What I intended to say is that for $800 I also expect you to make burnt offerings on my behalf to the triathlon gods.

Susan

[reply]What I intended to say is that for $800 I also expect you to make burnt offerings on my behalf to the triathlon gods.

Susan[/reply]

I will throw in some of the toast I make most mornings. Anything for the sale.

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Frank,
An original Ironman and the Inventor of PowerCranks

CT scan is normal. So I asked what's causing the swelling and edema and pain. The orthopedist doesn't know. Sometimes people just get nonspecific inflammation, he said.

How exquisitely unhelpful.

And his completely unoriginal advice: Stop running for at least a month, and build gradually when you resume.

Well, duh.

But back to the subject at hand, which is PCs. The guy at my LBS is off today, so it will be tomorrow before I can talk to him about making one set of PCs fit on both bikes.

It may be more of a hassle than I want to take on, notwithstanding your reassurances. I will let you know what I decide to do.

For sure if I still have pain when I start to run again in 2 months, I will be ready to think about a pain anesthesiologist.

Susan

"CT scan is normal. So I asked what's causing the swelling and edema and pain. The orthopedist doesn't know. "

Go back to the beginning and read my original post. I'm fairly certain this type of therapy might help you.

I was intrigued the first time I read your post, cerveloguy. The key probably is to find a really good chiropractor--easier said than done, in my experience.

Susan

[reply]"CT scan is normal. So I asked what's causing the swelling and edema and pain. The orthopedist doesn't know. "

Go back to the beginning and read my original post. I'm fairly certain this type of therapy might help you.[/reply]

Please explain how your explanation causes marrow edema?

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Frank,
An original Ironman and the Inventor of PowerCranks

My ankle hurt on my trainer tonight. And it wasn't a workout that should've been stressful. It makes me wonder if using PCs would hurt, too.

I don't understand it. And I wouldn't be obsessing about it, except I worry that bone marrow edema and swelling indicate tissue damage that I am making worse every time I do something that hurts. But in light of the fact that it hurts all the time, even when I'm just sitting at my desk, training may not really be an issue. But who the heck knows?

The orthopedist suggested a steroid injection. But I don't see how artificially calming the inflammation will address whatever the problem is.

Oh, well. You guys have been patient and kind to suffer through my hand-wringing and to offer suggestions for a problem that doesn't seem to have a solution. Maybe a pain anesthesiologist is the next logical step now--except that approach still doesn't address what's causing the edema and the swelling.

Susan

Try to see an acupuncturist. You'll never know.

I have an acupuncturist who is also an MD who I go to for stuff that can't seem to be solved by my physiatrist.

Another person who sees a physiatrist! I see a physiatrist, and in my "normal" life, everybody always says, "A what??"

I am happily discovering that people here are not "normal."

I hadn't thought of an acupuncturist. There's one at the local teaching hospital, although I'm not sure she's an MD--not that it matters.

What problems has your acupuncturist solved for you?

Susan

Weighing in a little late, but a few thoughts:

- the bone marrow edema in the calcaneus is possibly from damage to the subtalar joint, which can be injured in severe sprains - if the joint damage is not severe, it will eventually disappear

- although non specific inflammation in the ankle joint may not be a helpful diagnosis, it may be right, and is common after ankle sprains

- accupuncture cannot solve the inflammation, it can possibly mask the symptoms though not to a great extent - it is a pain treatment

- the steroid injection, on the other hand, can sometimes be curative in this situation - after the ligaments heal you sometimes get a sustained inflammation that no longer has an injury causing it, and the steroid can settle this. It is a misconception that it can 'mask' symptoms, as it is not an analgesic

- as long as you have an abnormal MRI which explains your symptoms, and with due respect to Frank, a pain specialist is not yet who you need to see

- again to be anal, RSD isn't generally called RSD anymore, it's CRPS, and there is doubt as to how sympathetically mediated it is, which is why the name is changed.

Deke

I had a moderate ankle sprain May of 2004, missed two months of running, and was uncomfortable with it through the summer. I had a big knot of scar tissue left in late September 2004 when I began my offseason program which included Bikram Yoga. The combination of stretching and stabilization work in Bikram yoga shrunk the knot of scar tissue and greatly helped with my recovery. It was far superior to the strengthening exercises a physical therapist had me doing all summer. I think it is worth a shot in your case. I'd recommend Bikram in particular as the combination of exercises they have you do are the same from location to location so if you go to a local place to do it you'll do the same sequence that worked so well for me. It's also great for knee and back pain.

