Leg Neuropathic Pain: Causes and Management Strategies

Q: Leg Neuropathic Pain: Causes and Management Strategies

Hello Mr. <br>Zac,<br>You mentioned that "when walking, the outer side of my left ankle feels like it's being electrified, and after this pain sensation appeared, my outer calf and the sole of my foot began to feel numb and tingly (which may indicate nerve damage)." This may warr

Leg neuropathy, polyneuropathy?

Hello Doctor, I have consulted multiple physicians (in rehabilitation, orthopedics, neurosurgery, and neurology), but I still cannot identify the problem...
I am 32 years old and work as a software engineer.
My symptoms seem quite variable, and I hold onto a glimmer of hope by reaching out to seek your expertise.
I will provide a segmented account of my medical history, the examinations I have undergone, diseases that seem to be ruled out, and possible conditions for your reference.
Thank you again for your assistance.
Medical History (01/01/2023 - 05/17/2023):
- In January, I noticed intermittent sharp pain in the front of my left thigh (above the quadriceps).
- On March 30, while walking, I experienced an electric shock-like pain in the outer side of my left ankle.
After this sensation appeared, I began to feel numbness and tingling in the outer side of my calf and the sole of my foot (suggesting possible nerve damage), which caused me to start limping.
After resting for three weeks (by April 19), I had significantly improved and could begin to walk slowly again.
I observed that maintaining an upright posture and avoiding bending my neck seemed to reduce the pain.
I also noticed that high body temperature appeared to trigger the electric shock-like sensation in my left ankle.
- On April 20, my condition worsened:
- I began to feel a similar sharp pain in the same area of my right leg (front of the thigh and sole of the foot), and my fingertips also started to feel tingling (similar to electric shocks).
However, maintaining an upright posture seemed to alleviate this pain, and three days later, the symptoms seemed to disappear, possibly due to anxiety or autonomic nervous system dysregulation.
Taking Xanax 0.5mg seemed to help alleviate these symptoms.
- I started having difficulty sleeping normally; when I tilted my head back or to the sides, my teeth would involuntarily clench, and my lips would tremble, resembling a seizure.
This symptom disappeared after three days, likely due to anxiety or autonomic nervous system dysregulation, and Xanax 0.5mg seemed to help.
- I experienced tingling sensations in my genital area, which also resolved after three days, possibly due to anxiety or autonomic nervous system dysregulation.
- On April 22, while walking in the sun with temperatures around 28-30 degrees Celsius, the electric shock-like sensation in my left ankle suddenly reappeared.
After this sensation, I began to feel numbness in the outer side of my left calf and the entire sole of my left foot.
It seems that each time this electric shock sensation occurs, my entire calf and sole become numb, and my foot feels tight, suggesting possible nerve damage.
The symptoms improved after about a week.
- On May 1, I was diagnosed with COVID-19.
I observed that when my ear temperature reached 38-39 degrees Celsius, the electric shock-like sensation in my left ankle would appear.
Even when lying down or sitting, the electric shock-like pain would occur at high body temperatures.
After taking antipyretics and reducing my temperature to 37-37.5 degrees Celsius, the nerve pain ceased.
This was the third time I felt the electric shock-like sensation in my left ankle, and I am unsure if my symptoms are related to body temperature.
- From May 1 to May 7, during my COVID-19 diagnosis, when my temperature was normal, the main symptoms were persistent numbness in the soles of both feet and intermittent sharp pain in the front of my left thigh (above the quadriceps).
- As of May 17, my current symptoms include persistent numbness and twitching in my left foot and calf, intermittent sharp pain in the front of my left thigh (above the quadriceps), and noticeable muscle fasciculations in my limbs and buttocks (more pronounced than before).
I can now walk normally and have attempted to start jogging.
During the month when I could not walk normally, my leg strength does not seem to have been significantly affected; I measured the circumference of both calves and found my left calf to be one centimeter larger than my right.
