Sunday, August 22, 2010
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
Anti-inflammatory measures to reduce the inflammation around the nerves (see posts on icing and contrast bathing)
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.