Allow me to bang on my naltrexone drum again.
Friday I had another LDN miracle to add to the pile. Not classic for CRPS, but close enough. Basically 100% relief starting 1-2 days after 4.5 mg/day LDN and sustained at the 2 week follow up. Had the problem for 10+ years prior. Her shoulder pain resolved as well. In other patients these results are generally sustained over the long term. LDN defiitley does NOT work for everyone, but I've had way too many success stories like this for it to be a fluke or placebo.
Here's her new patient note (mostly AI generated, so won't be perfect!):
Chief Complaint:
Chronic right foot pain involving the entire foot with radiation to the ankle, present since multiple foot surgeries, accompanied by right shoulder pain and cervical pain with associated headaches.
History of Present Illness:
Ms. Doe presents with chronic right foot pain that has persisted since 2011 following multiple surgical interventions. She describes the pain as affecting the entire foot with radiation extending up to the ankle and occasionally progressing up the Achilles tendon area. The pain is characterized as burning in quality and reaches a severity of 10 out of 10 at its worst. The discomfort is constant in nature, maintaining the same level of severity throughout the day, though it demonstrates significant variability with some days being pain-free while others involve severe exacerbations. The pain is notably exacerbated by prolonged standing, particularly during her 12-hour work shifts where she remains on her feet throughout the day. On these demanding work days, she experiences significant pain upon returning home. The pain episodes can occur spontaneously without apparent triggers, described as sudden onset where the pain grips her leg and causes throbbing sensations that can resolve just as suddenly. She reports that some areas of the foot have lost sensation while others remain painful. The pain follows the scar line from her previous surgeries and affects the dorsal aspect of the foot, lateral malleolus, and posterior medial malleolus region. She also experiences concurrent right shoulder pain that has been treated with physical therapy including dry needling approximately two weeks prior to this visit, which resulted in severe pain exacerbation requiring her to discontinue physical therapy. The shoulder pain is associated with supraspinatus tendon involvement and limits her ability to raise her arm and perform certain movements. Additionally, she reports cervical pain with associated headaches that she describes as migraines, characterized by pain starting at the back of the neck and radiating over the top of the head, sometimes presenting with aura and blurred vision, and frequently awakening her from sleep. She has a history of taking gabapentin 100 mg three times daily and has used Vicodin sparingly for severe pain episodes, though she prefers to avoid narcotic medications when possible.
Past Medical History:
Arthritis affecting the neck and back, high cholesterol, essential hypertension, migraine headaches, history of sebaceous cysts, previous dilation and curettage, and tonsillectomy.
Notes Reviewed:
MRI of the right ankle performed on 03/14/2025 at [MRI center] demonstrated tendinosis and low to intermediate grade partial-thickness tearing involving both peroneal tendons in the ankle and hindfoot. The study also revealed a low-grade sprain of the reconstructed anterior talofibular ligament, lateral hindfoot soft tissue edema, and a small amount of fluid in the common peroneal tendon sheath. Surgical anchors were visualized in the lateral malleolus and talar body with associated metallic artifact from previous surgical interventions. The patient has a complex surgical history on the right foot with four previous surgeries and is currently not considered a surgical candidate. A referral to [my pain clinic] was made by [PCP]. Previous conservative care measures have included trial of rest, activity modification, oral pain medications, physician-directed home exercise programs, and various medication classes including Tylenol, NSAIDs, oral steroids, anticonvulsants, and muscle relaxants starting 11/13/2024 with reevaluation date of 05/08/2025.
Objective:
Physical Examination Findings:
Tenderness:
Right cervical trapezius tenderness was noted, while left cervical trapezius showed no tenderness. Tenderness was present over the supraspinatus area of the right shoulder.
Range of Motion:
Cervical range of motion demonstrates some limitation with rotation and extension, particularly affecting the patient's ability to turn her head to certain positions due to pain and stiffness.
Neurological exam:
No specific neurological deficits were documented during today's examination.
Facet loading exam:
Facet loading tenderness in the neck bilaterally with rotation and extension
Joint exams:
Right shoulder examination revealed tenderness with palpation of the supraspinatus tendon area. Arm elevation and reaching around the back produced some discomfort, consistent with supraspinatus tendinitis.
