Toe trauma
 

Hi all, I'm looking to get some advice on my symptoms, treatment and possible recovery time (if at all :().

6.5 months ago I dropped an 80lb dumbell directly onto my pinky toe. To be honest I didn't think much of it initially, I figured it was bruised and the swelling would come down - I had some pain, but not much - so I continue my activities of walking etc.

About a month later, the swelling had not gone down. I got some xrays and had a fracture across my mid-phalanx, so I buddy taped it and tried to stay off it. Unfortunately 3 months after the initial injury it was still swelling - I reinjured it by knocking it off something and the next day it was completely black and blue like day 1. I went to a podiatrist, for more x-rays and was just told to give it more time.

Then, about 2 months later I went to see a different podiatrist as the symptoms were persisting, although the swelling had gone down a bit.

He diagnosed me with neuropathy and advised me to contrast bath twice a day (I also had some blood pooling across the foot). I also wore compression socks for a while, and wrapped the toe with Copan tape.

Here are my symptoms:
- I have my ups and downs but it's usually swollen. For a few days last week I thought it was better because I had 2 days in a row where the redness and swelling decreased a lot.

- Walking a lot, hot showers, and just general heat aggravates it a lot. It just goes bright red after a hot shower, and proceeds to swell up with burning and itching. It's as if the sheath is thin or damaged, but I'm not sure.

- Icing helps, and cold weather seems to stop extreme swelling. I also keep it wrapped with Copan tape, which helps a lot. I guess I'm lucky that I can just compress it to keep swelling down but I worry that restricting blood flow might be worse for it.

Anyone have any ideas, suggestions, help? The problem is I guess the swelling could be down to soft tissue trauma from the crushing, but the sign of sensory neuropathy are there for sure.

I thought I would attach a picture of the area after a hot shower to show what I'm describing (the swelling is pretty low today):

Attachment 7861

Similar symptoms, no dumbbell drop
 

That photo looked so familiar!--except that it's my fourth and fifth toes that turn bright red (and swollen), while the first three toes are more blue-purple. I didn't have a similar episode of heavy trauma, but my PN started with major swelling of the foot and leg, eventually spreading to other foot and leg.
(Tested for circulatory issues; none. Took med for Raynaud's; no effect. Advised to wear light compression stocking despite no circ issues, but that made the pain worse.) So I have no help to offer you -- just some additional sympathy, along with the observation that the symptoms might come from something other than blunt trauma. Good luck. (By the way, almost all of my shoes irritate my toes now, despite no perceptible change in shoe size.)

Is that toe only red like that after a hot shower?

Is is red all day long? Is it swollen when you first get up or only after you have walked around?

It only really get that bright red after a hot shower. Some days when I wake up its a normal color, and swelling is low especially after wearing the tape.

I had a couple of days last week where it was pretty normal and didn't even need to wrap the rape on one day and slept without it. Then is seemed to get a bit worse again for no reason and it's a little red and swollen most of the time.

Over the months, on average, I think it's come down a bit. It doesn't immediately balloon up after the shower anymore but just goes bright red. It's definitely inconsistent. I slept without the tape 3 nights ago and it was swelling without the red color (felt hard to touch), standing up immediately softened it. Weird.

If I walk for more than a few minutes (I'm still cautious while walking because it starts to hurt - maybe some soft tissue damage) it can swell up more and burn and itch. Alcohol seems to exacerbate this too.

Yes, alcohol would dilate the superficial capillaries and increase blood flow.

You know what you can try? Salonpas patches. The original type with methyl salicylate in them.

http://www.salonpas.us/product/salonpas-original/

I'd put a whole patch 1/2 over the edge of your foot where that toe is. Fold it so 1/2 is on the top of your foot and the other half goes over the side to the bottom. Place it so the top edge is as close to that pinky as possible. The anti-inflammatory actions will
seep into the area and give some relief perhaps. I use them on my feet all the time. I have broken sesamoid bones and arthritis.
(in addition to PN).

Another inexpensive remedy is Morton Epsom Lotion. This improves circulation to the periphery, so that the blood flow is more normal. Rub into the toe and top of the foot. Use only a small amount, as a little goes a long way. Inflammation closes off circulation, and by opening up the blood vessels, then the blood can do its job better. You may be having spells of constriction followed by dilation (which is the red part)

That red toe resembles what happens when you get cold shock, and then warm up, and the blood vessels dilate and turn things red. Ears for example exposed to cold turn red that way.

Morton's is at WalMart and Walgreen's locally. And online at Amazon.

http://www.mortonsalt.com/for-your-h...-epsom-lotion/

Thanks for much for the response!

So, are my capillaries malfunctioning? Most people seem to have issues with cold, rather than heat but nerve damage just means the nerves react the wrong way right in any direction?