I have also tried to relax and reassure myself that everything will be fine, and I have stopped taking Xanax for about a week, during which I have been able to sleep normally.
Examinations Conducted:
- Nerve conduction study - lower limbs: normal
- Sensory nerve conduction velocity study: normal
- H-reflex: normal
- MRI of the brain (self-paid, without contrast):
- A retention cyst, about 2.6 cm, located within the right maxillary antrum.
- No discernible organic brain lesion on this study basis.
- Cervical spine - self-paid without contrast report: Slight kyphosis of the cervical spine.
- Health insurance report with contrast: no definite MR evidence of Gd enhancing lesion at the cervical spine in the present study.
- Thoracic spine (self-paid, without contrast): No discernible thoracic spine lesion on this study basis.
- Lumbar spine (self-paid, without contrast): No discernible lumbosacral spine anomaly on this study basis.
Small perineural cysts at the S2 level, probably normal variants.
- CT of the brain:
- Normal density of gray and white matter, no obvious lesions.
No intracranial hemorrhage observed.
- Size of the lateral ventricles and third ventricle is normal.
- Posterior structures including the brainstem, cerebellum, and CP angles appear normal.
- X-ray:
- No structural issues in the left foot.
- No structural issues in the lumbar spine.
- The cervical intervertebral disc seems somewhat narrowed.
Diseases that seem to be ruled out:
- Multiple Sclerosis (MS): Dr.
Zhang from Linkou Chang Gung Hospital reviewed my MRI and concluded that I am likely not an MS patient, as my MRI results appear quite clean.
- ALS: Dr.
Zhang does not believe I may have ALS, primarily because my muscle strength seems unaffected.
- Thyroid issues: My blood test shows T4 Free at 1.92 ng/L (slightly elevated, normal range is 0.93-1.7) and TSH at 0.586 uIU/mL (normal), suggesting thyroid-related diseases can be ruled out.
- Diabetes: Glycated hemoglobin is normal.
- Inflammatory response: My blood test shows CRP <0.1 mg/dl, indicating no inflammatory response.
- CIDP/GBS: Self-assessment suggests no muscle weakness, so this condition can likely be ruled out.
- Familial amyloid neuropathy: No family history of this disease, so it can likely be ruled out.
- Nerve compression: MRI results indicate no herniated discs or nerve compression; however, my lumbar MRI report mentions small perineural cysts at the S2 level, which are probably normal variants.
I have researched the S1-S2 dermatome, which seems related to the outer ankle nerve, but I am unsure if it relates to the electric shock-like sensation in my left outer ankle.
However, this does not explain the intermittent sharp pain in the front of my left thigh (above the quadriceps), as my L2-L3 appears normal.
- Fabry disease: Dr.
Zhang from Linkou Chang Gung Hospital has conducted blood tests, and I am awaiting results, but it seems no one in my family has had this disease.
- Electrolyte imbalance: The likelihood seems low; my blood report shows slightly low potassium at 3.3 mmol/L (normal should be 3.5), and I have not exercised for a month.
- Medication side effects or toxicity: I currently do not have a habit of taking medications, mainly taking B1/B12/C and fish oil.
I have also posted on PTT seeking opinions from netizens, which may provide additional insights for you:
https://www.ptt.cc/bbs/Doctor-Info/M.1681565571.A.260.html
https://www.ptt.cc/bbs/Doctor-Info/M.1682150372.A.7B7.html
https://www.ptt.cc/bbs/Doctor-Info/M.1682817950.A.FBA.html
https://www.ptt.cc/bbs/Doctor-Info/M.1683688231.A.A6C.html
I feel quite helpless...
My symptoms are quite variable, and it seems challenging to pinpoint the issue.
Recently, I have considered seeing a traditional Chinese medicine practitioner, and some have suggested that I might have "blocked blood flow." Some doctors have also recommended that I see a psychiatrist (perhaps thinking I have mental health issues T_T).
I am afraid of making hasty medical decisions due to my anxiety, so I am seeking your expertise to see if there are other underlying causes for my current main symptoms: persistent numbness and twitching in my left foot and calf, intermittent sharp pain in the front of my left thigh (above the quadriceps), and noticeable muscle fasciculations in my limbs and buttocks (more pronounced than before).
Thank you once again, and I wish you a lifetime of peace and health.

