No back pain and bilateral "nerve" issues? Doubtfull from a radiculopathy. MRI of the spine would not likely be helpful. A very fun test that would be useful would be a NCV (nerve conduction velocity), usually done by a neurologist. Hope you like needles though ...

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Did the burning pain start before or after you went to the PT?

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Michael in Kansas
"Once you learn to quit, it becomes a habit"
"Its not whether you get knocked down, it's whether you get up" Lombardi

The pain was first there back in july when I was mis-diagnosed 4 separate times and then the pain was pretty much non-existent over the last month.

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http://slow-triathlete.blogspot.com/

Absolutely no other pain issues.

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http://slow-triathlete.blogspot.com/

This is a tough one......pain in the back of the knee can be the S1 nerve root....you 'can' have lower extremity nerve symptoms 'without back pain'. Since it's been bothering you for so long and continues to cause problems I recommend a diagnostic workup. I would start with a Lumbosacral x-ray and MRI of LS spine to check for spondylolithesis or herniated disc...If these are not helpful, then I agree with rroof and do the nerve conduction study next to rule out neuropathy. I can tell you that frequently these tests are normal but would get them since your doing so poorly......there are some medicines with can help nerve-mediated pain but get a workup first.....

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Michael in Kansas
"Once you learn to quit, it becomes a habit"
"Its not whether you get knocked down, it's whether you get up" Lombardi

thanks muchly for the ideas.

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http://slow-triathlete.blogspot.com/

long lasting "burning" pain in the absence of an obvious source and in a distribution that doesn't follow any known nerve distribution is an RSD (reflex sympathetic dystrophy) to me until proven otherwise. If you have any skin sensitivity in the area that would pretty much seal it for me. A sympathetic block to the area is both diagnostic and, usually, therapeutic. It won't be the first thing your doctor thinks of or tries probably but if they keep striking out and this doesn't get better keep bringing it up.

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Frank,
An original Ironman and the Inventor of PowerCranks

I am a neurologist and agree that a source from your back with burning pain only localized behind the knees would be very unusual . Pressure directly above the back of the knees wher the sciatic nerve begins to divide could bring this on . Sitting with your legs pressed against a hard bench . doing crunches with your knees hooked over a bar or anything of a similar mechanical nature could start it . Once it starts any pressure can bring it back . Nerve conduction studies in that area are not the best but they could tell if you have an underlying predisposition to nerve compression ( pre diabetes , Lyme , etc . Show this to the army doc and tell him it came from a former USN diving and submarine medical officer . If he is less than a LCDR ( Major ) he might listen . Good luck

thanks. I will.

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http://slow-triathlete.blogspot.com/

I had something very similar, less burning though and more tightness. Went through just about everything and tried every diagnosis from every doctor (other than the RSD Frank Day mentioned, I have heard him mention that before and wondered if that could be what I am dealing with, although I don't really understand what it is.)

I do have a compression fracture at my L3 vertebrae though so there is a back issue with me. However, 3 orthopedists, 3 rounds of bloodwork, multiple MRIs on the back and legs, that not-so-fun Nerve Conduction Test all showed nothing abnormal.

So a lot of patience and even more stretching has finally got me back running again, that's about all I can tell you. Kind of frustrating to have dealt with this for 6+ months with no real conclusion, but I am running again so I am happy about that.

Like I said, Frank Day's suggestion does make me wonder and I don't recall a doctor ever bringing that up, at this point I am just so burnt out on doctor's after way to many appointments.

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Portside Athletics Blog

[reply]
I had something very similar, less burning though and more tightness. Went through just about everything and tried every diagnosis from every doctor (other than the RSD Frank Day mentioned, I have heard him mention that before and wondered if that could be what I am dealing with, although I don't really understand what it is.)

I do have a compression fracture at my L3 vertebrae though so there is a back issue with me. However, 3 orthopedists, 3 rounds of bloodwork, multiple MRIs on the back and legs, that not-so-fun Nerve Conduction Test all showed nothing abnormal.

So a lot of patience and even more stretching has finally got me back running again, that's about all I can tell you. Kind of frustrating to have dealt with this for 6+ months with no real conclusion, but I am running again so I am happy about that.

