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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Exp 50 years

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What causes severe toe pain in a diabetic?

Answered by
Dr.
Dr. Praveen Jeyapathy

Diabetologist

Practicing since :2005

Answered : 324 Questions

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Posted on Thu, 11 Feb 2016 in Diabetes
Question: I have type II Diabetes. I have had severe excruciating pain in my toe next to my big toe for close to a year. We have hit it with anti biotics more than once, prednisone and removed the toenail and nothing has helped. recently I have had my 2nd epidural thinking that it was because of a bulging disc as an MRI on toe showed nothing, but MRI on back showed bulging discs. My doctors do not give me anything for pain relief! Please help me!
doctor
Answered by Dr. Praveen Jeyapathy 49 minutes later
Brief Answer:
Please provide a few more details so that I can assist you best.

Detailed Answer:
Hello. Thanks for writing to me with your problem.

Noted the detailed history and the medications you are on for gout as well as neuropathy.

May I ask you if you have the pain only while walking or exerting yourself in the region you mentioned or is it present throughout and predominantly in the night?

Can you post a picture of the site if possible?

I am awaiting your response so that I can guide you better.

Regards.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Praveen Jeyapathy 12 hours later
I am not sure where to post the photos yet. These were taken after I got up from sleep. It is most painful when I am idle as in laying down, sitting. I had to take some sleep aid to get to sleep, once asleep and deep sleep, when I wake up it is fine. It is just underneath the cuticle area and feels like a fire ant is crawling around in there and the pain throbs and stops briefly and throbs again. There are 24 hour periods I feel no pain at all. usually 1-2 days and then it starts up again.I did find way to upload my photos. Since Ihave been up and walking around, the pain is starting to slowly come back.
doctor
Answered by Dr. Praveen Jeyapathy 2 hours later
Brief Answer:
Reports checked

Detailed Answer:
Hello again Mrs XXXXXXX
Noted the contents of your reply and checked the pictures as well. Thanks for taking time to send it over.

It looks like an inflamed area. However it could be a lot different when examined in person.

Frankly speaking, its hard to tell what is causing it. We could however think about a few differentials.

Neuropathic pain in diabetes generally is bilateral and symmetrical and never localised unless there is nerve entrapment. Hyperuricemia (high uric acid) can cause pain but not usually in the region you mentioned. Vascular (blood vessel) pain can be localised but is generally present through out the time and worse on lying down as the blood has to flow against gravity. Though it can be localised its generally something that affects multiple toes. A remote possibility is one where there is spasm of the blood vessel due to a variety of reasons (external and internal - like cold, hormonal changes, sugar levels). The spasm of the vessel can cause localised pain and the associated changes to the tissue in terms of perfusion of blood and oxygen can cause a localised change which results in inflammation that could last a few days. Its however hard to test and confirm.

A few tests that could be of use would be a toe brachial index, a trans cutaneous partial pressure of oxygen measurement (tcpo2).

You are already on a good dose of neuropathic medications and I cant think of anything as an add on that can help you any further except medications like cilostazol, blood pressure agents like nimodipine which has a peripheral effect, nitrates and blood thinning agents like aspirin and clopidogrel which could help if changes are noted in the tests or a trial.

You could consider alternative medicine like accupuncture. It has been proven to be very helpful in many patients even when allopathic medications fail.

Hope this helps.
Warm regards
Dr Praveen
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Praveen Jeyapathy 9 hours later
If a vessel could be identified, could it be removed? I don't know that I can take this much longer and I am thinking of just taking the end of my toe off with a pruner. What risks do I have with that?
doctor
Answered by Dr. Praveen Jeyapathy 1 hour later
Brief Answer:
As mentioned below

Detailed Answer:
Hello Mrs. XXXXXXX
Well if a vessel is identified removing that may not be possible. Drugs as mentioned earlier can be tried.

Yes, in extreme situations when pain is refractory to all methods tried the final resort would be partial amputation of the toe. If the level at which its done has a good vascular supply it will heal without any issue.

Regarding the risks associated with amputation let me tell you that any form of amputation will lead to a well healed stump provided the area has a good blood supply. So you should make sure that the area is well perfused with an ABI, TBI test and also clinical examination. The possibility that the pain would completely resolve is very high. If the vessel spasm occurs more proximally or not can only be seen later but the chances are very slim of that happening. Amputation is a form of treatment in many cases where pain management becomes an issue.

However,i would advise you to not consider that presently and just proceed with the evaluation and medical management if feasible.

I understand how terribly painful it must be for you to consider such an extreme decision. But let us evaluate it a little more and try the other existing methods before considering surgical options.

Wishing you good health.
Warm regards
Dr Praveen
Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
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Follow up: Dr. Praveen Jeyapathy 10 hours later
I have an appointment today with a doctor. Likely get antibiotics again and I am asking for some pain medication. I will also let my primary dr know I am interested in the TBI measurement. I have had two ABI's in the last year. My right side is borderline normal and left side is normal. I appreciate your input on this, it does help me see things better. The pain tends to throw me off focus. It is hard to be objective when the pain is so great. If the blood flow is not what we would like, and at my age, it is likely to get worse rather than better no matter what I decide to do. Sometimes I feel like such a child when there are others that have to live every day of their lives in so much more pain than I do with no hope of change. Thank you so much for your help and insight on this issue.
doctor
Answered by Dr. Praveen Jeyapathy 18 minutes later
Brief Answer:
You are welcome

Detailed Answer:
Hello again Mrs XXXXXXX I am glad I could shed some light on the issue. It feels good to see you see the brighter side of things even in such worry. Let us remain positive about it and hope the pain disappears. I hope we get closer to the right set of interventions for that. I will be happy to help. Wishing you the best of health. Take care. Warm regards.
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Praveen Jeyapathy 21 hours later
2years ago, I started taking ropinerol hcl for about 8 months. I was taking it because my legs were jumping around so badly when I would lay down or even sit and this did help that. Then I went off of it because it had worked and thought that maybe I could be ok without it since the lyrica worked so well. In reflection, after what we have talked about here and that It did help me sleep and have a little more energy and stopped my legs from jerking, especially the right one, that I should try this again. I also have to be careful, because I only have one kidney. In 2003 I had a giant staghorn calculous kidney stone and my kidney was less than 4% functional so it was removed. I don't want to take anything that puts my kidney at risk, which the metformin did.

Yesterday I was put on Prednisone and antibiotics. The presence of pain is still known now, but level is now down to about 3-4 in general, before I went to sleep, it was back to about a 9 and I did finally get to sleep and slept very well.

How would Ropinerol do any changes to a spastic vessel? Thank you, Nancy
doctor
Answered by Dr. Praveen Jeyapathy 10 minutes later
Brief Answer:
Not much

Detailed Answer:
Hello again Mrs XXXXXXX Good to know you slept well. Ropinirole does not have a role in spastic vessels. However its indicated in restless leg syndrome and it may prove useful if that's the case. Its proven helpful earlier as well. If the renal function is fairly ok with a creatinine clearance of more than 30 it can be used. Warm regards.
Above answer was peer-reviewed by : Dr. Raju A.T
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