Question
QUESTION: I am writing to you concerning my husband who had a work injury about 15 months ago. He is 29 years old with no other health concerns. He worked in a factory and a tall cart with stacked trays fell on his left foot. The initial exam in the emergency room revealed nothing but a contusion. Ever since, he has had chronic pain that is localized to the back of the ankle by the achilles tendon. That spot is very painful and he cannot tolerate even the slightest touch. He describes the pain as a burning/stabbing pain. He also cannot move his toes on the injured foot. His entire foot can at times look red and feel hot to the touch and at other times, look bluish in color and feel very cold to the touch. We have been to several doctors and after a series of tests (MRI, CT scan, X-rays, ultrasound) they told us that he has reflex sympathetic dystrophy. They tried to do a nerve conduction test but could not finish the exam because he was in severe pain. An EMG test was never done. The nerve blocks he was given offered only temporary pain relief (a few hours). He then underwent a five-day epidural infusion in the hospital which offered a few days of pain relief upon leaving the hospital. He has been doing intense physical therapy for 15 months now but he cannot put any pressure on his left foot. He is still unable to return to work and walks with a cane. I am wondering whether this could be a nerve entrapment and not RSD? His doctors disagree and refuse to do an EMG. However, his doctors cannot explain why he cannot move his toes. (During the brief periods of pain relief following the nerve blocks he was able to move his toes) Could a nerve entrapment explain all these symptoms? If so, how could this be determined? He has been suffering for a long time now and we are desperate for some answers. Any insight you could offer on this matter would be greatly appreciated. Thank you.

ANSWER: Elena,
His problem is very likely nervous system related and he needs to have his nervous system evaluated and the underlying structures viewed to see what all is involved.  It is obvious that stretching and exercises are not what he is needing, so the PT is a waste at this point.  It is also obvious that the medical doctors are not able to help him either, this is another waste for him.  It is apparent that none of these health professionals have been able to locate the cause of his health trouble, so I would recommend going to a specialist who will look for the cause in his structural foundation and his nervous system.
That is actually what my specialty is, although unless he is in the St Louis area, there may be someone closer for him to go and see.
If you would like a referral from me to a specialist that may be able to help him, then send me his location and I will find someone to help.
Yours in Best Health,
Dr Robert Arnone
St Louis, MO, USA

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QUESTION: Dr. Arnone,
Thank you for taking the time to respond to my question.
We live in the Chicago area, so I would really appreciate a referral for someone in our area. What specialty should we be looking for exactly? He is already seeing a neurologist and a pain specialist. I would also like to ask you about the MR neurography test. I recently discovered on the internet that this test existed but it is not widely available. Can you give me your opinion of this test and if you know of any doctors in our area that are presently using it? Thank you, Elena

Answer
Elena,
I am sorry but I have been trying to find a specialist for him but I am coming up empty.  I used to work in an office in Chicago but have since moved to St Louis to practice.  There was another specialist in Chicago, but he also moved out of the area as well.  I will keep looking for you but I just may be your best option at this point.  We have many patients that travel from other states for their care, so that is not uncommon at all.  I will keep looking and see if I can locate someone for him again, and then we can go from there.
In the meanwhile, you can send me the pics from any cervical spine MRI, Xray, or CT scans.  Just email them to me at [email protected]
Yours in Best Health,
Dr Robert Arnone
St Louis, MO