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Ask an expert - muscles and bones - feet

31 questions

Q:  Four years ago I had surgery for an abscess in my foot, which has left me with nerve damage. The pain has got worse recently with constant throbbing day and night in my big toe, so much so that sleeping has become a problem. I have been prescribed Gabapentin which did help with sleeping but I have had several side effects and I do not like the idea of being on medication permanently. I do take regular exercise. Do you think acupuncture would help?

A:  This is rather difficult to say. A great deal depends on what damage was actually caused during the operation, and more particularly why the pain has started to get worse four years after the event. There is quite a deal of evidence suggesting that nerves in the periphery can regenerate, and one would assume that after four years most of this has already taken place. If there is now continuing and increasing pain, it suggests that either a nerve ending has permanently severed and rather like phantom limb syndrome is sending out signals which cause considerable pain, or there is scar tissue from the operation which is now impinging on a nerve and generating pain. The latter would seem more likely on the basis that natural changes in the gait might be more likely to bring the scar tissue into increasing play, but this is speculation - the bottom line is that you have pain.

From a Chinese medicine perspective, pain results from changes in the flow of energy, either excess or weakness of flow, or more often blockages. The aim of treatment is to restore the proper flow in the simple but effective belief that improved flow means less pain. Interestingly there is evidence for the treatment of phantom limb syndrome, as we wrote recently

There have been a number of studies over the years which describe the use of acupuncture in individual cases, and if you google 'acupuncture phantom limb pain' you will find examples such as:

http://www.ncbi.nlm.nih.gov/pubmed/6972207

We are also aware of a paper published in the Journal of another acupuncture association which cites the following papers about phantom limb sensation.

Bradbrook D (2004) Acupuncture in Medicine Acupuncture Treatment Of Phantom Limb Pain And Phantom Limb Sensation in Amputees. 22; 2; 93-97

Hecker H. -U et al (2008) Color Atlas of Acupuncture 2nd Ed. Thieme, Stuttgart

Hill A (1999) Journal of Pain and Symptom Management Phantom Limb Pain: A review of the Literature on Attributes and Potential Mechanisms. 17; 2; 125-142

Johnson M.I. et al (1992) Pain Clinic Treatment of Resistant Phantom Limb Pain by Acupuncture: A Case Report. 5; 2; 105-112

Liaw M.-Y et al (1994) American Journal of Acupuncture Therapeutic Trial of Acupuncutre in Phantom Limb Pain of Amputees. 22; 3; 205-213

Monga T.N et al (1981) Archives of Physical Medicine in Rehabilitation Acupuncture in Phantom Limb Pain. 62; 5; 229-2321

The mechanism by which the treatment works is not at all clear from a Western medical point of view. From a Chinese medicine perspective it is perhaps easier to make sense of the appearance of the pain from the fact that the channels which run through the affected area spread out across the body, and even in 'conventional' Chinese medicine treatment it is not unknown to treat a problem in the lower left limb by using points in the upper right limb. The fact that the opposite limb is missing would not necessarily render the treatment useless.

and we have also written about scar tissue and its impact on health. There is little research to back this up, but many of us have had the clinical experience of using very simple treatments across scar lines to 'join the dots' as it were and often to great effect.

Since each particular instance of damage will be unique and different, though, the only really good answer we can give you is to visit a BAcC member local to you for a brief face to face assessment of what may be possible. What we would say, though, is that if your health is otherwise good, you would be well advised to limit the number of treatments you have initially to three or perhaps four. Our experience is that if something is amenable to change then there should be some signs quite rapidly. What we don't like to see is patients buying into extended courses of treatment when there is really no evidence of change.

We should also mention that acupuncture can be used as a more general systemic agent of pain relief. Indeed, after Nixon's visit to China in the 1970s and strange footage of people having operations without anaesthetic a great deal of research was done about the ability of needles to release the body's own painkillers, enkephalins and endorphins. There is substantial evidence supporting this facility, and the question is how much relief and how sustainable. Unless the relief is very long lasting, though, or the pain so intractable that any relief is worthwhile, it may not be an economically viable option for most people if the improvements are only ever short term.

