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Sunday, June 26, 2016

Morton's Neuromas: Which Shots to Get?


  Morton's Neuromas are inflammed swollen nerves in the front of your foot , usually found between the third and fourth metatarsals (as seen in the above MRI), and sometimes between the second and third metatarsals, and sometimes between both. You count the metatarsals from the big toe #1 to the pinky (baby) toe #5. The symptoms from these inflammed nerves are nerve symptoms: burning, tingling, numbness, electrical, radiating, buzzing, sharp, and/or feeling like a rolled up sock. They are abnormal sensations, also called dyskinesias (just to show you how smart I am). But, this pain may be not be from the foot at all. Nerve pain in the foot can originate from nerve irritation at the ankle, knee, hip, or low back. Nerve pain in the foot can also be systemic (from the body) called peripheral neuropathy. So, it can be very challenging to diagnosis the source of pain in many patients, and thus treat it properly. Any workup for nerve symptoms in the foot should look for possible causes other than the foot.
Photo shows typical problem between 3rd and 4th metatarsals.

     One of the mainstay treatments of Morton's Neuromas involves injections. There are three common shots, and other combinations of medications used in injection form. First of all, there is the diagnostic injection of local anesthesia (like novacaine) to see if injecting the nerve gives complete pain relief. It sometimes proves that the nerve the doctor thought was the problem really is not the problem. These local anesthetic injections should be given with medications that last around 5 hours (commonly Sensorcaine, Marcaine, or Bupivacaine) so that the patient can be 100% sure of the relief attained--100%, 80%, 50%, 30%, or 0%. I am a big believer in this method of identifying the right nerve, if it is a nerve at all, since you only inject the nerve and not the tendons, ligaments, joints, etc. Sometimes, even though you are giving an injection which should last 5 hours, since you are blocking the pain cycle, the relief can be much, much longer. Many doctors will give these injections once or twice a week until the severe pain cycle is completely broken down and the symptoms greatly minimized.

     The second most common type of injection involves cortisone. No one knows for sure how much should be given, since that varies from person to person and body part to body part, but I have lived by the rule of no more than 5 shots per year. I can count on one hand how many patients have needed more than 3 per year, so 4 or 5 shots is unusual, but sometimes necessary. Each one of my cortisone shots is 10mg of long acting steriod. Long acting means that some of the medication is still working for 9 months. As the crystal dissolves, there is slowly less cortisone working on a daily basis. Cortisone can allow healing to occur since it removes swelling. Swelling is our enemy. Swelling cuts off the normal circulation to an area inhibiting healing. So it it more than just a bandaid or temporary fix--it can fix the problem!! I find no use for short acting cortisone. It only lasts for 3 days or so. So what? If you think the patient needs cortisone, use the good stuff. I once had a patient come in for surgical consultation after she failed to improve with 10 cortisone injections over a 6 month period. Surgery had been recommended, and I was a simple appointment to verify that this was appropriate. When we found out what the doctor had used in each injection, I was dumbfounded. He was using long acting cortisone, but in a homeopathic dose of 0.1mg per shot. If you do the math, you would realize that it would take him 100 shots to equal the dosage of one of my shots. Oh my!!??!!

     Why am I discussing dose? Because you should know if you are getting a foot or ankle shot, if it is long or short-acting cortisone, and how much? The 5 dose recommendation per year is based on actually getting 50 mg of long acting cortisone in one area. It does not mean that you can not get the same amount in another area of your foot. One smart patient, with one smart doctor, helped me understand that a local cortisone shot can affect the entire body since small amounts do get absorbed into the body. I call this Dorothy's Rule, after one of my patients, that a patient should not get more than 1 shot of long acting cortisone per month for their entire body. I like this rule since cortisone does affect us in many ways. This applies to patients whom are getting cortisone shots for their foot, and at the same time for their knee, shoulder, etc.
    