Like I said, Frank Day's suggestion does make me wonder and I don't recall a doctor ever bringing that up, at this point I am just so burnt out on doctor's after way to many appointments.[/reply]

Most docs don't have a clue regarding RSD. In my practice it was the most common missed diagnosis when people came to me. The problem is the text books only describe the worst condition, when people have withered hands and are totally debilitated. Unfortunately, RSD comprises a spectrum so those with "lesser" disorders usually go undiagnosed and labeled as it being "all in their head" since they can't find ANYTHING.

The key words that patients would use to describe their problem that raised my suspicion were "burning", "hot", "tightness", "sensitive", and "continuous". Also, if the distribution of the pain didn't follow any normal known nerve patterns suspicion should be raised.

RSD is simply a disorder of the nervous feedback system and somehow the sympathetic nervous system is involved. When you hit your thumb with a hammer you feel this burning pain. That is normal. When it doesn't go away, that is not normal and that is RSD. RSD is set off by some trauma, although it does not have to be major, stubbing your toe can be sufficient. A related disorder is post-herpetic neuralgia (shingles).

It is "easy" to diagnose because a sympathetic block to the area makes all of the symptoms go away completely, at least for the period the block is present. In my experience in about 50% of those who get this diagnostic block, the block is also therapeutic and when the block wears off the problem is better and a small series of three blocks cures the problem. Of those who don't respond easily about 50% of them can be cured with more prolonged or aggressive treatment and the remaining people tend to be much more difficult to cure, although the pain can usually be minimized. those who had "mild" symptoms tended to be easier to treat than those with severe symptoms. Thermography is a non-invasive test that can also be used to confirm suspicion (although it cannot confirm or "make" the diagnosis) as many times there is usually temperature changes in the area, usually cooler than the other side but it can be hotter. Normal temperatures does not exclude the diagnosis however.

You need to find a doctor experienced with giving sympathetic blocks and treating RSD. Most of these are going to be anesthesiologists and anesthesiologist pain specialists.

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Frank,
An original Ironman and the Inventor of PowerCranks

Thanks for the reply. As I said, tightness was my biggest symptom and words like constant and sensitive certainly ring true. I have also had several doctors tell me "We are going to do this test and if nothing shows up, put the issue to bed as not being anything," or like you said "all in your head."

Forgive my ignorance, but is an anesthesiologists just a specific type of doctor like an orthopedist, podiatrist, etc.? I don't really know much about them and am wondering about finding one, insurance, etc.

So using the Slowtwitch 6 degrees of seperation theory that there is always someone who knows someone who knows someone...do you know, or have you come across in your travels any good anesthesiologists in the DC area or do you know someone who might? I am always hesitant just picking doctors out of the insurance booklet. Thanks again.

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Portside Athletics Blog

[reply]
Thanks for the reply. As I said, tightness was my biggest symptom and words like constant and sensitive certainly ring true. I have also had several doctors tell me "We are going to do this test and if nothing shows up, put the issue to bed as not being anything," or like you said "all in your head."

Forgive my ignorance, but is an anesthesiologists just a specific type of doctor like an orthopedist, podiatrist, etc.? I don't really know much about them and am wondering about finding one, insurance, etc.

So using the Slowtwitch 6 degrees of seperation theory that there is always someone who knows someone who knows someone...do you know, or have you come across in your travels any good anesthesiologists in the DC area or do you know someone who might? I am always hesitant just picking doctors out of the insurance booklet. Thanks again.[/reply]

An anesthesiologist has specialty training in anesthesia, that is putting people to sleep (or parts of their body to sleep in the case of regional anesthesia) for operations and then, most importantly, waking them up again. It is the regional anesthesia training that will most interest you as that is where the blocks are learned.

Anesthesiology is the only specialty I know of that requires all of its trainees to undergo 3 months of subspecialty pain diagnosis and treatment. Unfortunately, not all of them (most in fact) are not interested in this so it does them (and you) little good. You need to find someone who has an interest in this. Your doctor should be able to find someone for you with just a few phone calls. Show him this thread and tell him to get on it.