Q:  I have morton neuromas on both my feet affecting the toe next door to the little toe in both cases. I have had steroid injections in the past but want to look into alternative treatments and thought acupuncture the best place to start. Can you advise me if it is affective please?

A:  We have to be honest and say that there is not a great deal of evidence for the effective treatment of Morton's neuroma with acupuncture. We published an answer through this same section three years ago to a question from a patient who was convinced, and with some justification, that treatment with one of our colleagues has been wholly responsible for a complete improvement in his condition. 

We have to say, though, that our clinical experience runs counter to this, which is why the very upbeat tone of webpages like that of this American practitioner

http://acuroots.com/mortons-neuroma-treatment-plan-with-acupuncture-and-tui-na/

(informative as it is) raises a wry smile. If only... Having said that, what he describes in the formation of the tissues which cause the condition is something with which we deal elsewhere on the body, and in theory there is no reason why treatment should not be able to reduce some of the discomfort. However, we would be very surprised if this could be done without the aid of orthotics which reduce some of the pressure on the affected areas while any treatment beds in.

Each case is unique and different, however, and the only real solution is to seek face to face advice from a BAcC member who can look at exactly how the problem manifests in you, and more importantly, can see the overall context in which it is occurring. One of the great strengths of Chinese medicine is that it looks at the whole system, not simply at a symptom which is regarded as merely a warning sign. Thousands of people with identical foot structures to you will walk thousands of miles without getting neuromas, and there may be systemic problems which have predisposed this to happen.

The other recommendation we would make, and we are sure that you have done this already, is to find a good chiropodist or podiatrist who can work alongside any other treatments you try to help to maintain improvements. Working in partnership with other health professionals for problems like yours can often be extremely powerful


Q:  I have morton neuromas on both my feet affecting the toe next door to the little toe in both cases. I have had steroid injections in the past but want to look into alternative treatments and thought acupuncture the best place to start. Can you advise me if it is affective please?

A:  We have to be honest and say that there is not a great deal of evidence for the effective treatment of Morton's neuroma with acupuncture. We published an answer through this same section three years ago to a question from a patient who was convinced, and with some justification, that treatment with one of our colleagues has been wholly responsible for a complete improvement in his condition.

We have to say, though, that our clinical experience runs counter to this, which is why the very upbeat tone of webpages like that of this American practitioner

http://acuroots.com/mortons-neuroma-treatment-plan-with-acupuncture-and-tui-na/

(informative as it is) raises a wry smile. If only... Having said that, what he describes in the formation of the tissues which cause the condition is something with which we deal elsewhere on the body, and in theory there is no reason why treatment should not be able to reduce some of the discomfort. However, we would be very surprised if this could be done without the aid of orthotics which reduce some of the pressure on the affected areas while any treatment beds in.

Each case is unique and different, however, and the only real solution is to seek face to face advice from a BAcC member who can look at exactly how the problem manifests in you, and more importantly, can see the overall context in which it is occurring. One of the great strengths of Chinese medicine is that it looks at the whole system, not simply at a symptom which is regarded as merely a warning sign. Thousands of people with identical foot structures to you will walk thousands of miles without getting neuromas, and there may be systemic problems which have predisposed this to happen.

The other recommendation we would make, and we are sure that you have done this already, is to find a good chiropodist or podiatrist who can work alongside any other treatments you try to help to maintain improvements. Working in partnership with other health professionals for problems like yours can often be extremely powerful.


A:  The most obvious advice to offer for the tear in the plantar fascia is to rest the foot as much as possible and to stop any exercise which might put strain on it. The treatment for plantar tears will be much the same as the treatment for plantar fasciitis, on which we said a while ago

Can acupuncture help with plantar fasciitis?

Plantar fasciitis can be a very unpleasant and debilitating problem. There is some evidence for the use of acupuncture treatment, as this paper shows,


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094706

and if you google 'acupuncture' and 'plantar fasciitis' you will find a number of other papers which suggest that there may be benefits from treatment. However, the combined weight of the various studies is not enough to be able to give an unqualified recommendation.

