What Causes Numbness In Feet And Pain In Leg?

Brief Answer:
Diabetic neuropathy combined with other problems

Detailed Answer:
Good morning and thank you for your return question.

Let me clarify a couple of things which we can expand on in followup questions and answers...but I wanted to get something out to you more quickly now to think about.

If a person is diabetic and if they suffer from the classic symptoms of a neuropathy which is likely linked to that diabetes in the PAST then, over time bring their diabetes under good control. Maybe even excellent control....such as HbA1C- 5.3 and if it remained that way for the rest of their lives unfortunately, the neuropathy does not NECESSARILY have to get better and still may progress over time.

It is very similar to a condition of HYPERTENSION and white matter changes in the brain which is a different subject from this where a person may come under excellent control yet still suffer what appears to be ongoing damage or progression...despite excellent control.

So it is very nearly impossible to ever prove a theory like this but we see it in reality that diabetics who come to us with classic symptoms of neuropathy come under control for their diabetes but continue to somehow have symptoms or even progress over time. There are many conditions in medicine which are the same thing, asthma, COPD, emphysema, etc.

However, with you there is the added complication of the central canal stenoses and complicated arthritic changes adding to the picture.

At any rate, permanent damage without chance of improvement..I believe there is ALWAYS chances of improvement? We can discuss that also in our follow-up discussions. There will likely be some residuals of symptoms in your case which we can discuss further on follow up questions....

In the mean time if you have any diagnostic studies or more recent other test results that you can upload to the system so I can look at them please do and we can talk about them.

Cheers--- How cold is it in Canfield? Cleveland--- -6 Degrees F

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Brief Answer:
Stay calm and focused

Detailed Answer:
Yes, I agree after re-reading all of the other posts since December that you've put on the system that you're not diabetic.

If you'd like to upload a copy of the EMG/NCV report I'll be happy to look at the study and see what exactly it showed. For instance if all they did were nerve conductions but without needle evaluation then, there would be incomplete information to come to any solid conclusion of your condition.....at least not enough to conclude a definite or even probable "diabetic neuropathy" as you said was the opinion of the electromyographer (who was not a neurologist).

Having said that, you should know that your statement of being "pre-diabetic for a few years" brings to mind additional information which has only more recently come to light about neuropathies and diabetes and that is the following--

We now have reason to believe that the condition of PREdiabetes and HYPERGLYCEMIC STATES in a person (meaning having elevated blood sugars...not necessarily enough to be called insulin resistant or diabetic.....but elevated all the same) are positive risk factors for the development of NEUROPATHIES....not RADICULOPATHIES such as what's going on in the right leg with quad weakness and compression of the right L3/4 nerve root. Furthermore, it's not yet defined whether or not there is a certain amount of time that must have elapsed before one can say for sure that neuropathic symptoms can be attributed to a PREdiabetic condition or not. We just don't know what the minimum time frames are...just that hyperglycemia is a risk factor in the development of metabolic neuropathy.

The other thing you haven't mentioned is how aggressive the workup has been for NEUROPATHIC causes of your symptoms and I'm referring mainly to what appears to be the bilateral and symmetric affectation of the ankles and tops of the feet (according to my interpretation of what you've written). In other words has your doctor gotten your blood work tested for the rest of the gamut of metabolic tests we typically look at when evaluating the neuropathic patient. Remember, neuropathy really refers to symptoms of numbness/tingling/reduced reflexes/burning quality sensations and other weird feelings in a limb or part of limb. They tend to be BILATERAL and SYMMETRIC as opposed to focal.

You also mention the onset of LEFT toes that are tingling. This really doesn't go with the right sided L3 nerve compression. But you do have some action going on in the L4/L5 area which shows grade one antherolisthesis of L4 on L5. There is also reported moderate DJD changes and a mild disc bulge. Additionally, there is moderate to severe central canal stenosis and narrowing of both lateral recesses with mild narrowing of both foramina (i.e. where nerve roots exit). At L5/S1 there are also moderate bilateral DJD changes and mild disc bulges seen with small right lateral recess protrusions and narrowing of the right lateral recess.

The question of time frame for doing decompressions surgically on nerve roots before PERMANENT damage occurs is an age old question. Nobody knows exactly in terms of weeks, months, or years what the waiting period or how far one can push continuing with symptoms (with or without PT and other conservative measures) before the point of no return is reached...follow me?

But here's what we do know.