-Marc

Deke -

Frank and I had this discussion a while back about the name change from RSD (which I like to call Refer to Some other Doctor) to complex regional pain syndrome (and the like). Remember, he is in a "new" career now ...

I personally would have done the steroid injection a long time ago, but that is me. Also remember her chronicity, a simple sprain or subtalar effusion shouldn't last 6 months +

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

He treated a lingering pain in my iliac crest and remnants of my trochanteric bursitis. My physiatrist couldn't solve my pain in my iliac crest and it was gone in two sessions with the acupuncturist.

When my back feels funky and knotty he does cupping which works better than massage.

Good luck!

[reply]Weighing in a little late, but a few thoughts:

- the bone marrow edema in the calcaneus is possibly from damage to the subtalar joint, which can be injured in severe sprains - if the joint damage is not severe, it will eventually disappear

It is going on 6 months. When will it disappear if it is not a severe sprain? If it is a severe sprain, why is everything else in the MRI, CT normal?

- although non specific inflammation in the ankle joint may not be a helpful diagnosis, it may be right, and is common after ankle sprains

Of course it is right because it is in the diagnostic manual and the doctor wrote it down because he doesn't have any criteria to give another diagnosis. It is called a wastebasket diagnosis. Edema, NOS.

- accupuncture cannot solve the inflammation, it can possibly mask the symptoms though not to a great extent - it is a pain treatment

Actually, I disagree. Chronic pain, especially when it is caused by RSD, but, through other mechanisms also, can cause chronic edema. Accutpuncture probably works through counter stimulation and can break up the pain pattern, and if the pain pattern is relieved, and this is the source of the edema, the edema will resolve.

- the steroid injection, on the other hand, can sometimes be curative in this situation - after the ligaments heal you sometimes get a sustained inflammation that no longer has an injury causing it, and the steroid can settle this. It is a misconception that it can 'mask' symptoms, as it is not an analgesic

I have no problem with a steroid injection here. Ugh, where are you going to inject it? If she ends up with a ruptured achilles (that is a risk isn't it) I don't think she will think you are considerate of her athletic aspirations. How do the risks of a steroid injection compare to the risks of a diagnostic sympathetic block? Guess it depends on who is doing the block, doesn't it. Just because you are not qualified doesn't mean the block carries ANY significant risk in the right hands.

- as long as you have an abnormal MRI which explains your symptoms, and with due respect to Frank, a pain specialist is not yet who you need to see

I don't see how this MRI explains her symptoms. Could you explain? All I see is it confirms there is something amiss and she is not being dismissed as a drug seeker or mainpulator, or hysterical or something else. OK, she doesn't need a pain specialist. All she needs is someone who can solve her problem. If her problem is an RSD you solve it for her.

One more question, exactly when is the time for her to see a pain specialist? How long does she have to suffer before you will take treating her pain seriously? Six months isn't enough? After all, it would appear that the only thing preventing her from getting on with her life is pain as there appears to be nothing structurally wrong to account for her ongoing symptoms. Or do you disagree? Oh, I forgot, subtalar damage, NOS does the trick.

- again to be anal, RSD isn't generally called RSD anymore, it's CRPS, and there is doubt as to how sympathetically mediated it is, which is why the name is changed.

It is being anal and shows a poor understanding of the disorder. I accept that it is not generally called RSD anymore. The name was changed by those who do not have the capability of doing sympathetic blocks or have never seen an adequately performed block in a patient with RSD. This allows them to "justifiably" avoid sending these patients to doctors who can actually perform this treatment. Anyone who has ever seen a patient with this disorder receive a diagnostic block and then be cured as the block wore off (or after a short series of blocks) would never say the sympathetic nervous system is not involved in maintaining this disorder and this is a reasonable name for the disorder, although my preferred name for the disorder was sympathetic maintained (or mediated) pain syndrome. If I had said she had SMPS no one would have known what I was talking about. RSD has name recognition and legs.

In my opinion, the diagnositc criteria for the diagnosis of CRPS should require the patient to have failed to respond to an adequately performed sympathetic block. Then, it really is complex and may be something different than a simple RSD. In my experience, if Susan had come to see me I would have given her a 75% chance of being pain free and cured in less than a week. The same odds would hold 2 months from now should her symptoms remain as it is possible she will continue to improve with her current treatment plan. After all, tincture of time is sometimes the best choice. Only question, how much time?

The reason for making any diagnosis is to provide a basis for therapy. The proof of any diagnosis is response to appropriate therapy.

