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Sunday, August 22, 2010

Morton's Neuroma: Treatment Options

Morton’s Neuroma: Treatment Options
Morton’s Neuroma denotes a swollen inflamed painful nerve classically between the third and fourth metatarsals, radiating into the third and fourth toes (toes are numbered one for the big toe and 5 for the pinky toe). It can also be between the second and third metatarsals, or between both the third/fourth and second/third just to make diagnosis more difficult. The nerve symptoms created can be more like numbness, tingling, buzzing, burning, sock rolled up sensation, etc on one side on the spectrum, to sharp, radiating, and electrical pain at a level 8 to 10 on the pain scale. One of my unfortunate patients described it as lava flowing in her foot!! One third of all patients only have numbness as the chief complaint, one third have a combo of numbness and some pain, and one third have only pain (lucky them!!) The pain can be so bad that the differential diagnosis could only be a broken bone, however the history of onset of pain does not match up with a fracture, and there is no swelling. Neuromas rarely have swelling.


When a patient presents with symptoms of Morton’s Neuroma, the treatment plan should address 8 areas. These are:


Mechanical support behind the metatarsal heads to off load the sore areas immediately in any shoes which produce pain (see post on Hapads)

Mechanical support of any over pronation affecting the ankle (see posts on biomechanics)

Shoe gear changes to minimize daily aggravation (various factors affect each case—amounts of cushion, heel lift, flexibility, tightness, stability, arch support)

Changes in digital (toe) motion with taping or Budin Splints

Tightness in the ligaments and other soft tissue around the toes and metatarsals

Anti-inflammatory measures to reduce the inflammation around the nerves (see posts on icing and contrast bathing)
Nerve stabilizing methods (see post on Neuro-Eze)

Diagnostic testing to determine where the source of the pain originates, whether or not there are classic neuromas present (MRI best)



Luckily, less than 10% of patients do I consider for surgery to remove the nerve if their symptoms do not improve well, but the other 90% can have a rocky road getting their symptoms under control. Remember, first and foremost that this is a nerve problem. Nerve problems hurt more than any other injury. There are more nerve endings on the bottom of your foot per square inch than any where else on the body. Nerve pain goes straight to the brain and is quite intolerable by most. The treatment should be aggressive and multi-factorial. It takes about 1 year of treatment in the recalcitrant cases (slow ones) to decide that surgery should be done. If you are in the unlucky 10% requiring surgery, 50% of you will heal quickly, and 50% will take up to two years to really feel somewhat better (if at all). So, 5% or 1 out of 20 patients with nerve pain still have nerve pain to some degree 3 years after I start treating them. So, try your hardest to be in the 95%.



Remember that nerve pain makes nerve pain by itself. So, the cycle of nerve pain spiraling out of control must be stopped. Golden Rule of Foot: Treat Neuroma/Nerve pain aggressively, or it will decide to stay around. When I first feel symptoms of numbness or pain in the front of your foot, seek immediate help (like reading this blog). But, there are so many aspects of treatment that the patient can only do like icing, shoe gear changes, add Hapads, start Neuro-Eze, limit pain producing activities (if there is pain), doing daily self massage, etc. When I first got into practice 29 years ago July 1981, 50% of all neuromas diagnosed were surgically removed. Now, less than 10% are surgerized (my own word!!) so medicine is moving in the right direction on this one.



Neuroma or nerve pain in the foot must be treated at the foot, but it can be caused by irritated nerves from back problems, ankle problems, sciatic nerve problems, and peripheral neuropathies (nerve diseases) from diabetes, B12 deficiencies, etc. Even with our most sophisticated workups on nerve pain, the nerve pain can occur 5+ years earlier than the diagnosis. These are some of the neuromas removed, and yet the patient feels little or no improvement. Medicine has to get better in this area.



I will have another post which will be a checklist of all the treatments you should have tried and failed before surgery is performed. But for now, let us focus on what should happen in the first 2 or 3 visits (probably over a 6 week period) with a doctor whose diagnosis is Morton’s Neuroma. These are:



Begin a program of anti-inflammatory measures, which is done daily, and could involve one or several cortisone shots (see post on cortisone shots)

Begin to change from all shoes that aggravate the symptoms (take each shoe separately since you may be surprised what feels okay)

Avoid barefoot walking

Begin some evaluation of the possible source of the nerve pain (low back evaluation at a minimum with straight leg raise and Tinel’s test at ankle)

Add some Hapad or other metatarsal arch support to all shoes that have adequate room

Begin some exercises that relax the tissues around the inflamed nerve (like toe waving exercises)

Begin some massage to desensitize the nerve with Neuro-Eze, some heat lotion (i.e. Ben Gay), or warm face cloth wrapped around foot as long as the massage doesn’t irritate the nerve

Begin controlling pronation if the ankle mechanics could cause pulling on the branch at the ankle (in what they call the tarsal tunnel)

Discuss the timing of possible MRI, Nerve Conduction Test, alcohol injections, course of cortisone injections, possible casting in removable boot



See you and your health care provider have some work to do. Work on shutting off the nerve painlessly, and as quick as possible, before the symptoms get worse.