FIRST SCENARIO: If a nerve root compression can be easily correlated to SEVERE PAIN in a limb to the point of literally causing either significant disability performing day to day activities or on the job performance begins to suffer....OR that the pain makes the person BED RIDDEN and this is the only way to get rid of the pain after having tried medications, PT, heat/ice/massage, etc. etc. etc. THEN, surgery should be offered to such a patient.

SECOND SCENARIO: If a nerve root compression can be clinically and electrodiagnostically correlated to MUSCLE WEAKNESS in a muscle or group of muscles to the point of causing ANY AMOUNT of disability performing either day to day activities or on the job performance begins to suffer OR that this weakness makes an individual bed-bound then, that patient should be offered surgery.

The second scenario is usually the easier one to spot when it occurs because the marker of WEAKNESS is obvious to both practitioners and patients. In your case right quad weakness in the setting of an obvious right sided L3 nerve root compression should be the GO signal for decompression. However, as I had previously stated in December there is about a 50% remission rate on COMPRESSIVE RADICULOPATHIES according to Greenburg et al with simple conservative measures and so the fact that you started to show improvement in several parameters including pain, weakness, and functionality was a positive sign and apparently seemed to be the right thing to do. However, you then, plateaued in terms of the quad weakness and that has continued.

Now, there are paresthesias to add to the picture- albeit in a location that seems less to do with L3 compressions and more along the lines of either the beginnings of a PERIPHERAL NEUROPATHY of some type vs. all the degenerative changes listed above having to do with L4/5 and L5/S1 problems. Obviously, (and I said that before) tying everything together in a nice package so that ALL your symptoms go with what's either SEEN ON MRI or other studies as well as through the neurological examination would be the best thing in the world.

But on the other hand-- you should also be aware of the fact that all of the degenerative seen on the MR of the L4/5 and L5/S1 can be seen in normal subjects without symptoms of any sort. In fact, in your case you don't even report that much back pain which is a bit unusual for someone who has as much degenerative pathology as you seem to have per MRI of the lower lumbar spine.

So at the end of the day how does THIS NEUROLOGIST see your situation?

First of all- I don't think it's terribly complicated but there are a few moving parts that have to be separated and we need to keep our eyes on each individual element so we make sure all bases are taken care of the best way possible.

1. You need to be seen and examined by a GOOD NEUROLOGIST who will take the time to do a thorough neurological evaluation and map out both motor and sensory deficits so that we have clear documentation as to which SYMPTOMS of yours correlate to which SIGNS the examiner discovers. We also want to be able to see which nerve root distributions are clearly being affected since the MR evidence in my mind has not entirely been corroborated clinically.

2. I think a good EMG/NCV study should be done by an eletromyographer of repute and experience. The reason is this....with a nerve compression farther north than other pathology we really need someone to be able to distinguish between what's going on in each place of interest (i.e. L3 vs. L4/5 vs. L5/S1) as opposed what could be going on symptomatically in your feet, ankles, and toes as a CONSEQUENCE of what's happening at L3/4 which would then, suggest that the MRI findings of L4/5 and L5/S1 are clinically silent.

3. I think a good and complete NEUROPATHY workup needs to be done in order to rule out possible metabolic derangements which may be present and adding to some of the symptoms without being clearly evident in other ways (i.e. thyroids, RFT's, LFT's, B12, folate, Vit. D, magnesium, etc.)

4. I would love to send you information on some of the more recent findings and recommendations for conservative and preventative measures that we can take against significant osteoarthritic disease which has not yet gotten out to the masses because everyone is still of the opinion that it's an inevitable fact of life and there's nothing that can be done to get in its way. Yes, osteoarthritis is the most common arthritic form of disease and YES, age is the #1 risk factor....BUT NO-- it is not true that nothing can be done.....there are even recommendations for good diets and specific exercises....not just PT....REGIMENTED EXERCISES to be done including AQUATHERAPY...my favorite all my patients are given is WATER JOGGING.

5. If surgery is to be contemplated I would NOT think about doing any type of fusion/laminectomy etc. since those types of procedures tend to destabilize the vertebral column and although there are things such as cadaveric implants and even pretty strong "silly putty" (that's what I call it! HA!) that can be inserted as artificial disks etc.....I frankly try and have my patients avoid all that in favor of what's referred to as a minimally invasive procedure done PREFERABLY by a NEUROSURGEON since my feeling is that they are much more in tune with the neurological aspects of the procedure as opposed to orthopods who simply like to get in and out and sometimes leave more problems to deal with than benefits. Of course, that's an unfair bash on some very competent surgeons who do very good work....but that is my bias and so I tend to funnel my patients who have radicular issues and need nerve root decompressions to neurosurgeons.