Depending upon where you are I might be able to give you some names.

Good luck.

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Frank,
An original Ironman and the Inventor of PowerCranks

[reply]So using the Slowtwitch 6 degrees of seperation theory that there is always someone who knows someone who knows someone...do you know, or have you come across in your travels any good anesthesiologists in the DC area or do you know someone who might? I am always hesitant just picking doctors out of the insurance booklet. Thanks again.[/reply]

Oops, missed the area. Don't know any specific names in the area but there are so many teaching hospitals there with anesthesia programs that it shouldn't be hard to find someone there. If you are in the military I would recommend Bethesda over Walter Reid simply because when i was on active duty the Navy had the one program with the absolute strongest regional anesthesia program plus many Navy docs were trained by me and if any of these are still around (and happen to be there) they are much more likely to know what to do right off the bat.

It will be somewhat hit or miss until you find someone who knows what I am talking about. When you do you will know it. I was able to have about 50% of the patients with your story pain free within about 1 week of first seeing them. But, I was very aggressive compared to most. If you have any questions you can always PM me.

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Frank,
An original Ironman and the Inventor of PowerCranks

There are two types of anesthesilogists...one who put you to sleep for surgery and others who have expertise in pain management, such as epidural steroids, narcotic management, pain blocks, trigger injections, etc......you could call your teaching hospitals in your area and ask for the anesthesia department and then ask for the pain management subset of this department...that should help....could also ask your primary physician or an orthopedist, neurologist,etc. you've worked with as they have their favorites...

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Michael in Kansas
"Once you learn to quit, it becomes a habit"
"Its not whether you get knocked down, it's whether you get up" Lombardi

Frank, I agree that RSD is in the differential of causes but it is rare....it usually start with some sort of trauma such as surgery, fracture or other injury...do you think there's enough trauma here to cause RSD?....absolutely agree that a sympathetic ganglion block by an anesthesilogist will prove diagnostic to rule in or rule out RSD....if it turns out to be RSD then some repeat blocks could help as well as some meds such as Lyrica or Neurontin....I have never seen RSD in a Bilateral extremity situation either, but as an orthopedist I do see and treat this condition but I am not an "expert".....let me know your thoughts....

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Michael in Kansas
"Once you learn to quit, it becomes a habit"
"Its not whether you get knocked down, it's whether you get up" Lombardi

Actually, it is not rare. I would put this fellows chance of having it based on the history alone at above 90%. Only the textbook descriptions of RSD are rare. The mild cases are always missed and the moderate cases are usually missed. In my experience it is the most missed diagnosis causing chronic pain complaints that walked through my door.

And, the trauma does not have to be severe to set it off. It can be caused by stubbed toes or IM injections or even be so minor the patient doesn't remember it. A muscle pull in an athlete is all it would take. All it takes is trauma and the right scenario (whatever that is, no one knows) to set things off in the WRONG direction.

And I disagree that a ganglion block makes or breaks the diagnosis. It may but a fair number of these have bilteral (cross) innervation so a one sided ganglion block cannot completely block or treat the problem so the only way to really know is to do a bilateral sympathetic block. So I routinely did epidural blocks (even for the upper extremities and head where I would put the catheter tip about T2-T4 - remember all the sympathetic nerves leave the cord below T2 and above L5) and my end point was always complete pain relief, which sometime required a motor block as there was not always the textbook differentiation between fibres we were taught. If I could not achieve complete pain relief then there was most probably a problem with the catheter placement and I would bring them back the next day and perhaps do a spinal, depending upon the situation. A bier block would work well for something isolated to the hand or foot although these are not very effective therapeutically since IV reserpine (guanethidine doesn't seem as effective but is used as the alternative) was taken off the market (these would be added to the block to extend it after the tourniquet is let down). I only did ganglion blocks if I was considering doing a neurolytic block or sometimes for pain in the face where a stellate might be done. But, if I could not get complete pain relief doing one, I always did an epidural to get a bilateral block before I moved on.