8 comments:

  1. i'vd gone to a dermatolist,ortopedic,poddiatrist&md/gotten several diagnosis,been on keflex,cortizone shot.blood work&culture taken,still hurts

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  2. Marsha, If you read the post you will see you really have had very little treatment. I hope by now more aggressive steps have been taken to calm the nerve down. Dr Rich Blake

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  3. My neuroma, which first appeared years ago, recently began acting up: at the ball of my foot, I felt if I were walking on pebbles. I am an old person and don't really care what I wear on my feet, so I gave up my sneakers and started wearing Crocs, for which I had purchased insoles separately. They give my feet plenty of space, especially in the front. In addition, I used ice treatment from time to time. Still, an severe burning pain radiated to the top of my second toe -- VERY annoying and restrictive. Interestingly, I dealt with that by applying generous amounts of an anesthetic ointment (there are many; I used BioFreeze), which seems to have solved the problem. (A cortisone shot did work briefly, but the Crocs, ice, and ointment seem to be more reliable and to do the job.)

    ReplyDelete
  4. Happy to find your notes. So very fearful that I have a dorsal foot malignancy, (there are other medical problems). The pain is one thing, you know? Trouble is, every practitioner I have seen of late goes straight to big-time imaging when it isn't even appropriate - and, I won't have it done simply because it's 'easy'.

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  5. I had MN in my right foot. I visited three podiatrists before finding one who was willing to perform the surgery - and he changed my life by doing so. I had orthotics, splints, injections - everything - over a 12 month period. Nothing helped and I woke one day wanting to cut off my foot (seriously, that is what I told my wife).

    After changing from a PPO to Kaiser, I once again visited the Podiatrist. The doctor immediately said, "If you've tried other remedies, then you need surgery." I had the surgery two weeks later, and was walking with a padded covering the next day. The difference almost brought tears to my eyes.

    I know of two others (also runners) who have had MN and the only remedy was surgery. The podiatrists I fired were all unable to perform the surgery, so they tried to offer every remedy under the sun except the only one that would help. Makes me angry even typing this.

    I now have MN in my other foot (presumably years of running and years of marching are taking their toll). I see my doctor next week and I am quite certain that he will go back and pull the nerve. IT IS THE ONLY TRUE REMEDY IF YOU ARE IN PAIN.

    Dr. Blake - saying that only 5% require surgery simply cannot be true and is certainly misleading to the patients seeking comfort in a very painful foot. I fear that they will follow the guidance and try to seek comfort with other treatments for at least one year (as you suggest) like I did. For the third of sufferers who have the pain in their foot, especially at the 8-10 on the pain scale, they will not be cured with orthotics, therapy, injections, etc. Surgery is their only cure.

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    Replies
    1. Thank you so very much for your heart felt comment. Most of my patients who have surgery for Morton's Neuroma feel the same way. When you need surgery for Morton's Neuroma, you should have it. This does not however mean that conservative treatments should not be tried before. There is typically a 3 month window of time after the patient first presents with MN pain that 2 things happen: A) an attempt at conservative treatment is initiated, and B) MRI documentation along with an evaluation of other causes of nerve pain. If by the end of the first 3 months, the conservative treatment is not working well, the MRI documents a MN, and other forms of nerve pain (like low back referred pain are ruled out), surgery is recommended. The gray areas come from patients where the pain is manageable, the MRIs are inconclusive, and there is some suggestion of low back involvement. So, I am very happy for you. I am biased to avoid surgery when possible, and that bias does come across strongly. I always feel bad when the patient and I work hard together to avoid surgery, but in the end surgery is needed. But, my patients know that if conservative treatment fails, surgery is our last resort option. How does conservative treatment fail? One way is that the pain level is not managed in the 0-2 range (Good Pain). During the first few months, while conservative treatment is being explored, it is imperative to do whatever to get the pain under control. This is more true for nerves than any other structure. Dr Rich Blake

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  6. Hi, thanks very much for your blog. I had my first injection of alcohol this week and found it incredibly painful. Particularly in the second foot where it seemed that I could feel the effects all along the nerve fiber, up into my toe. It was over quickly but while it lasted it was incredibly intense. The doc, who seems to have lots of experience with this technique and is well recommended, was very surprised by my experience. How do you understand my experience? Although the injections seem well supported by research, my experience makes me question this technique.

    Thanks!

    Cathy

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    Replies
    1. Cathy, these injections are designed to desensitize the nerve, but they can irritate before they do their job. I have patients have up to 4 days of irritation with these shots, and sometimes it is because the nerve is too inflamed. If you try again, ice pack 20 minutes before leaving the office and twice more that night. Any bad reaction to injections to nerves is possible overall. Do you have more nerve irritation from your back or neck that could make the nerve more sensitive? Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.