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I have a young female patient complaining of numbness to the entire great toe from the base to the tip, dorsal and plantar. It's constant and painful as well as numb. This is obviously a nerve problem but my question is how to distinguish which nerve since it's crossing multiple different nerve paths? I've tried local anesthetic to different nerves at different visits and none of the diagnostic injections have gotten rid of the pain. Any help is appreciated.

 

Hi and :welcome:

I've found the most common causes of hallux nerve pain / paresthesia to be medial dorsal cutaneous nerve compression or deep peroneal nerve entrapment. Or obviously neuropathy.

However your post is slightly confusing. You say you've performed diagnostic anaesthesia to no avail (i presume tibial, s.peroneal and d.peroneal). Is this not impossible, at some point blocking innervation to the hallux would provide symptomatic relief? Sorry to question your technique, but are you performing the injections correctly?

George

 

When blocking the toe I've blocked one nerve at a time, on different visits, to see if one would significantly decrease her pain. She's noticed that with each block she notices numbness but no decrease of the pain. She's had EMG/NCV's which show no abnormality. As of today her pain is progressing proximally. No skin changes, no temperature changes, no swelling. Vascular status is normal and Capillary refill time is normal. No injury. Pain has been on going, constant for a few months. She's guarding and extremely tender with even the slightist palpation.

 

Due to the allodynia, you must consider this patient has chronic regional pain syndrome (CRPS). I suggest a referral to a podiatrist who sees lots of these patients or to a pain management specialist for consultation.