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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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What causes pain under right foot, knees, calves, fatigue and back pain?

Answered by
Dr.
Dr. Mukund Savaskar

General Surgeon

Practicing since :1978

Answered : 3607 Questions

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Posted on Tue, 7 Jun 2016 in General Health
Question: Hi Doctor...I got your email and wanted to follow up...I saw a podiatrist and my feet are terribly flat - 9 on a scale of 10, so that has caused some pain in my legs, but I wanted to give you a complete overview of my leg and back symptoms. Although diagnosed with moderate vascular claudication, I tend not to agree...below is what I mean:
SYMPTOMS – LEGS AND LOWER BACK – XXXXXXX reilley April 12, 2016

1) shooting pain under right foot for 3, 5 seconds at time at night when lying on right side & twitching of right leg
2) sciatica in left and right bums when lying on each side
3) dull pain in lower back when lying on back radiating down to top of calves and feet
4) pronounced fluttering of nerve in left bum when lying on left side
5) dull ache in lower back when standing
6) numb right toes when standing and twisting torso
7) pain in both knees – worse in left knee but getting better with TENS
8) pain in calves of both legs when walking: lower calf and shin splints. Worse in right leg after 10 minutes. Sitting improves it for 2,3 minutes as do orthotics
9) very tired, aching legs after 2 miles’ walking
10) dull bar-like pain in lower back when in extension mode
11) sore ankles and toes when first walking in morning until I put shoes with orthotics on
12) sore calves when standing at times – i.e.: cocktail party etc…

MRI in 2011 showed severe foraminal LSS, and moderate central spinal stenosis. Suffering from degenerative disc disease since 1990.
Had a recent MRI of lower spine on April 8, 2016.
Podiatrist diagnosed extreme flat feet on April 4, 2016 affecting tendons below calves at interior side and causing shin splints during walking.
Vascular lab diagnosed Peripheral Artery Disease (PAD) with claudication in 2011, but Neurogenic Intermittent Claudication (NIC) caused by Lumbar Spinal Stenosis (LSS) CAN also affect Ankle Brachial Index (ABI) readings. Readings in 2011 and in 2015 were moderate.

What do YOU feel?
doctor
Answered by Dr. Mukund Savaskar 5 hours later
Brief Answer:
Yes,Neurogenic Dominance is more in your leg pains !!

Detailed Answer:
Brief Ans-Yes,Neurogenic Dominance is more in your leg pains !!


Hi Dear XXXXXXX Reilley!! Thanks for your query to HCM.
I read the facts of your query and reviewed it in context to your health issues submitted in your query.

I understood your health concerns and feel Concerned about them.
Thanks for updating Me on the latest reviews on your MRI tests and other updates.

I would be interested to know- how much has improved after orthotic correction,especially in your right calf pain,which was your main worry in last session?
Before I can opine on the query-as to whether your leg pains are due to PAD and or/ due to Neurogenic, I would like to know few things about your bodily parameters-

What's your weight and height?

Have you reduced your weight by any specific efforts, if suggested from your doctors attending on you?

How much is the Canadian day temperature variation over a day- like in morning / evening?

Based on the facts of your query the reply of your query is-

Your current health issues seem to be due to Your Musculo-skeletal imbalance with Neurogenic dominant factor in causing the pains in your calves.

Besides this, just tell Me how much improvement in right calf pain has occurred after correction of your flat foot ?

Its seems that Sacro-iliac arthritis is also contributing to your pains,as you have pains in low back while lying down.


Do's-

Continue with whatever is on.

I would suggest you to review about the pains in low back and legs after following medicine.
Cap Neurontin- 300 mg x 2-3 times a day for 1 week, for which you should get script from your doctor there.

Please Update Me after a Gap of 1 weeks after stopping Neurontin.

Assess how much relief you get on pain score, and update me after 2 weeks.
Hope this would give some lead about the solution regarding your complaints.

Do Contact for any further query in this regard by a direct question to ME, at following HCM link-
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=70229

Do close this query with your words of praising /excellent comments to boost the morale of My visiting patients at HCM Virtual forum.

Good Day!!

Wishing Good Healthy Life!!

Dr.Savaskar M.N. XXXXXXX Surgical Specialist
M.S.Genl-CVTS

Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Mukund Savaskar 2 hours later
My weight is 225 lbs - large athletic frame. About 5-10 pounds overweight. I am attempting to lose weight.
My height is 6 foot 2.5 inches.