Frank

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Frank,
An original Ironman and the Inventor of PowerCranks

[reply]My ankle hurt on my trainer tonight. And it wasn't a workout that should've been stressful. It makes me wonder if using PCs would hurt, too.

I don't understand it. And I wouldn't be obsessing about it, except I worry that bone marrow edema and swelling indicate tissue damage that I am making worse every time I do something that hurts. But in light of the fact that it hurts all the time, even when I'm just sitting at my desk, training may not really be an issue. But who the heck knows?

The orthopedist suggested a steroid injection. But I don't see how artificially calming the inflammation will address whatever the problem is.

Oh, well. You guys have been patient and kind to suffer through my hand-wringing and to offer suggestions for a problem that doesn't seem to have a solution. Maybe a pain anesthesiologist is the next logical step now--except that approach still doesn't address what's causing the edema and the swelling.

Susan[/reply]

One won't know if PC's will bother you or not. They do reduce the stresses on the joint as you don't have to push as hard. Only way to know is to try.

Steroid injection is reasonable but may involve the risk of a achilles rupture. While small, it does happen. A probably more effective alternative would be a short course of high dose oral steroids. Another advantage of this approach is one isn't dependent upon the physician injecting the steroid into the right spot (after all, where is the problem?) and it will be cheaper.

If the edema is coming from an RSD, seeing the pain anesthesiologist does address the underlying issue. I am more suspicious now that you are also having symptoms riding the bike but do think a trial of steroids would be useful before searching out one of these specialists.

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Frank,
An original Ironman and the Inventor of PowerCranks

My SIL says Bikram yoga cured her back pain. She lives in another state and has heard that the Bikram yoga place where I live is not as "good." I don't know what that means, but I have been put off by the facts that the classes are scheduled at times that conflict with my job and that they last 90 minutes. I already spend so much time in physical therapy, between my ankle and my shoulder, that committing to that much more time looks pretty imposing. On the other hand, if it would fix my ankle . . . .

Susan

Personally, I did not have enough time for yoga during the season last year so picked it up as soon as I finished serious racing. I noticed the improvements in my ankle after just a week or so of practice, so it might be worth it for you to try it out and see--- You've got nothing to lose. Now I make time for yoga once a week during the season because it has been so good for me.

-Marc

"Please explain how your explanation causes marrow edema? "

Here's my take. Please correct me if I'm wrong, but also please don't try to sell me a set of PC's. :)

Chronic edema is very common in ankle problems. In an ankle sprain the talus bone becomes mildly subluxated. The ankle joint is a ligamentous joint and is now biomechanially ineffecient and unstable. Hence the edema which doesn't seem to go away.

I disagree with the chiropractor that suggests that "adjustments" of the joint aren't likely to help once the injury has become chronic. This hasn't been my personal experience in dealing with these injuries. I've seen quite a number of these in 23 yrs and will admit that nothing is a guarantee, but this type of treatment can often resolve the problem. The "adjustment" of the joint is a long axis traction of the joint with a "shotgun thrust". You'll actually here a popping sound much like when a chiropractor manipulates a spinal joint. Usually I'll also treat with low volt to attempt to reduce any edema. Six to nine treatments or so and most people seem to notice a significant improvement. I've had a few that don't respond but in general most people do.

What you're suggesting with the RSD block would probably work, but I don't see this tx as addressing the biomechanical cause of the problem.

[reply]"Please explain how your explanation causes marrow edema? "

Here's my take. Please correct me if I'm wrong, but also please don't try to sell me a set of PC's. :)

Chronic edema is very common in ankle problems. In an ankle sprain the talus bone becomes mildly subluxated. The ankle joint is a ligamentous joint and is now biomechanially ineffecient and unstable. Hence the edema which doesn't seem to go away.

I disagree with the chiropractor that suggests that "adjustments" of the joint aren't likely to help once the injury has become chronic. This hasn't been my personal experience in dealing with these injuries. I've seen quite a number of these in 23 yrs and will admit that nothing is a guarantee, but this type of treatment can often resolve the problem. The "adjustment" of the joint is a long axis traction of the joint with a "shotgun thrust". You'll actually here a popping sound much like when a chiropractor manipulates a spinal joint. Usually I'll also treat with low volt to attempt to reduce any edema. Six to nine treatments or so and most people seem to notice a significant improvement. I've had a few that don't respond but in general most people do.

