Peripheral Neuropathy Questions

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New Hope for Neuropathy

Foot and ankle neuropathy has been a very confusing and debilitating disease. Once diagnosed little hope is given. Patients are told that nothing can be done about the cause, because they really do not know why they even have developed the neuropathy in the first place. The pain and symptoms will only get worse until there is complete numbness. The pain will usually only get worse and you are doomed to many sleepless nights. It will usually take years for the pain to subside and for complete foot/ankle numbness to ensue. Once complete numbness is present there is severe risk for puncture wounds, ulcers, and infections.


Symptoms of Foot and Ankle Neuropathy

Initially, there is a numbing feeling into the middle toes/balls of the foot after prolonged walking/standing. With time there is a numb feeling to the feet during the end of the day. Eventually, there is pain/burning of the feet at night. Then the pain may wake you after going to sleep but then subsides after getting up and walking for a while. There may be cold toes to touch while there is an overall burning feeling to the foot. Just like there is an overall numb feeling (like the foot has been anesthetized) but there is feeling to touch the foot. Other times there can be very severe hypersensitivity to the feet. Due to the numbness in the feet and toes there is a loss of balance and coordination. There are many different symptoms but the overall process is the same.


Diagnosis of Peripheral Neuropathy

There have been reports that as high as 20 million Americans have been diagnosed with some form of peripheral neuropathy. The evaluation of peripheral neuropathy has often been very time consuming, painful, and costly. After all of the various tests treatment is often very limited. A careful history about the symptoms, distributaries and course of the nerves is the starting point. A detailed neurological evaluation is taken. A variety of tests are also available including: electromyography, nerve conduction studies, pressure specified sensory testing, vibration thresholds, radiographs, bone scans, as well as a battery of blood tests. Even after peripheral neuropathy little was done but to give various medications and order tests to see the progression of the nerve damage.


What happens to the nerve in Peripheral Neuropathy

Despite all the diverse medical disorders that have been linked to the cause of the peripheral neuropathies the peripheral nerves have only a few distinct pathologic findings. No one has been able to fully figure out the specific mechanisms by which the various disorders affecting the peripheral nerves induce these pathologic changes. There are three findings consistently. First is partial to complete interruption of the inner core of the nerve fiber (axon). This usually results from nerve trauma or nerve infarction. Second, is what is referred to as “dying-back” phenomenon. The axon degenerates at the end of the nerve fibers. This is attributed to the metabolic disorders. It usually occurs symmetrical (both feet and toes) and starts at the tips and comes closer to the body. Thirdly, the outer band of tissue covering the nerve which conducts the nerve impulses are destroyed. Immune and inflammatory mechanism are blames for this disease of the nerve.


Treatment of Peripheral Neuropathy

The treatment of peripheral neuropathy has been an up-hill battle and focused primarily on external application of creams/ointments, acupuncture, light therapy, massage, etc. There are also several medications that have been prescribed to treat/alleviate the symptoms. Initially, these may prove to be helpful, but since they are only working on the symptoms of the disease and not the disease itself, the symptoms will continue to get worse. Finally, these types of treatments are of no use.


New Hope for Neuropathy

Further investigation into the cause of peripheral neuropathy has revealed that in a rather large population of patients with this form of neuropathy there is actually a compression of specific nerves of the foot. Initially, it was discovered with carpal tunnel syndrome a condition of the wrist where there was constriction of the nerve in the canal of the wrist entering into the hand, with various activities there is compression of the nerve which leads to the loss of feeling in the hand. Surgeons would decompress the nerve and sensation and strength were restored. Finally, attention was directed to the foot which has a similar tunnel (tarsal tunnel) and when that nerve was compressed there was nerve damage that occurred in the foot/toes. A simple comparison is standing on a garden hose, the flow of water is decreased. Likewise with compression of the nerve, the feeling is decreased. Once the pressure is taken off of the hose there is a rush of water, so to the nerve that the sensation chemicals have been building up and once the pressure is taken off the foot there is increased pain.

The tarsal tunnel, located behind the inner ankle bone, contains the posterior tibial nerve. This nerve then divides into three branches, two of which enter into the bottom of the foot through two canals. The other nerve supplies sensation to the back of the heel. It has been found that in the majority of patients with foot/ankle neuropathy they have constricted canals and thickening of a ligament which compresses the nerves. Common sense tells us that if the condition is caused by a physical constriction of the nerves, no matter what is done topically, or internally with medications the constriction is still present.