My right leg pain score since taking orthotics is about 50% better...with custom orthotics should be about 80% better. I will purchase them soon.

Temperature variation here in spring time is about 10C degree variation between morning and late afternoon. I usually walk in late afternoon. I walk 4 times per week. Blood flow seems to be improving due to weekly acupuncture in right leg.

I still believe that all claudication pain is neurogenic in nature...

It will take about 6-8 weeks to get recent MRI results. When pain is bad in lower back and bum, I take arthrotec 300 mg. as needed.


I have also started taking Omega 7 plus nutritional yeast. Omega 7 for PAD.

What do think now? I personally think it is NIC...
doctor
Answered by Dr. Mukund Savaskar 1 hour later
Brief Answer:
Update information on high/ low temp of local weather!!

Detailed Answer:
Brief Ans-Update information on high/ low temp of local weather!!

Hi, Dear !! Thanks for your updates.
Its good that you are on Omega 7 plus and walk in late afternoon.

Reply to your query of NIC-
Dear, With more interactions with You, the reply to your question -as to if its NIC?
is getting more interesting and tricky and complex and challenging too, for Me as an expert.
So give Me time and more information to exactly suggest on your complex health issue.
This becomes specially complex when your Vascular lab Says its PAD and When the latest MRI report is not updated to Me.

I just want to review the MRI dtd.8.4.2016, before I could reply on this complex question.

My Reply -for the time being-
i- Till then I stand by My earlier opinion as replied in last session.
ii- Possibility of-CCCS- Chronic Compartment Compression Syndrome needs to be verified.

Need More information-please bear with Me till then !!

How frequently you take Arthotec 300 mg in a week?
Has this frequency-of taking Arthotec 300 mg- reduced after Orhtotic correction?
What is your current main complaint? is the lower back pain ? or the Claudication with fast walking exercise, you do?
What is your presenting complaint, which is bother you NOW?
How are your bowel movements? Any recurring constipation ?
Any more information on past illnesses like diabetes?


Update asap-
Awaiting for your updates as asked above.
Also update the MRI report- dtd.8.4.2016 / or if report is not ready, update the Scan of the MRI Plate.
and don't forget to Update information on high/ low temp of local weather!!

Welcome with any further information and report updates, in this regard.


Good Day!!

Wishing Good Healthy Life!!

Dr.Savaskar M.N. XXXXXXX Surgical Specialist
M.S.Genl-CVTS
Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
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Follow up: Dr. Mukund Savaskar 19 minutes later
Yes, strong possibility of CCCS!

When I rub my coccyx, I get tingling all down right leg to the feet. When I had my herniated disc in 1990, I could not walk, I had to crawl. Pain was so bad on right leg even when a bed sheet touched it.

Bowel movements are excellent! No constipation.

Athrotec is taken on an as needed basis for my back and sciatica.

Main complaint is claudication pain and very tired aching legs when walking and after I walk. I always have to walk 2.5 miles in three stages...and when I start out I am fine for about 10-15 minutes then tiredness in legs with pain starts. So, I stop for 2 minutes, sit and rest and then continue.

If CCCS, then this can affect ABI. NIC can also affect ABI reading...there is research available. You should know that I believe. And why would you suggest an anti-epileptic drug??? = Neurontin???

NO diabetes ever. Very low lipids all my life....symptoms started shortly after first MRI in 2011...which showed severe LSS. I would be interested in seeing new MRI but have to wait. Comments please?
doctor
Answered by Dr. Mukund Savaskar 1 hour later
Brief Answer:
Mostly -Its LSS with ?CCCS with ? PAD/ Under Evaluation

Detailed Answer:
Brief Ans-Mostly-Its LSS with ?CCCS with ?PAD/ Under Evaluation

Hi Dear !! Thanks for the updates with more information.
Read and Reviewed Your updates in context to your health concerns, which is more from-Claudication pain-meaning while you walk pain increases and you have to stop and start to reach your target.
LSS with PAD -are the established diagnosis in your case.
I would be interested to see the report of CT-Angiography done, which confirmed your PAD.

In the given circumstances-because of Your LSS -centrl Spinal Stenosis-nerves are more sensitive in general.The PAD,if its there would -exaggerate the Claudication pain response in your case and hence exactly this pain is coming after 10 minutes of walking(about a 1km).
CCCS which if accompanies in such scenario- would expedite the pain coming with less of Claudication distance, as is the case mostly in your case.
If your Claudication distance has improved over a time, please confirm if it did in your case.
Thus LSS is having major contribution to the Claudication pain your case, which needs to be verified for accompanied CCCS.