     When giving cortisone shots the doctor should stay away from the skin, buring the injection as deep as possible, and avoid tendons if possible. Cortisone near a tendon can weaken it, and cause tearing, as it can thin the skin. The skin usually gradually gets healthy, but can take 9 months or longer, and can not tolerate further shots at this time. Cortisone is normally mixed with the long acting local anesthetics to get 5 hours of post shot pain relief. If the patient does not feel any relief after the shot, the shot missed the painful spot. After cortisone, patients are told no running or jumping for 2 weeks (another reason athletes hate cortisone shots). The patients are told to check pain relief in the first 5 hours, at a week, and at the 2 week followup. If the 10mg is not enough (with the goal 80% reduction in pain), a second shot is given and the two weeks starts over again. During these shots, I do not have the patient go to physical therapy, but they can cross train with non jumping and running activities. With many activities like cycling, they have to assess if it has a negative impact on them. During these shots, the patients are told to ice the area 3 times daily (see separate post on icing). At each two week interval, if the patient seems to be at the 80% level (familiarize yourself with a pain chart and read the separate post on the Magical 80% Rule), activity is gradually returned. Hopefully, the doctor and patient have learned what to avoid, what to wear in the shoes, how to tape, etc, to minimize the re-irritatation during the return to activity program. Any cortisone shot after the first shot in the 9 month window of time is considered a booster shot.





    The third most common type of shot is to desensitize the nerve with alcohol. We use to teach that the alcohol would kill the nerve, but it has been shown only 40% alcohol will do that. Most podiatrists do not feel over 20% alcohol is safe for the foot, so many podiatrists never risk injury by staying at 10% max. You definitely do not want to damage other structures in your attempt to desensitize the nerve. How long does this desensitization last, not sure, but typically for years. The jury is still out.  I mix long acting local anesthetic with 100% concentrated denatured alcohol to achieve a 6% alcohol solution. Then 1 ml of this solution is injected at the most proximal aspect of the nerve in a bolus (not spread out as taught earlier). You attempt to hit the thinnest part of the nerve before its thickens to become the neuroma. Topical cold spray is used to anesthetize the skin, so 100% of the medicine is deposited along the nerve. These injections are given in series of 5, each one 7 to 10 days apart. 50% of patients get excellent results, 20% good (some improvement) and 30% none. After each series, 1 month is recommended to rest the soft tissue. If the patient noted no response from the first series, a second series is not normally recommended. Of the patients alcohol helps 20% or so need only 1 series of 5 injections to feel 80% better, 70% need 2 series, and 10% need 3 series. I know this is alot of numbers, but I love numbers, and this is my blog!! As with the photo at the start of this article, the bigger the neuroma on MRI, the less likely the alcohol shots will work. But, the art of all this is deciding who has a chance. If it was my foot, I would go through the alcohol series to achieve the 80%, and if 80% were not achieved, I would get sporadic cortisone shots, get great orthotic devices that take pressure off the area, ice my foot 2 to 3 times daily, and do the other things on the Morton's Neuroma link below. You can also give the cortisone shots while doing the alcohol shots if there is an unexpected flareup.I sure hope this helps.

http://www.drblakeshealingsole.com/2010/08/mortons-neuroma-treatment-options.html

23 comments:

  1. Top of the right foot leading to the 3 toes-Sural nerve.
    I have had the lydocaine shot (24 hours of relief!!), I just had a cortisone shot and now the pain is worse - much worse! I go back in 3 weeks and the next steps are the series of alcohol injections.
    Are they painful?
    I am already in considerable pain and do not relish additional pain. The cortisone shot was VERY painful.
    Thank you So much!

    ReplyDelete
  2. Dear Anonymous, Sorry you are feeling so much worse from the cortisone shot. Please find out if the shot was long or short acting cortisone. For sural nerve problems, with the diagnosis being made by the local anesthetic shot, I tend to treat topically only, although weekly local anesthetic shots to block the pain cycle is appropriate. I have not used alcohol shots for sural nerve, and personally hate to give cortisone or alcohol in such a superficial area. It is not saying it is bad, I just feel uncomfortable. I would consult with Dr Gary Dockery in the Seattle area who has done these alcohol shots the most. However, before I would do anything other than local anesthetic I would use three times daily topical OTC NeuroEze (in previous posts), or a topical compound medication with Ketamine/Gabapentin/Lidoderm mixture. You will have to have a podiatrist, physiatrist, neurologist, or pain specialist prescribe. The prescription would be for several monthes. You may have to go into a removable boot if you can not take shoe pressure. Warm water soaks 3 times daily for 10-15 minutes with gentle massage should help calm down the nerve. Nerves tend to hate ice, and avoid anything that stimulates the pain cycle. Give me some feedback after you have initiated some of these. Rich Blake