CRPS exam:
CRPS examination of the right foot revealed hyperesthesia along the dorsum of the foot and ankle, right lateral malleolus, and along the scar line at the posterior medial malleolus. Light touch sensation was more intense compared to the unaffected areas, described as more tingly and producing dysthetic nerve sensations. No hyperpathia was demonstrated with repetitive tapping. No classic stigmata of CRPS were present in either foot.
Diagnostic Test Results:
MRI of the right ankle performed on 03/14/2025 showed tendinosis and low to intermediate grade partial-thickness tearing involving both peroneal tendons in the ankle and hindfoot, low-grade sprain of the reconstructed anterior talofibular ligament, lateral hindfoot soft tissue edema, and small amount of fluid in the common peroneal tendon sheath. Surgical anchors were visualized in the lateral malleolus and talar body with associated metallic artifact from previous surgical interventions. Mild degenerative changes were noted in the head of the talus on the lateral side and mild fourth and fifth TMT joint degenerative changes were present.
Procedure History:
Multiple foot surgeries performed since 2011 including anterior talofibular ligament reconstruction. Recent dry needling of the right shoulder performed approximately two weeks prior to this visit by physical therapy, which resulted in significant pain exacerbation.
Summary of Conservative Care for Insurance:
Date Problem Started: 2011 for foot pain. Conservative Care Period Start Date: 11/13/2024. Conservative Care Period Re-Evaluation Date: 05/08/2025. Physical Therapy Start Date: 2011. Physical Therapy End Date: Recently discontinued due to pain exacerbation from dry needling. Complementary Conservative Care Trials: Trial of rest, activity modification, physician-directed home exercise program. Medication Trials: Tylenol, NSAIDs, oral steroids, anticonvulsants, muscle relaxants, gabapentin. Total Weeks Conservative Care: Ongoing since 11/13/2024.
Assessment & Plan:
Right foot pain, multifactorial:
Assessment: Complex right foot pain involving the entire dorsal and lateral aspect with radiation to/from the ankle, present since multiple surgical interventions in 2011. MRI findings demonstrate tendinosis and partial-thickness tearing of both peroneal tendons with associated soft tissue edema. Clinical presentation suggests multifactorial etiology including myofascial components and neuropathic pain elements. There may be an element of complex regional pain syndrome and centralized pain affecting the right foot, given spontaneous outbursts of pain that do not appear to have specific triggers and altered sensory processing with hyperesthesia.
Plan: Initiate trial of low-dose naltrexone starting with one pill daily for seven days, then increase to two pills daily if no improvement is noted by day seven. Follow-up at 14-day mark to assess response.
Chronic bilateral neck pain with facet joint involvement:
Assessment: Bilateral neck pain that can be provoked with rotation and extension, suggestive of facet joint arthritis. Pain is associated with functional limitations including difficulty turning the head to certain positions.
Plan: Monitor for now. Future treatment options include diagnostic medial branch blocks followed by radiofrequency ablation if conservative measures fail. This typically involves a three-step sequence with two diagnostic blocks followed by radiofrequency ablation, which can provide three to five years of relief for cervical facet joint pain.
Cervical occipital neuralgia and migraine syndrome:
Assessment: Patient experiences pain in the neck that radiates over the top of the head, which could represent part of a migraine phenomenon or reflect peripheral nerve entrapment as occipital neuralgia. She reports classic migraine features including aura, blurred vision, and frequent awakening from sleep due to headaches.
Plan: Monitor for now. Treatment options include occipital nerve hydrodissection for peripheral nerve entrapment components. The patient may benefit from evaluation of small peripheral nerves including supraorbital and supratrochlear nerves that can contribute to frontal headache symptoms.
Right shoulder pain with supraspinatus tendinitis:
Assessment: Right shoulder pain that can be provoked with strain on the supraspinatus tendon with associated tenderness over this area. She has tried dry needling through physical therapy without improvement and experienced significant pain exacerbation requiring discontinuation of physical therapy.
Plan: Continue to monitor for now. Treatment options include supraspinatus tendon sheath injection or platelet-rich plasma therapy if conservative measures continue to fail.