I think the reason my toe stayed normal for a whole day with proper skin tone and minimal swelling is because I kept it really cool the whole time, and only had mild showers to stop the trigger. Do you think I should avoid contrast baths at this stage? Sometimes when I wake up and take off the tape, the skin switches to normal skin color, and then the baths make it go red and swell a bit again - not sure if I'm better off doing the baths to keep the blood flow higher, or just work to minimize the swelling - maybe it's a catch22!

I actually ordered some Epsom IT lotion yesterday on your recommendation so thanks for that - I'll give it a try. Sometimes, it can feel raw, red, itchy and hopefully the cream helps with that.

Honestly, I don't experience much pain with it when I keep it cool and don't walk too much. In fact, I never had bad pain which is strange - and I'm guessing this was because I destroyed the nerves. I still cycle 6 miles a day without pain (some niggling, tingling) but even that has subsided a bit - it probably is because it's freezing cold outside :)

Do you think those patches could help if I wanted to go out for a few drinks, because I know it will flare up and burn?

The patches are for inflammation. When you injure tissue, that releases cytokines (inflammation chemicals)...which in the short run work well, but in the long run can keep inflammation working when it is no longer needed.

By turning off these chemicals with the Salonpas, then inflammation goes down, redness goes down, and pain goes down.

The Morton's or your Epsom IT is more for circulation. If your skin is really broken or irritated, the magnesium lotions may sting.
Use them then, slightly away from the toe skin, more toward the top of the foot area.

There is fascia in the foot, tendons, besides the bones, and any or all of them could have been injured. If you feel pain, your nerves are not dead, but just reacting to it all.

Using topical things on the foot, should be tried first, rather than drugs. Sometimes these topicals are better than oral things because they fix the blood flow which may be messed up and not let things in the blood to heal thru to the toe damage.

Ice always feels better on an injury. And also nerve injuries like ice better than heat. You can try ice packs on your foot 2 or 3 times a day and see if that speeds things along too. Since cold feels better, try that. Don't over do, and max of 20 minutes at a time.

Interesting, so I might still have repairing soft tissue damage and the neuropathy is just a manifestation of that? i.e. it might not just be chronic neuropathy at this stage - I guess it's too early to tell.

I know the bone didn't union properly either at the time - it's an awkward spot to immobilize.

My podiatrist recommended Neuro-Eze, but I could only find it online and my instinct tells me it's a bit of a scam but I could be wrong - it is supposed to improve oxygen using L-Arginine but I don't even know if that is permeable through skin.

I will probably continue to ice it. It definitely give some relief when it swells or burns. Do you think I should just leave out the heat bath then? And should I ice it even if it's not swollen when I wake up?

I'd only ice it if it hurts.

Are you really tall? I suspect from your photos that you are. If so it is a LONG way to that pinkey! ;)

Arginine is in some diabetic foot creams to increase circulation.

The Magnesium lotions do the same thing. So I'd start there. Magnesium also blocks the NMDA pain receptors, so it is more useful than arginine.

You could combine the heat treatments followed by ice... see how that goes. Don't over use cold though, as that constricts blood flow.

Think about how your hands feel in the snow without gloves. Then you come in and warm them up.... and they get red and tingle and burn! Same thing with that pinkey. If it hurts at bedtime do the cold treatment then. You will not be standing up and the blood flow with return to normal quickly, when you are sleeping.

Injuries can take a while to heal. Give it time. Don't worry about neuropathy at this point. You just have a trauma toe.
I'd take some vit C daily.... 500mg for about 2 months. Also so other antioxidants, if you want. Some people develop RSD from injuries or surgery or trauma to the ankles/feet and wrists. Vit C seems to block this potential. Since you are taking a while to heal you will want to prevent RSD.

RSD patients however do hate cold treatments, and prefer heat, so you are still the reverse of that. RSD may become permanent, but studies in Europe show Vit C prevent that for many patients.

Keep your foot elevated when you can, at home, etc. I had a surgery on my foot when I was 12, on the instep and it took over a year to heal. Foot injuries take time.

Hi Mrs. D
 

Can Solompas be cut into strips like the lidocane patches? May be direct contact with whole little toe would get more benefits? I have wrapped my big toe (PN) with the lidocane (strips) works great and the very mild compression seems to help me. Can he do that with Solompas? Just wondering if that would work. Someone on NT told me to give that a try. ginnie:grouphug:

Yes, the Salonpas original can be cut. I do that for my fingers.
I use them on my right thumb and first two fingers often.
And my big toes on occasion.

BTW they have changed the stickem and improved them. My new box is very nice and different!

I don't want to be a downer, but I did have a crush injury on my right big toe years ago...a boulder fell out of a wall we were repairing and broke it in two places. It has always been stiff and problematic for me since.

But I have smashed my pinkey toe (it turned black) once when I was vacuuming..and it healed up easily.