Once a good block was done the diagnosis would be pretty evident to almost everyone. These people would be able to do almost everything that they couldn't do before until the sympathetic portion of the block wore off but the lucky ones would be better when the block wore off. In these patients a repeat block the next day and a third 2 or 3 days later usually resulted in cure.

The key to successful treatment of these patients in my opinions is 1. a high index of suspicion so the diagnosis can be made when it exists. 2. adequate therapeutic blocks (complete pain relief is the only end point that means anything to me, not just seeing warming of the extremity, which only is evidence of a partial block) 3. an aggressive attitude with repeat blocks until the problem is gone in those who respond to the blocks (it usually doesn't take to many) and aggressive alternative treatments in those who do not.

Frank

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Frank,
An original Ironman and the Inventor of PowerCranks

I know this is getting off track some, but have you had some success with extremity Bier blocks for CRPS/RSD and have you ever added Wydase (hyaluronidase) to facilitate the lidocaine or whatever amide anesthetic you were using?

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

[reply]
I know this is getting off track some, but have you had some success with extremity Bier blocks for CRPS/RSD and have you ever added Wydase (hyaluronidase) to facilitate the lidocaine or whatever amide anesthetic you were using?[/reply]

I am not sure this is completely off track. After all, the term slowtwitch does have a physiological/medical basis. :-) And the term bier block does seem somewhat related to the beer block that many here do once in awhile. Anyhow . . .

Yes, I have had success using bier blocks. Back in my day the best adjunct to add was reserpine. But it was taken off the market in the injectable form. When they announced it was going to be no longer available all the pain specialists I knew bought up as much as they could, but it eventually ran out. Guanethidine was the substitute we used but it never seemed to work as well.

Have no experience with hyaluronidase so can't comment. Not sure why it would work but I am not sure why a lot of stuff I did worked. I was just glad it did in these difficult patients. It would seem that it would be pretty benign to try. Whatever works in these difficult patients should be publicized and applauded.

Have you had success using hyaluronidase in Bier blocks to treat RSD/CRPS? If so, could you PM me some details. I would like to present it to a chronic pain list serve I am a part of to get their thoughts. Also, I would suggest trying to write some case reports or letters to the editor to get the word out.


Frank

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Frank,
An original Ironman and the Inventor of PowerCranks

Actually, I have NOT used Wydase for this. But, it is widely used in opthalmic surgery as the protein greatly facilitates the uptake of amide anesthetics so they can use less (as would be cricitcal around the small occular muscles).

I have thought along these lines with a Bier block (using less anesthetic that is) since so much is needed with a cuff around an ankle/calf. I'm always worried when letting it down, compartment syndrome, etc. Using less anesthetic to obtain the same effect only makes sense. There has been a shortage of Wydase as well I have gathered from speaking with my opthalmic colleagues.

You can google some info on Wydase and its use, but I have not been able to find anything re: Bier blocks, but I don't see why this would not work? Common sense/experimentation is tough to find in Western medicine though as I'm sure you are well aware. I see a bit of RSD as well (since my index of suspicion is high) and I have 1 pain guy in my area I like, but most others are either booked, can't get in in time (no good for RSD patients where time is often critical), or are just plain bad.

Thanks for your thoughts!

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Frank,

Your ideas so far are interesting to say the least.

I looked up RSD and took in all I could from a history student's eyes. I can see that I meet almost all the symptons in the pages I visited. I did not think it was possible at first since I had no real trauma to the areas but I guess if the first diagnosis was correct when I had more of a deep pain than a burning and was told I had probable minor tears in the hamstring, then that could end up being a trauma to the area.

The one sympton I do not have as far as I can tell is the sensitive skin, I mean it feels burning and pins and needly but not sensitive like nipples after a marathon.

I am in the Canadian military so no reid or bethesda for me. I am stuck on an island vancouver island in victoria. Do you have any recommendations for specialists in this area.

once again thanks for all of your help and roof and the others of course, I am learning a lot.

Brian

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http://slow-triathlete.blogspot.com/

[reply]
Actually, I have NOT used Wydase for this. But, it is widely used in opthalmic surgery as the protein greatly facilitates the uptake of amide anesthetics so they can use less (as would be cricitcal around the small occular muscles).

