history and description of the symptoms.

Conventional treatment methods for foot numbness, tingling, weakness and swelling include medications and physical therapy to improve the blood circulation, ease the swelling and discomfort in the foot. Physical therapy helps regain the strength and flexibility of the ankle and foot.

ALTERNATIVE TREATMENT METHODS AT DAYSTAR CLINIC, ALAPPUZHA AND BETH YEHUDAH ARTHRITIS CENTRE, PULLAD

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

Patient Benefits of NESTIT treatment:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who want to avoid if not delay surgery.
• Significantly reduces the neural symptoms associated with mild to moderate Compression/ Inflammation/ Irritation of the nerve.
• For those who are not medically fit/ do not want to undergo Spine surgery.
  Significantly reduces the neural symptoms associated with Inflammation.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces pain, numbness and discomfort in most patients.
• More effective treatment method in neural symptoms like numbness, tingling and weakness caused due to nerve sheath swelling secondary to nerve compression and inflammatory conditions.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of pain, numbness, and function if given in series.
• NESTIT may be followed by regenerative injections like Comprehensive Dextrose Prolotherapy at a later date to address the problem of neck instability which is the root cause of neural symptoms in many cases.
• More effective treatment method in neural symptoms like numbness, tingling and weakness caused due to nerve sheath swelling secondary to nerve compression and inflammatory conditions.

REGENERATIVE ORTHOPAEDIC TREATMENTS

The root cause of most nerve compression due to disc prolapse is Spinal Instability. The stable spine behaves like a see saw with its fulcrum at the facet joint. The disc in front is kind of balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr Tejaz John’s experience Platelet Rich Plasma Prolotherapy and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region.
Chronic Conditions caused by Cervical Instability: Radiculopathy, Spinalal Canal Stenosis, Degenerative disc disease, Herniated disc, Numbness/ Weakness in upper/ lower limb & Spondylosis.

Many times a patient with neck pain; despite various treatments still has pain and now has been recommended surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

In our clinical practice we often see patients with severe back pain bring an MRI, X-ray and/or scan that may show an inaccurate picture of what is causing their pain. The MRI cannot show muscle spasms from a simple cervical or lumbar strain which can cause excruciating pain. Neither can it detect micro-structural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.

Here is a statement from the medical journal Spine: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic lower back pain patient may have history of trauma or overuse to the lower back that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent spinal instability.

PRP for Spinal Instability Research studies in the past have shown that Platelet-Rich Plasma Therapy (PRP) is effective in treating the degenerative spine by dealing with the problems of spinal ligament instability. The sooner the spinal ligament instability is treated, the better the results and patient satisfaction. In fact, many doctors now think that stress on the ligaments may be the cause for most pain in degenerative disc disease. PRP eliminates pain by stimulating the local immune response to heal the underlying tissues and may help avoid surgery in cases of spinal ligament instability.

PRP prolotherapy is a combination treatment where PRP is injected into region of the joint and Dextrose prolotherapy is given to the ligaments and soft tissue attachments around the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the knee, hip, spine and/ or other joints where osteoarthritis is present.
Platelets present in the blood are the first responders to an injured area and helps build up new tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.

Patient Benefits of PRP Prolotherapy:

1. Minimally invasive treatment method
2. Almost painless injection technique using very thin needles under local anesthesia
3. Avoid if not delay Joint Replacement Surgery
4. Significantly reduces the symptoms associated with osteoarthritis
5. Reduced risk of adverse events
6. Repairs and strengthens ligaments improving joint stability.
7. Safe and effective treatment method
8. Faster healing and recovery
9. PRP Prolotherapy results in safe, significant, effective, progressive improvement of knee pain and function.

At Beth Yehudah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Nerve Compression/ Numbness/ Weakness. We tailor a non surgical customized treatment plan to treat patients suffering from these conditions. To know more about treatment plans and treatment cost, book an appointment now.