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  3. Dear Anonymous, I have more completely answered your question in a separate post coming out tomorrow 11/1/10. Hope it helps and you are able to see it. Rich Blake

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  4. Dear Dr. Blake,

    I see I'm late to this neuroma party, but I'm the not so proud owner of one, and I have the following comment: There appears to be no generally accepted treatment protocol! Some say sclerosing injections are dreck; others say they provide 80% relief in 70% of cases. The same goes for cryogenic ablation. There are even studies reaching diametrically opposed conclusions on these and other treatment issues. My pod hates both modalities, though he did give me a cortisone shot this week finally, but it seems to provide no relief. What's a patient to do? Who is right? (Btw, see the Angry Pod blog for opinions that wildly diverge from yours.). On a related note, who would you see in the Harrisburg, PA area? Thanks

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  5. Sorry for your dilemma. There are so many reasons that neuroma treatment is so difficult that I will try to address in a post this week of May 28th, 2013. Thanks for the email.
    Rich
    PS My contacts in Pennsylvania are in Phily. You can call Drs Howard Palamarchuk or Gary Gordon to see who to see in Harrisburg.

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  6. Hello Dr. Blake,
    I have a neuroma in my right foot. Had three cortisone injections and they did not work. I will be getting my fifth alcohol injection this afternoon. The pain is about 75% gone. What would you recommend I do next if today's injection doesn't get me to 100% relief? And how long should I wait to judge the overall effectiveness of the alchol shots?
    Thanks very much.

    ReplyDelete
    Replies
    1. Thanks for the comment. I will put on my blog today. Rich
      Good luck!!

      Delete
  7. Great post. Thanks.

    I have had a neuroma for a LONG time, likely the result of cranking down ski boots during race training. It is near zero pain day to day, which gets to the unbearable level after 50 miles on a road bike, or 4 hours of back country skiing (incidentally my top two activities)

    Cortisone shots once a year work quite well.
    I would like a more permanent solution.
    Can you refer me to a Seattle specialist. Can't find Gary Dockery. Is he in Mexico and/or retired now?

    ReplyDelete
  8. Just heard a great shoe lecture from a Seattle area podiatrist Mark Reeves. I also know Dr Rich Bouche and Dr Kirk Herring. You would not go wrong with any of those 3. Tell them I sent you. Rich

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  9. Very helpful information. FYI my cortisone shot lasted for 14 months with problems between the 3rd and 4th. Just had my second shot and hoping for the same results. But having your opinion is great, affirming my good doctor's care.
    Thank you, Dr. Blake.

    ReplyDelete
  10. I had cortisone eleven days ago and I am in a lot of pain I went to the hospital to ask there advice was told to take co codomol but I had bad side affects is there any thing else I could do to relive the pain

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    Replies
    1. Janet, thank you so very much for the comment. I am sorry to hear the shot irritated you. Ice pack for 10-15 minutes every hour or two may bring down the inflammation. You may need good old fashion opiates to get over the hump. The doctor that gave you the shot needs to be involved, and perhaps send you to a pain specialist. I have done this to my patients a few times (never a pleasant time) and typically 4-14 days are necessary for the pain to calm down. You need to ask about the chance of RSD developing because the treatment protocol calls for an immediate sympathetic nerve block. Hope this helps. Rich

      Delete
  11. Great post! This helped me on my study on morton’s neuroma so much.I have been looking everywhere for something like this!

    Thank you form sharing.