I know of a couple of excellent surgeons here in the XXXXXXX area who I think you should at least TALK TO without any commitment to a procedure (if it may seem to come to that recommendation) and see what they think about such an approach as opposed to signing off on any radical back procedure involve multilevel fusions or debridments that may not give the results you're looking for and possibly create other complications that need not be created.

If this information has been helpful and I've answered your question satisfactorily would you do me the favor of some written feedback and a STAR RATING of the answer. Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.

If you would like the educational material that I distribute to all my patients on osteoarthritis and how to put a roadblock in its way by doing simple things that you can do immediately with respect to diet, exercise, and so forth please send me your email and I will return a .pdf file with great information you can put to use right away.

I think you certainly know how to contact me personally since you've done that already but just to be sure you can land on the following webpage and direct any question you'd like at:

bit.ly/drdariushsaghafi

This query has cumulatively required 110 minutes of physician specific review, research, and final draft documentation for envoy.

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Brief Answer:
Chronic nerve root compression

Detailed Answer:
Good morning once again.

I will happy to send you educational material on osteoarthritis and what you may be able to do to become proactively involved with putting a roadblock in its way though you likely have it at this point. Please look for this information in the next day or so. I have noted your email address.

In terms of taking a flatly conservative and nonsurgical approach to relieving the compressive symptoms of your lumbar radiculopathy I believe while certainly an option if I were in your position and if clinically, there was demonstration of weakness in a nerve distribution then, I would look for a definitive way to relieve the compression as soon as possible. The longer the compression continues unchecked then, the more likely ongoing and permanent damage will occur which can eventually lead not only to the leg itself becoming weaker but muscles of the pelvis and genitalia can also become weakened since they too are innervated by the L3 nerve root.

Specifically, the following muscle and sensory regions of the leg are at risk for ongoing deterioration over time:


Femoral – innervates muscles that help the leg bend and straighten
Genitofemoral – innervates muscles associated with the reproductive organs
Lateral cutaneous of the thigh – innervates the epidermis in the mid- to
upper-leg regions
Obturator – innervates muscles in the pelvis and hip
Quadratus lumborum – innervates a muscle that connects the pelvis to the spine

If my symptoms were purely sensory and NO PAIN WERE INVOLVED then, perhaps I would choose to wait until either sensation became sufficiently altered that I began injuring myself, falling, tripping, or otherwise developed severe pain....which you don't have.

However, as I mentioned in my previous messages to you....weakness that can be clearly correlated by EMG/NCV studies to clinical parameters are usually considered the GO signal for decompression of the nerve root to take place. It is, however, true that one of the most common symptoms of an L3 compression is PAIN and a fair amount of it. However, if you've also received epidural injections or if the L3 nerve root was specifically injected then, your pain may be still under the influence of the injection...it may recrudesce at any time and in the mean time weakness could become worse.

So, pain should not be used as the barometer in all cases of severity of nerve root compression or compromise. And also remember one more bit of information that most DOCTORS forget about in these cases. For the patient (or even the doctor) to be able to detect a small decrease in overall leg muscle strength in the affected L3 muscles....there will have to be a much GREATER deterioration or loss of nerve function in the nerve root since there is a lot of redundancy built into the system and other muscles automatically take up the slack on weakened muscles without your noticing it to keep you walking, erect, balanced, and functional.

However, there is additional stress put on those muscles, those joints, and those nerve roots responsible for recruiting the extra groups to counter for the L3 weakness and that will eventually lead to potential problems if you can follow what I just said.

Bottom line- Muscle weakness (with or without pain) is the GO signal for decompression. However, as previously stated I would not consider laminectomy and fusion necessarily without getting an opinion from a minimally invasive surgeon first to see what they can offer.

Anyways, if this answer to your questions has helped in some small measure would you do me the great favor of providing written feedback and a STAR RATING as you generously did in your other post back in December.

Also, I'm a neurologist so if you'd like to also ask me additional questions about this or any other topic of interest then, please visit me at:

bit.ly/drdariushsaghafi and send me your questions.

All the best.

This query has cumulatively required 132 minutes of physician specific review, research, and final draft documentation for envoy.

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