That said, the strength of Chinese medicine is that it operates from an entirely different paradigm or theoretical basis, and has different ways of making sense of the symptoms which a patient is experiencing. This can sometimes offer treatment options which would not necessarily translate into a western understanding of physiology, although there is usually an overlap. The system of medicine rests on a theory of energy, called 'qi', whose flow and balance determine how well the various systems of the body function. Many problems like plantar fasciitis point to local blockages and disturbances, often due to over-use or poor gait, which once they have become established remain a problem even after someone's habits have changed. Symptoms such as this can also point to more systemic problems, and the skill of the practitioner lies in making a clear diagnosis of the whole system before starting to correct aspects of it.

In this case, since the presentations of plantar fasciitis can be very different, we would advise you to visit a BAcC member local to you for a brief face to face assessment of the problem before committing to treatment. We are fairly sure that you will have seen a chiropodist as well as your GP, but if you have not, we would highly recommend that you do. There are a number of treatment options which can work alongside acupuncture treatment to great effect, and with these sorts of problems it is often a combined approach which pays the greatest dividends.

There is less evidence for the treatment of a calcified achilles tendon, but we would probably tend to see both symptoms together as evidence of a disturbance in the flow of energy caused by over-use which has led to a deficiency of flow and in turn a number of blockages in the area. Our practical experience is that there is often a response to treatment, and the main issue is not whether treatment will work but the extent to which it works and how sustainable any change might be.

All in all, though, there is usually an underlying cause of over-use or poor use, and the most important thing alongside rest and treatment is to see if someone can provide the kind of analysis of the mechanical structure of the movements of the foot while running or exercising which show if there are any displacements putting pressure on specific parts of the structure of the foot. Some sports shops offer tread analysis, and this can often highlight a need for orthotics in running shoes which can prevent uneven strain.

Of course, if you are not over-doing the exercise, we would be interested as practitioners to see what other constitutional factors were in play to generate a problem which is normally associated with running. Local injuries are often predicated on overall weaknesses in the system, which is why people living an identical lifestyle can be symptom free.  The skill and art of the Chinese medicine practitioner lies in making sense of the overall picture to ensure that local treatment can not only be effective but stay effective.

As the earlier answer says, the best advice is to visit a BAcC member local to you for a brief assessment where they can take a look at the problem and offer a slightly better informed view than we can offer at a distance.

A:  We have to say that a great deal depends on the extent of the damage resulting from the diabetes, and to a lesser extent whether you have type 1 or type 2 diabetes.  Generally speaking, there is a growing amount of evidence suggesting that acupuncture may be able to help with pain arising from diabetic neuropathy, and a number of studies and papers which make very encouraging noises. We aren't going to reference them here because they are quite complex and not easy going even for us. If you want to look at the scientific evidence, however, you might want to google 'ncbi acupuncture diabetic neuropathy.' This accesses a database of all the studies in the largest medical databases, and will provide with references to dozens of papers.

Numbness of the feet is another matter, however. There are fewer papers, although the ones that we could find, such as this one.

http://www.ncbi.nlm.nih.gov/pubmed/20633522

seem very positive.  Using the same search technique for the term peripheral neuropathy will generate another list of studies, most of which refer to PN induced by chemotherapy, but some of which, including the one we have mentioned, do address the problem from a diabetic perspective.

In traditional Chinese medicine, however, numbness of the feet can be a symptom of a much wider number of problems with the system than the small number usually identified in the west. Chinese medicine has an entirely different diagnostic system based on an understanding of the body as a system of energy in flow, called 'qi'. If this flow is interrupted, for any reason, then pain or numbness can result, and the skill of the practitioner lies in being able to determine whether the flow is damaged by local disturbance of systemic problems. There are functional disturbances in the whole system which can prevent energy getting to the extremities.

This does mean that there can on occasion be symptoms which are automatically assumed to be a part of a larger condition but which may not always be so. A good example for us is the number of patients with low back pain and X-rays with degenerative problems in the spine but who now have no pain although it was assumed that the spinal damage would continue to generate the same problems.

What we would suggest is that you visit a BAcC member local to you for an informal chat to see whether there are particular features of your presentation which encourage them to believe that treatment may help. We are confident that they will be honest in their assessment and tell you if they think there is nothing that they can do. It is likely that this is what they may conclude; the nerve damage caused by diabetes is usually irreversible. However, there is always a possibility that the causal chain is a bit more complex and that they may find diagnostic information which leads them to believe that they may be able to help.

 

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