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  12. Hi,
    I have had 4 cortisone shots and my neuroma is still bothering me. I am strongly considering alcohol injections. Do you have someone you could recommend in Texas? I currently live in Corpus but am willing to travel. Thanks
    Jas

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    Replies
    1. Jas, go to the AAPSM website site and see if there are any local podiatrists on that this. Most will be very familiar with this technique. Hope it helps. Rich

      Delete
  13. I have been told I have sural nerve pain following tendon surgery two years ago. The pain has been constant since the surgery. I have seen a podiatrist and have been given the cortisone shots and topicals, pills, etc. Now the dr I'm seeing wants to do the alcohol shots to kill the nerve, but I'm very leary of this as I have has tremendous pain from the cortisone shots. I am leaning toward another surgery to have the nerve removed. Please give me your thoughts on this.

    ReplyDelete
    Replies
    1. First of all, I am sorry I got so behind with my answer. I have never seen the alcohol shots work other than for morton's neuroma cases, but it still makes sense. This is a common surgery done, but it will leave you with some sensory deficiencies on the side of your ankle and foot. This may or may be a problem in the future, but who wants to live in pain. If you live near Seattle, Washington, you could consult with Dr Gary Dockery about the alcohol. I would definitely have a pain management specialist try their tricks, and Calmare therapy considered, before surgery. Rich

      Delete
  14. I am really struggling with my neuroma problems! I was diagnosed in February 2014 and after 4 shots and no relief I opted for surgery which I had in November 2015. Since the operation I have had no relief and awful nerve pain in my toes. I cant even have the duvet on my foot in bed at night! I have been told that it is now scar tissue that is causing the issues.
    In May 2016 I was given another Cortisone shot which did help clam things down but by August I was back to the pain.
    Last week I had another shot and I have been in agony ever since. Its made things a lot lot worse, my foot feels kind of 'full' When I was having the shot it didn't feel right at the time. After so many before I am worried there could be an issue this time. The nerve pain is as bad as before I had the op.
    I am waiting to see my consultant now but I just don't know what else to do. Ive had an MRI and he thinks there are not other issues other than bursitis which the shot should of calmed but honestly its so painful every step is so painful. I just want an end to this problem!

    ReplyDelete
    Replies
    1. I am so sorry I am not keeping up with my emails. Typically this one of two things: the original surgery missed the correct nerve (I have seen this!!) and a re-operation is needed, or the foot nerve pain is actually coming from the back (I have seen this!) where the foot treatment never really works or has to combined with back treatment. For now, stay away from the surgeon and see if the back is the issue. I hope you can or have gotten some relief by now. Rich

      Delete
  15. I have had 2 cortisone shots since april of this year, pain is acting up again just being on my feet to long in one or two day spurts. He never told me to ice 2-3 times a day for ever! Or do I know what dose i am getting! Please explain more about alcohol shots. How often? what dose each time?. Pain after? The cost thanks

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    Replies
    1. Typically alcohol is used to desensitize the nerve. I have been using 10% alcohol in a local anesthetic base with a total of 1 ml per shot. You do 5, once weekly for 5 weeks, then rest for a month. After that time, you evaluate. These shots are always painful unfortunately, but usually feel back to normal next day, unless you hit the nerve right on. If you email me at drblakeshealingsole@gmail.com, I will try to give a more complete answer. Rich

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  16. I had a cortisone injection a month ago in my neuroma and am super happy that the pain is gone and I can walk several miles in my wide toes shoes with arch supports in :) however I still have toe numbness which I thought meant that the neuroma wasn't quite better since that was my early symptom, before I realized there was an issue with my foot -- the Dr.'s office told me this is normal and additional injections would only cause more numbness -- I would like to understand why this is and they were unable to explain it in a way that made sense to me. thanks

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    Replies
    1. Thank you so much for the question. Any abnormal pressure on the nerve from the bones and swelling can cause numbness, pain, or a combo. In your case, the pressure of walking, and maybe some other cause of nerve tension (low back) is causing the numbness, with the pain from the swelling pushing against the nerve. All the cortisone did was to shrink down the swelling, so we know that caused the pain. But, the pressure against the nerve is still there, thus the numbness remains. Hope this helps. Part of your treatment should be metatarsal supports behind the nerve to take some pressure off the nerve, a look at the low back or other sources of nerve irritation, an understanding of what stresses out the sciatic nerve and how to avoid it, and perhaps the numbness will slowly get better. Rich

      Delete

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.