You can be creative with the Salonpas. I think they are very handy and very inexpensive for the return you get from their use.

I have been eating tart dried cherries for the past month, and see a definite improvement in my arthritis too... they are really good antioxidant sources:
http://www.ohsu.edu/xd/about/news_ev...ry-juice-r.cfm

http://www.fooducate.com/app#page=pr...2-FEFD45A4D471
These are the ones I use. Doesn't take very many to get a good result either.

Thank you, I just wonder if I should stop using the Coban compression tape then and use the Salonpas patches instead.

Taping (light compression) around the pinky toe has been the best method I have for keeping the swelling down. Sometimes it manages to completely remove the swelling, then after I take the tape off you can almost see the capillaries fill up with blood and the swelling starting within minutes.

I don't think I need any pain meds, I don't have much noticeable inactive pain at all, until I allow the swelling to go out of control by walking or drinking alcohol. Right now I just have a deep itch/tingling in the toe (comes and goes).

I have noticed my gait is off when I do walk. Overextending the toe still seems to cause 'normal' pain - I'm guessing this is just ligament/tendon injury that's persisting.

With the baths I had been using ice bath for 1 min, warm water for 4 mins and alternating. But the warm bath does cause the swelling to increase.

I was thinking about this, but I'm wondering if:
a. The circulation is just bad in general (like cold ears/hands), and the heat is actually helping by increasing the blood flow?
OR
b. The circulation is normal, but the damages nerves are overcompensating by dilating the vessels too much and allowing too much blood in (and therefore swelling)?

It's funny you say that because my podiatrist said almost the opposite :) Well, he said, don't worry about the hairline fracture and focus on the neuropathy.

Actually, I should mention that right after that visit (4.5 months after injury) I started putting weight back on the foot, did one contrast bath and the toe came alive - burned really bad all night long - I interpreted this as a good thing though - that maybe I had them firing again - not sure if it was the weight bearing or contrast baths that did this though. It was only for one night though, it died down over the next few nights.

Taping that toe tightly to the others is going to reduce circulation to it.

I have broken sesamoid bones in both feet...they have never grown back together. I have to wonder if the really small bones just have a lower potential for repair?

I looked up your pinky healing rate, and many sites suggest another opinion, after 6 wks if healing is delayed.

You might consider that.

If your toe does not throb in the night, consider that a plus.

My toe only throbs when I remove the tape, and it's hot - it throbs due to the swelling which can make the toe hard and the skin a bit shiny even.

Right now, I'm only using the Epsom lotion like you recommended, without any tape. It's swollen for sure, but more a purplish color. I'm going back to the podiatrist next week to ask about the bone. I'm not sure why he was so certain I should ignore the bone and it was fine after looking at the xray.

I never took any B12 supplement, just Calcium and Vit C. Since my neuropathy is trauma induced, it's less likely to be a deficiency I guess.

If there are small bone fragments in that toe, and they move around, each time you remove the binding, they will move again, and inflame the tissue around them. This is what the little sesamoids in the ball of the foot do when they are cracked and then stressed.

The body tends to cause swelling, redness when there are broken bones moving around. This is why you should probably get another opinion. There is also a membrane over the bone, and when it is damaged it sets up lots of inflammation.

You should try some aspirin or AlkaSeltzer original formula and see if it relieves your swelling...this would indicate you have inflammation going on.

This is a good website with anatomy to illustrate for you what your toes look like on the inside:
http://www.northcoastfootcare.com/pa...e-Anatomy.html
This site is a great resource for all sorts of mechanical foot problems. I post it often.

B12 is actively involved in bone formation. So you might try it anyway as a helper to heal the fractures.

If you smoke, try to quit. Smoking inhibits bone fusion and healing too.

Don't use ibuprofen or other NSAIDs all the time for pain, as they also slow bone growth and fusion. A little aspirin here or there may help but just not all the time. Try to use Tylenol if you need pain relief for now.

Do you think I could have Erythromelalgia?

ahni.com/Specialties/Foot+and+Ankle/Articles/Common+Disorders/Erythromelalgia.html

Erythromelalgia often responds to magnesium. Magnesium is also used in bone mineralization.

What I think happens is that the membrane over the bone has been damaged. If there are fragments moving around, without the protective membrane on them anymore, then the body forms a localized tissue reaction. Crushing type injuries are pretty damaging to all the tissues in the foot. So it might not be just the bones themselves, but a combination of tissues reacting.

The menthol in the the Salonpas patches should take down any heat or burning type pain for you.

There is another menthol containing product called Biofreeze gel.
This works well for burning too. But using the Salonpas you should not need the Biofreeze on top of that.

If your redness changes, starts spreading or including the whole foot, that is the time to start worrying. Also you might seek another opinion.
Foot injuries take time to get better. And sometimes they do not return you to what you were before... there may always be some issue with that toe. (stiff, color changes, etc).