Surgical Decompression of the Entrapped/Compressed Nerves

Dr. Anthony Weinert is one of only a handful of surgeons trained in surgical decompression associated with peripheral neuropathy of the foot. Under loop-magnification, he will decompress the entrapped nerves of the foot. The surgery, which is performed as an out-patient surgery under twilight sedation, typically takes 45 minutes to perform. Only one foot at a time is worked on. Dr. Anthony Weinert has been performing this surgery for years in metro Detroit and is the only of the only podiatrists in the area trained to perform this technique.


The Results

Previous studies have been performed which have shown a success rate of 80%. The results can be instant relief to months before any changes are noticed. There are many factors which affect the outcome of the surgery. No guarantees are given on the success of the surgery.


The Risks

As with any surgery and although rare, there are potential risks of surgery including but not limited to: blood loss, infection, delayed wound healing, scarring, increased nerve symptoms due to regeneration of the nerves, increased numbness, need for further surgery, failure of the surgery to achieve its desired goal, and death.


The Benefits

Imagine no more pain or numbness. There may be a new lease on life, instead of being house bound you can go for walk without suffering. You can increase your metabolism to decrease your weight, lower your blood sugar and blood pressure. Once sensation is restored to your feet, you’ll have no more worries about ulceration and the other complications of numb feet.


Who is a candidate for this type of surgery?

The ideal candidate for surgery is someone who is beginning to experience numbness and tingling in the feet. If the sensory loss progresses to the point where you have numbness and tingling throughout the day and weakness or clumsiness interferes with your daily activities, then you may be a candidate for surgical decompression of the nerve. The ideal candidate does not wait until there is no feeling left or until there is already an ulceration present. The ideal candidate seeks surgical consultation while there is still time to reverse the damage to the nerves.


Adjunctive Procedures

Many of the patients seen with this condition also exhibit excessive motion in their feet (hyperpronation). This is determined by clinical examination, radiographs, and gait analysis. Typically, there is partial to full obliteration of the sinus tarsi (a space between the ankle bone and heel bone).

Obliteration of this space makes the ankle bone (talus) turn inward which in the majority of cases lowers the arch, the same turning in can also be seen with a high arched foot. There is overstretching of the posterior tibial nerve and constriction of the nerve to the bottom of the feet.

The average person takes between 10,000 to 15,000 steps per day. This excessive motion is another factor which overstretches the posterior tibial nerve and constricts the medial and lateral nerves as they branch off of the posterior tibial nerve leading to further nerve trauma. This hyperpronation explains why there is increased pain in the feet with increased activity. The more walking leads to more trauma to the nerve, leading to numbness. Since the nerve is traumatized during the day it goes numb. Just like falling asleep on you arm and it goes numb it takes a while for it to “wake up” after the pressure has been released. Likewise, it takes a while for the nerves in the feet to wake up after they have been “put to sleep”. That is why the pain is worse at night once one has limited their walking. Usually, as the disease process progresses, the patient will usually get up and walk around for a while, due to the severe pain, and the pain will subside. The nerve is being put back to sleep.

Dr. Anthony Weinert treats this condition, hyperpronation, by inserting a stent into that space. There is the normal motion of that joint complex but the sinus will no longer be obliterated. Many physicians treat the obliteration of that space with an arch support (orthotic), but an orthotic cannot prevent that space from being obliterated. For more information on that procedure please visit

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Dr. Anthony Weinert

Anthony Weinert, DPM, FACFAS, FACCWS is a double board certified foot and ankle specialist with office locations in both Warren and Troy, Michigan. Dr. Weinert is a physician and surgeon of the foot and ankle who believes in providing his patients with the most state of the art treatments in a patient friendly environment. He believes in providing quality patient care and safety and was honored with being one of the first foot and ankle specialty centers in Michigan to receive accreditation by the Joint Commission (JCAHO) which is the gold standard in healthcare for providing patient care and safety.  He believes in the philosophy of patient education for their foot and ankle disorders and also believes to treat every patient the way he would like to be treated.

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