I have thought along these lines with a Bier block (using less anesthetic that is) since so much is needed with a cuff around an ankle/calf. I'm always worried when letting it down, compartment syndrome, etc. Using less anesthetic to obtain the same effect only makes sense. There has been a shortage of Wydase as well I have gathered from speaking with my opthalmic colleagues.

You can google some info on Wydase and its use, but I have not been able to find anything re: Bier blocks, but I don't see why this would not work? Common sense/experimentation is tough to find in Western medicine though as I'm sure you are well aware. I see a bit of RSD as well (since my index of suspicion is high) and I have 1 pain guy in my area I like, but most others are either booked, can't get in in time (no good for RSD patients where time is often critical), or are just plain bad.

Thanks for your thoughts![/reply]

The issue of volume can be solved with using a smaller concentration. So, 50 cc (don't let Dan see this) of 0.5% lidocaine is only 250 mg. but it is only 125 mg of 0.25%. 100 mg of lidocaine is given iv bolus to treat arrhythmias without problem. I would never use anything but lidocaine in a bier block as it has such a lesser toxicity problem compared to the other local anesthetics, although I could possibly consider using a drug like nesacaine that is metabolized differently. So, there is no real risk from the local anesthetic after about 10 minutes because most of it has entered the tissues and bound to them, so even if the cuff fails after this time the uptake will never reach critical levels.

The reason we augmented with reserpine (or guanethidine) is they would deplete the nerve endings, prolonging the block (and, hopefully, augmenting the therapeutic effect). Bier blocks are so safe, if the person doing it is paying attention for the first 10 minutes, that i can't see that adding hyaluronidase to reduce the dose would offer any therapeutic or safety benefit.

I believe the opthamologists use this to facilitate diffusion, reduce the volume so as to have a smaller effect on intraocular pressure, and because of the risk of injecting into an artery and sending the drug directly to the brain (so reducing the amount gives them a little bit more room for comfort - probably more treating themselves than doing anything for the patient). Injecting directly into an artery would be like injecting into the carotid artery trying to do a stellate ganglion block. Seizures will almost invariably result. Not that they can't be managed but sort of ruins the calm atmosphere and godlike image you have been trying to facilitate. This is especially disastrous to someone who is not trying to change intraocular pressure.

Of special interest here is, I believe, the eye muscles the opthamologists are trying to get are mostly fast twitch muscles. Dan may soon delete this thread as a result. :-)

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Frank,
An original Ironman and the Inventor of PowerCranks

[reply]
Frank,

Your ideas so far are interesting to say the least.

I looked up RSD and took in all I could from a history student's eyes. I can see that I meet almost all the symptons in the pages I visited. I did not think it was possible at first since I had no real trauma to the areas but I guess if the first diagnosis was correct when I had more of a deep pain than a burning and was told I had probable minor tears in the hamstring, then that could end up being a trauma to the area.

The one sympton I do not have as far as I can tell is the sensitive skin, I mean it feels burning and pins and needly but not sensitive like nipples after a marathon.

I am in the Canadian military so no reid or bethesda for me. I am stuck on an island vancouver island in victoria. Do you have any recommendations for specialists in this area.

once again thanks for all of your help and roof and the others of course, I am learning a lot.

Brian[/reply]

First, it is rare for everyone to have every symptom described in the book. In fact, RSD can occur in the absence of ANY pain. It has been described to occur with only motor abnormalities. I can give you the reference if you want. It is just in most people pain is the predominant symptom.

I would simply recommend that you ask your doctor to find someone for you who is well versed in this area. In my experience military doctors are better than average as this goes. Show this thread to your doc and tell him this describes you and ask him to help you out. Most major metropolitan areas have one or two and the military will send you to the experts you need if they understand you need them, at least that is my experience. You will know based upon how they deal with you and your problems if they know what they are doing or not. If you are not satisified, then keep looking.

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Frank,
An original Ironman and the Inventor of PowerCranks

Which person are you talking about with the 90% chance? Me (the guy with the past L3 compression fracture and the pain and tightness behind both knees) or the original poster with the burning?

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Portside Athletics Blog