Zac, 30~39 year old female. Ask Date: 2023/05/17

Dr. Jiang Junyi reply Neurology

Hello Mr.
Zac,
You mentioned that "when walking, the outer side of my left ankle feels like it's being electrified, and after this pain sensation appeared, my outer calf and the sole of my foot began to feel numb and tingly (which may indicate nerve damage)." This may warrant consideration of peripheral nerve compression.
Common symptoms include: pain, numbness, and weakness.
In practice, these symptoms can easily be confused with other conditions originating from the muscles, bones, or spine.
Symptoms of peripheral nerve compression include:
1.
Pain characterized by burning or tingling sensations.
2.
Symptoms that have a specific band-like distribution, which can be triggered by touch or pressure.
3.
Accompanied by muscle soreness and weakness.
Examinations for peripheral nerve issues typically involve electrophysiological studies to assist in diagnosis.
Nerve conduction studies assess the transmission speed and waveform of large fiber nerves.
Electromyography (EMG) evaluates the muscle response in the areas supplied by the affected nerves.
It seems you did not mention the report from the EMG.
I recommend consulting a physician specialized in peripheral nerves, as they have more experience with EMG examinations.
Thank you for your inquiry, and feel free to discuss any related questions! Wishing you good health, peace, and joy.
Dr.
Jiang Junyi, Taoyuan Medical Center, cares about you.

Reply Date: 2023/05/17

More Info

Understanding leg neuropathic pain can be quite complex, especially when the symptoms are multifaceted and the underlying causes are not immediately apparent. Based on your detailed account, it seems you have been experiencing a range of symptoms affecting your legs, particularly the left side, with sensations that include sharp pain, tingling, and muscle twitching. These symptoms can be indicative of neuropathic pain, which is often caused by nerve damage or dysfunction.

Potential Causes of Neuropathic Pain
1. Nerve Compression or Injury: Although your MRI results did not show any significant nerve compression, it's important to consider that nerve injuries can occur without visible structural changes. Conditions like a herniated disc or spinal stenosis can sometimes lead to neuropathic symptoms even if imaging does not reveal clear abnormalities.

2. Peripheral Neuropathy: This condition can arise from various factors, including diabetes, vitamin deficiencies (especially B vitamins), and exposure to toxins. Given your normal blood sugar levels, it seems less likely that diabetes is the cause, but it might be worth investigating your vitamin levels further.

3. Psychological Factors: You mentioned experiencing anxiety and stress, which can exacerbate physical symptoms. Conditions like somatic symptom disorder or conversion disorder can manifest as physical pain without a clear medical cause. This is where psychological factors play a significant role in the perception of pain.

4. Infection or Inflammatory Conditions: Your recent COVID-19 diagnosis could also be a contributing factor. Viral infections can sometimes lead to post-viral syndromes that include neuropathic pain. Additionally, inflammatory conditions affecting the nervous system, such as Guillain-Barré syndrome, should be considered, although your symptoms and tests seem to rule this out.

5. Idiopathic Neuropathy: In many cases, the exact cause of neuropathic pain remains unknown, which can be frustrating. This is referred to as idiopathic neuropathy, and it can occur without any identifiable underlying condition.

Management Strategies
1. Medication: Since you have been prescribed Xanax, it may help with anxiety but is not a long-term solution for neuropathic pain. Medications like gabapentin or pregabalin are often more effective for neuropathic pain management. These medications work by stabilizing electrical activity in the nervous system and can help reduce pain signals.

2. Physical Therapy: Engaging in physical therapy can help improve mobility and strength while also addressing any postural issues that may be contributing to your pain. A physical therapist can tailor a program to your specific needs, focusing on exercises that promote nerve health and reduce discomfort.

3. Lifestyle Modifications: Stress management techniques, such as mindfulness, yoga, or cognitive behavioral therapy, can be beneficial. These approaches can help you cope with anxiety and may indirectly reduce the perception of pain.

4. Diet and Nutrition: Ensuring you have a balanced diet rich in vitamins and minerals, particularly B vitamins, can support nerve health. Foods like leafy greens, nuts, seeds, and lean proteins are beneficial.

5. Alternative Therapies: Some patients find relief through acupuncture, chiropractic care, or massage therapy. These treatments can help alleviate muscle tension and improve circulation, potentially reducing pain.

6. Regular Monitoring: Since your symptoms have been fluctuating, keeping a detailed diary of your symptoms, triggers, and any changes can be helpful for your healthcare providers to identify patterns and adjust treatment accordingly.

Conclusion
In summary, while your symptoms are complex and multifactorial, a combination of neuropathic pain management strategies, lifestyle modifications, and psychological support may provide relief. It’s crucial to maintain open communication with your healthcare providers and consider a multidisciplinary approach to address both the physical and psychological aspects of your pain. If your symptoms persist or worsen, seeking a second opinion or consulting a pain specialist may also be beneficial. Remember, you are not alone in this journey, and there are various avenues to explore for relief.

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