Conway McLean, DPM, Journal columnist

People tend to take many things for granted, some of them precious and historically rare. The freedoms and liberties we have today are an obvious one. At the height of our youth, another we take for granted is the ability to walk, safely and comfortably. But this common “simple” act can be snatched away in the blink of an eye, all with the most innocuous injury imaginable.

This is a case history, the story of a particular patient, a pleasant middle aged fellow we’ll call Bill (obviously not his real name). He was a true outdoorsman, hunting, fishing, whatever the season called for. This is how Bill had grown up, out in the woods, on the lake, enjoying nature. One recent winter, our protagonist suffered what initially seemed like a very minor injury, his foot going through the ice into knee high water. It’s hard to see any repercussions with such minimal trauma. His foot got wet but, at the time, it seemed not much else!

Nerves are a strange and amazing tissue, capable of transmitting signals at lightning speed, they are fragile and easily damaged. Naturally, there are varying levels of nerve injury, with the mildest amounting to basically a bruising of the nerve, in the worst, it’s cut into two pieces. But nerves have a less than abundant blood supply and consequently, a low metabolic rate. The result? They heal slowly, if at all. Even more significant, a chemical reaction can take place making the nerve forever incapacitated.

These thin, delicate structures are usually buried deep in a limb, generally protected from the harsh outside world. But much to Bill’s dismay, there are exceptions and when he stepped through the ice, the edge impacted the side of his leg, just below the knee. This happens to be the location of one of those exceptions. The Common Peroneal nerve runs from the back of the thigh to the front of the lower leg. The nerve gets there by traveling over the head of the fibula (the outermost of the two lower leg bones). This makes it extremely susceptible to blunt injury.

Along with having sensory functions, the Common Peroneal controls the muscles that pull the foot up when the leg is swinging through the air during the process that is ambulation, aka walking. Whatever the reason, when the foot isn’t pulled up sufficiently, it will catch the ground and cause the individual to trip and often fall. These can result in bodily harm, especially to the aged and infirm. Bill developed a foot drop, making it difficult to walk without tripping, and unable to continue work.

Treating many nerve injuries can be challenging, especially since they are rarely recognized and accurately diagnosed in an expedient fashion. When the nerve is transected (i.e. cut), microscopic surgical techniques can sometimes re-connect the cut nerve, leading potentially to renewed function. The success of these procedures is dependent on many factors, especially the length of time prior to attempting repair. A “dying back” phenomenon occurs to the nerve over time making repair impossible.

Bill’s injury had taken place months before an accurate diagnosis, but time had provided no improvement. By the time Bill presented, he was beyond frustrated. He had no pain from the side of his leg where the injury occurred, nor from the muscles affected, but he couldn’t walk well. Trying to get around out in the woods was scary, having taken a couple of bad “spills” already.

Physical therapy of the exercise variety, things like balance board work, resistance bands, etc, had been attempted without success. Research reveals the more effective approach is the application of some form of electrical stimulation, of which there are many types. In Bill’s case, we utilized FREMS therapy (Frequency Rhythmic Electrically Modulated Stimulation), a unique technology which seems able to stimulate blood flow through the tiniest of vessels, the capillaries, especially those supplying nerves. Developed specifically for another type of nerve problem, peripheral small fiber neuropathy (the kind diabetics get), there are no complications or hazards to its use.

A hot topic in the treatment of many injuries is regenerative medicine. This involves, in some way, the recruitment of stem cells to grow new, healthy tissue, be it bone, muscle, even nerve. Although various techniques can be seen in the media, the longest used is prolotherapy, which stands for ‘proliferation.’ This approach has been in use for decades, well before we recognized the concept of regenerative medicine. Although relatively low cost and free of complications, many health care providers are unfamiliar with prolotherapy. The concept with ‘Prolo’ is to jump-start the healing process which, although gradual, generates lasting improvement: it is not a band-aid.

Bill was treated with a series of FREMS and prolotherapy treatments, ten and four respectively. Although a gradual process occurring over several months, he slowly lost the weakness, as well as the numbness in his foot and ankle, indicating some healing of the damaged nerve. Bill was able to return to work, and his hunting (although he became noticeably cautious when on ice). Long term follow-up revealed no loss of the strength regained.

Often a traumatic nerve injury is not precisely diagnosed in a timely fashion. This means primary surgical repair is often impossible. Unfortunately, the benefits of those conservative measures typically used have often proven inadequate. Presented here is a new and unique approach entailing minimal risk while providing significant and obvious improvement to the individual’s health and wellbeing.

Orthopedic medicine has come a long way. Did you know we can lengthen limbs and correct all manner of musculoskeletal deformity with established surgical techniques? Replacing diseased or damaged joints is routine, with many senior citizens living a fulfilling life with a fake knee. Nerve surgery, in contrast, carries with it a poorer success rate. It’s time for modern medicine to examine more closely these newer concepts of therapeutic intervention. Although the health insurance industry may never choose to “recognize” them (since it would hurt their bottom line), regenerative medicine is here to stay.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.