What you're suggesting with the RSD block would probably work, but I don't see this tx as addressing the biomechanical cause of the problem.[/reply]

I don't know if you are wrong or not. Neither of us "knows" what is wrong with her and I don't normally bother getting imaging in these kinds of things as I find them pretty useless in helping the patient and most have had all this before they came to me. I do know that edema can occur with RSD as it can with any chronic instability. My experience with chronic instability has mostly been with the spine and marrow edema is not in my experince one of the findings on MRI.

In this instance, in my experience, if the sympathetic block takes the pain away but then it continues to come back without improvement I always suspect an undiagnosed structural problem causing the recalcitrance that must be corrected before blocks will be effective (if they will be needed after the structural correction). In this instance I redoble my efforts in finding something. Her pain is described as a neuropathic pain so it is possible that there is something going on in the back causing the nerve irritation that is causing pain in the foot/ankle, or it could be local as you suggest. If a sympathetic block takes the pain away and it doesn't come back, then there is no structural problem, or at least, no structural problem causing chronic pain.

With both of our scenarios, there is no test that can prove the diagnosis before a trial of therapy. So, she is going to have to pay her money and take her chances. If whatever she chooses first doesn't work, she, at least, has other options. If she decides to go the block route she should PM me so I can help her find someone competent to maximize her chance of success.

If these efforts also fail, I have other ideas for her but those are premature to suggest at this point.

I am also wondering what happened that she got worse since this thread started. She was going to get a boot to wear except when riding. Did she get worse (that is, now having pain riding the bike) after she started wearing the boot? If so, I suggest that also supports the RSD diagnosis and not a chronic sprain. Movement is good for RSD, bad for a chronic sprain.

Frank

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Frank,
An original Ironman and the Inventor of PowerCranks

Frank:

I agree with a lot of what you say, particularly about your comments about patients doing well with sypmathetic blocks on an anecdotal basis. The literature, however, does not support your view well though, and maybe that's because of the diagnostic criteria being a problem, which is a point you have emphasised.

The steroid injection would go in the ankle joint, where the effusion is. There is no evidence of increased risk of Achilles rupture unless you put it around the tendon, which I would never suggest. I don't think very many people would really suggest that a sympathetic block is easier to do than an ankle joint injection. As you say depends on who does it, but an ankle injection is pretty easy and safe for an orthopaedic surgeon.

I agree that chronic pain can cause chronic edema, even bone marrow edema, which may be the basis for positive bone scans in CRPS. However, it would usually be a generalised edema, in the regional bones, rather than a specific spot like the calcaneus near the subtalar joint. Subtalar joint damage is a simpler explanation. I should clarify that the sprain and the subtalar joint damage I would think of as two different entities caused by the same injury. The subtalar damage I would think of as a joint contusion as one sees around the knee with ACL injury.

I realise that your thoughts on CRPS are valid, but they come from the population that you were referred. If I sent everyone with a severe ankle sprain with pain at 6 months to a pain specialist, the pain specialist would make a lot of people better, but a lot of the people would have gotten better anyway, and they do in the population that I see. There would an awfully high number of blocks. I just don't think that her investigation and treatment has been inappropriate so far.

I agree with you final comment about response to treatment being proof of diagnosis. I like doing differential intraarticular blocks when a diagnosis is in question - perhaps this would be a case for this.

Interesting to hear your thoughts on this - please don't take offense at the discussion.

Deke

"Movement is good for RSD, bad for a chronic sprain. "

Frank, here's a thought for you:

Movement is bad for chronic sprain because of the mild subluxation of the talus. When I use term "mild subluxation" we're not meaning a mild dislocation but rather an abherrent movement of the talus in it's articulation with the distal end of the tibia during it's normal range of motion. Essentially what chiropractors deal with with their manipulation therapy is correcting irregular or limited joint movement that is not functioning within it's normal physiological range of movement and not "bones out of place" which is just a general expression sort of like saying a "slipped disc". Movement is bad for the chronic sprain because of the irregularity of the talus/tibia articulation after a sprain which is now constantly being irritated. If the talus biomechanics is corrected through an "adjustment" the healing process can then begin.

I can think of one case in particular with a patient that had two previous ankle fractures complete with screws many years earlier. Since coming out of the cast his ankle had never been properly functional. In fact, just regular walking would irritate it. He had constant chronic edema and very limited plantar/dorsi flexion in the ankle. After a series of treatments and custom orthotics his range of motion was restored to 80% of normal and his edema went away. The ankle will never be as it was pre trauma, but was considerably improved, even years later. This is an example how proper follow up was ignored initially.