Its ultimately the -neural pathway which alerts with pain feeling after the low oxygen induced from PAD or CCCS. This means with LSS, your nerves are still working and are oversensitive due to compression edema/inflmmation caused from Canal Stenosis in your case.
So if your claudication distance has increased, it means that the Vascualr factor is more in your case.If the Claudication distance has not improved with walking exercise
But before that I would need to review CT-Angiography report and the plate,before I suggest any further investigations for CCCS-in your case.



Why Neurontin-?
LSS being the major contributing factor in your claudication symptom,
With My experience- I have suggested a trial of 1 Week Neurontin, to study and review if the neurogenic factor is more in your case or not.
Neurontin-Gabapentin- is also effective in intractable neurogenic pain,as is the case in your case- with LSS.
I don't remember if you are on any Vasodialators for the PAD and you are depending mainly on collateral circulation built up from walking exercises.
Hence therefore In view of neural compression from LSS, I would suggest you to do a 1 week trial with Neurontin.
If the pain relieves to a large extent-then NIC is the major contributor in your case, than the PAD ,as was thought in discussions during last session 4 weeks ago.


Please update if you are on any vasodialators for PAD? in next session.

Hope the above reply and explanations would resolve the complexity of your query and would help you take the right course of treatment in time to come.

Alerts-Suggested-

1-You should reduce your weight more seriously,by atleast 10 %-ie by 10 kgs( or 22 lbs).
2-You should add 20 minutes jogging in gradual stages.If you can withstand that-your PAD is taken care of by the collaterals-from the blocked arteries in the leg.
This would mean as if achieving a natural By-Pass for the blocked PAD in your legs.And this is My aim to be targeted in your case.
3-Please update Me on-
CT-angiogarphy report / updates on -if any Vasodialators are prescribed to you/.

Hope with this Your query should resolve by next session.

Keep Me updated in time to come by Do Contact for any further query in this regard by a direct question to ME, at following HCM link-
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=70229

If you still want to continue with more query in this regard,You are most Welcome to ask any further query in this regard.

Do close this query with your words of praising /excellent comments to boost the morale of My visiting patients at HCM Virtual forum.


Good Day!!

Wishing Good Healthy Life!!

Dr.Savaskar M.N. XXXXXXX Surgical Specialist
M.S.Genl-CVTS





Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
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Follow up: Dr. Mukund Savaskar 3 hours later
OK...when the PAD was diagnosed, there was no CT Angiograph....it was purely an ABI. Ankle Brachial Test...

I take baby aspirin only...plus Ezetrol.

The walking distance is always the same when the pain starts in calves. After 5, 10 minutes. then I rest for 2 minutes, and then start up again...same scenario whereby I have to stop and rest when pain gets too much.

We will only know with the results of the recent MRI.

Thank you Doctor...I will close shortly.
doctor
Answered by Dr. Mukund Savaskar 3 hours later
Brief Answer:
Ok.Lets' review afterrecent MRI reports !!

Detailed Answer:
Brief Ans-Ok.Lets' review afterrecent MRI reports !!

Hi Dear !!Thanks for the updates to HCM.
Please update what was the first ABI and the current one -if done recently.
By the time you update Me on MRI-reports,I conclude as follows-
a-Weight Reduction by 10 kg to be achieved soon.
b-Orthotic Correction with Customised shoes to be continued.
c-Baby asprin and Ezetrol to maintain the current status of PAD
d-Daily walk to be continued,with jogging if tolerated to be added gradually.

You being other wise healthy and careful,Continue to maintain good foot circulation,which I should not stress more to YOU.

To Conclude-
Hope this reply and the current interactive sessions have reduced your current worry, and have set a way out of further management of the PAD and LSS problem in your case-IMP lead was the Weight Reduction by 10 %.
Keep Me updated on your MRI reports dtd.8.4.2016

Do Contact for any further query in this regard by a direct question to ME, at following HCM link-
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=70229

Do close this query with your words of praising /excellent comments to boost the morale of My visiting patients at HCM Virtual forum.

Good Day!!

Wishing Good Healthy Life!!

Dr.Savaskar M.N. XXXXXXX Surgical Specialist
M.S.Genl-CVTS
Above answer was peer-reviewed by : Dr. Deepak
doctor
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