Thank you, I really hope it doesn't spread! I'm suspicious about the bone fragments too, although the bright red burning is more symptomatic of nerve damage. I'm going back next week to request more x-rays or MRI.

See some more images from today just at the office - see the purple color which I think is more consistent with soft tissue damage rather than neuropathy?

(by the way I am not tall, I'm 5'7 :) - hmmm I should cut my nails)

Does it hurt when you press on it?

I really think you should see another doctor for another opinion.

This has been going on for a while now, as you said.

Toe ouch
 

I agree with Mrs.D. Maybe go to another physician. If it were me I would pick an orthopedic surgeon. They go into the most detail in my opinion. I did for my ankle, toe and PN, and got the right DX. ginnie

I've seen two podiatrists already. First guy looked at x-rays and just said give it more time and it's aligned an looks OK. Second guy looked at x-rays and said it's aligned an it will heal and to focus on the soft tissue and neuropathy.

I might indeed to an orthopedic expert to get another opinion.

It does not hurt if I press on it or bend it, although the joint is obviously inflexible. Sometimes when the swelling comes down enough, I can bend that top bone back and forth without pain too. It only starts to hurt if I walk on it for too long and then I can feel a slight pain with each step.

Does it hurt walking barefoot? Or only in shoes?

Does only the toe hurt, or also part of the instep leading to the toe?

Feels like a light sprain in the toe itself, but it's not a localized sharp pain. Worse on hard ground. I just walked around the carpeted office there with and without shoes and it didn't hurt. It hurts more when it's in a swollen state - right now I have it wrapped in Coban so it's not too swollen.

I'm going to insist on more x-rays when I visit next week - the thought of bone fragments in there freaks me out. :)

I just wanted to give a quick update. I had MRI and more x-rays and the good news is the fracture has healed.

The report does indicate swelling of the bone marrow, and 'osseous contusion' which is a bone bruise. I looked up the symptoms of bone bruising and I think this is pretty consistent - the weight must have cracked the harder bone and crushed the soft bone.

I clearly still have nerve issues though - the swelling has calmed down a bit - I've been applying the Epsom lotion. It's pretty good during the day but then every night at about 8pm it starts swelling and burning again - I can literally feel it swelling up and getting harder! Also, even drinking a glass of wine flares it up.

I'm trying to narrow the cause down, I usually have some spicy food around this time - could this be a factor? I'm hoping the neuropathy clears along with the bone bruising over the months but who knows. I've been referred to a rheumatologist to look at the arthritis.

Thanks for the update...

I'd avoid the alcohol and wine for now. This dilates blood vessels and there are other chemicals called congeners in wine, and also sulfites which are problematic. If you avoid these foods, for 2 weeks, and see improvement, then that is your answer. You could reintroduce them after 2 wks and see if the swelling comes back. That would be a further diagnostic sign.

And yes, spices too.

It might be you are destined to have problems with some foods, and the toe accident is just an early warning sign. Avoidance of problematic foods, may prevent PN spread for you in the future.

Thank you, I think I may have desensitized the nerves in the entire foot. I've been doing ice and contrast baths for quite a while now, and tonight I decided to put my good foot in too. I noticed the good foot felt the cold MUCH stronger than the bad foot. Maybe I should lay off the ice :(

If you are not having burning pain... that distracts you daily, I don't think you need the ice treatments.

What the contrasting baths do is retrain the brain and spinal cord.
The theory is that the pathways of chronic pain are "learned" and are formed over time in chronic conditions, and then are difficult to un-learn. This is all unconscious. The contrasting ice/heat baths, override the other pain signals present and train the brain to temperature.

If you don't have chronic pain anymore, you probably don't need the contrasting temperature baths.

But if certain foods and drinks flare you, I think you should avoid them for now. You might be able to go back to them in a few months, but this might also signal that you are sensitive to them, and if you have another incident or injury, you may become reactive again to them. I think wine is a very difficult thing to consume. It has polyphenols which dilate blood vessels, congeners from the fermentation left in the bottle, sulfites which many people react to, and then the alcohol.

you might want to see a neurologist also

I thought I'd give a long due update on this. It's been around 18 months since the injury. It doesn't really bother me much anymore except there is still an imbalance and extra stiffness in the foot after running.

The toe does still swell up, turn red and slightly sting in warm weather, or at night. I'm guessing there's still prevailing sensory nerve damage there.

I don't know if it will ever heal...

Thanks for this (generally) good news. And here's another update on my similar symptoms: last spring, I was diagnosed with erythromelalgia, which someone also mentioned on this thread. So far, it's controllable, and my flare-ups don't last too long. The same is true with my predominantly motor PN. All in all, I'm grateful.