In another life I was orthopaedic technition. In fact, that's how I worked thru chiropractic college. A typical treatment at the hospital at the time was to automatically throw any ankle sprain coming into emerg into a below the knee walking cast for 4-6 wks. The cast would be taken off, the patient told he/she is OK and no advice or follow up would be given. I put on hundreds of casts knowing fully well that proper follow up was not being done, nor was this usually the best treatment.

Many people will complain that once they've had a badly sprained ankle they are much more subject to re-occurences. Typically the family physician or even ortho surgeon will tell them that this is because the "ligaments have been stretched" and they'll have to live with it. In reality, I'm convinced that the reason for the re-occuring sprains is because of the irregularity of the talus that has occured in the initial sprain. Hence it becomes a chronic condition that could have possibly been prevented if addressed initially.

[reply]"Movement is good for RSD, bad for a chronic sprain. "

Frank, here's a thought for you:

Movement is bad for chronic sprain because of the mild subluxation of the talus. When I use term "mild subluxation" we're not meaning a mild dislocation but rather an abherrent movement of the talus in it's articulation with the distal end of the tibia during it's normal range of motion. Essentially what chiropractors deal with with their manipulation therapy is correcting irregular or limited joint movement that is not functioning within it's normal physiological range of movement and not "bones out of place" which is just a general expression sort of like saying a "slipped disc". Movement is bad for the chronic sprain because of the irregularity of the talus/tibia articulation after a sprain which is now constantly being irritated. If the talus biomechanics is corrected through an "adjustment" the healing process can then begin.

I can think of one case in particular with a patient that had two previous ankle fractures complete with screws many years earlier. Since coming out of the cast his ankle had never been properly functional. In fact, just regular walking would irritate it. He had constant chronic edema and very limited plantar/dorsi flexion in the ankle. After a series of treatments and custom orthotics his range of motion was restored to 80% of normal and his edema went away. The ankle will never be as it was pre trauma, but was considerably improved, even years later. This is an example how proper follow up was ignored initially.

In another life I was orthopaedic technition. In fact, that's how I worked thru chiropractic college. A typical treatment at the hospital at the time was to automatically throw any ankle sprain coming into emerg into a below the knee walking cast for 4-6 wks. The cast would be taken off, the patient told he/she is OK and no advice or follow up would be given. I put on hundreds of casts knowing fully well that proper follow up was not being done, nor was this usually the best treatment.

Many people will complain that once they've had a badly sprained ankle they are much more subject to re-occurences. Typically the family physician or even ortho surgeon will tell them that this is because the "ligaments have been stretched" and they'll have to live with it. In reality, I'm convinced that the reason for the re-occuring sprains is because of the irregularity of the talus that has occured in the initial sprain. Hence it becomes a chronic condition that could have possibly been prevented if addressed initially.[/reply]

I don't doubt what you are saying. In my experience we saw this all the time in the spine, although it is not so easy to fix with manipulation as it is due to the loss of disk height. Spinal spurring seen on xray is a result of chronic abnormal movement, subluxation. The only problem is many have this condition without pain.

However, for Susan, is mild talus subluxation the operative problem here? Not sure why this alone problem would cause her to have pain when riding her bike, which seems to be occuring now. Perhaps, if you are right, in addition, it is possible such a problem could set up an RSD type pain, so both could be operative and she won't get better until both are treated. Or, if once the subluxation is corrected, the "RSD" irritant may go away and the "RSD" could correct itself. Or, there may be no underlying problem now and it is purely an RSD. Or, something else none of us have thought of. She doesn't want to hear that I am sure but we won't know what her problem really is until we know what corrected it.

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Frank,
An original Ironman and the Inventor of PowerCranks

>"A typical treatment at the hospital at the time was to automatically throw any ankle sprain coming into emerg into a below the knee walking cast for 4-6 wks. The cast would be taken off, the patient told he/she is OK and no advice or follow up would be given. I put on hundreds of casts knowing fully well that proper follow up was not being done, nor was this usually the best treatment.

Many people will complain that once they've had a badly sprained ankle they are much more subject to re-occurences. Typically the family physician or even ortho surgeon will tell them that this is because the "ligaments have been stretched" and they'll have to live with it."<

As I'm sure you're aware, that's why we don't do the cast thing anymore - at most a functional brace. Also, most recurrent sprains are not from strteched ligaments, but proprioceptive damage, which can eventually be rehabilitated - perhaps this is what manipulation helps with.

Deke

[reply]Frank:

I agree with a lot of what you say, particularly about your comments about patients doing well with sypmathetic blocks on an anecdotal basis. The literature, however, does not support your view well though, and maybe that's because of the diagnostic criteria being a problem, which is a point you have emphasised.

The steroid injection would go in the ankle joint, where the effusion is. There is no evidence of increased risk of Achilles rupture unless you put it around the tendon, which I would never suggest. I don't think very many people would really suggest that a sympathetic block is easier to do than an ankle joint injection. As you say depends on who does it, but an ankle injection is pretty easy and safe for an orthopaedic surgeon.

I agree that chronic pain can cause chronic edema, even bone marrow edema, which may be the basis for positive bone scans in CRPS. However, it would usually be a generalised edema, in the regional bones, rather than a specific spot like the calcaneus near the subtalar joint. Subtalar joint damage is a simpler explanation. I should clarify that the sprain and the subtalar joint damage I would think of as two different entities caused by the same injury. The subtalar damage I would think of as a joint contusion as one sees around the knee with ACL injury.

I realise that your thoughts on CRPS are valid, but they come from the population that you were referred. If I sent everyone with a severe ankle sprain with pain at 6 months to a pain specialist, the pain specialist would make a lot of people better, but a lot of the people would have gotten better anyway, and they do in the population that I see. There would an awfully high number of blocks. I just don't think that her investigation and treatment has been inappropriate so far.

I agree with you final comment about response to treatment being proof of diagnosis. I like doing differential intraarticular blocks when a diagnosis is in question - perhaps this would be a case for this.

Interesting to hear your thoughts on this - please don't take offense at the discussion.

Deke[/reply]

Most would agree that a sympathetic block is not easier to do than an ankle injection because most have not been trained to do the first and most don't care if they actually get the needle actually into the joint in question. I for one find joint injections much more difficult than sympathetic blocks as there is no good endpoint to ensure it is technically good without Xray confirmation. I did a lot of subacromial bursa blocks for shoulder impingement syndrome (without xray) as I found that was one of the very common missed diagnoses for upper extremity pain, pain that would look like an RSD but wasn't. With sympathetic blocks there is a good endpoint always available to let you know the block was technically good. We are not talking brain surgery, nothing more complicated than a labor epidural. If these can be done routinely with almost zero serious complication rates in patients in labor, they can be done easily in anyone.

If you will do a literature search read the my rebuttal to a supposedly academic review of the literature "proving" the non-existance of RSD by a "highly respected" neurologist pain specialist. Published in Muscle and Nerve back in the 90's. The non-anesthesia literature currently is dominated by those who don't do these blocks (and few of the anesthesiologist pain docs are really any good at them I am ashamed to admit). For some reason all the current crop of anesthesiologist pain docs need CT scan to help them place the needle even though it adds nothing to the safety or efficacy. Then they use the CT to prove it is an adequate block, rather than the response of the patient. Why do they need CT in the chronic pain patient when they don't for the labor epidural? The answer should be colored green and given by a lawyer I am afraid.

So, 6 months is not long enough for you for the patient to suffer with pain before you refer them to a pain specialist just so the pain specialist doesn't make too much money becaause the patients are mostly going to get better anyhow. Just what is your limit in this regards? Are you providing them with enough pain medications in the interim while waiting for enough time to pass. I never found pain medications particularly effective in treating neuropathic pain but maybe you have. Wonder what pain medicaations Susan has been given and how they work for her. I suspect she has been given nothing. Do you normally asked the patient what their limit is in this regards or make the decision for them?

A differential interarticular block would be a great idea here although it would not answer the question definitively as sometimes neuropathic and central pain can respond to iv lidocaine, because it will surely be absorbed.

Anyhow, it drives me crazy. One of the ethical duties of a physician is to relieve pain and suffering. Susan's pain somehow doesn't seem "severe" enough to be taken seriously by her doctors. Lucky for her she has an abnormality on MRI or she would be thought of as a total crock, still having complaints after "everything had been done". How these patients are typically ignored and shunned by the general medical population is a disgrace.

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Frank,
An original Ironman and the Inventor of PowerCranks

I might add, if you are interested in this chronic pain business I invite you, or anyone else, to join one or two chronic pain list-servers I particpate in. One is devoted mostly to clinical issues, the other is much more political. The political one gets most the traffic. If you are interested PM me and i will give you the info to join.

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Frank,
An original Ironman and the Inventor of PowerCranks