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Friday, May 6, 2011

Morton's Neuroma: Email Advice

Email received 5/5/11


Dear Dr. Blake,

I'm going to preface my question with a thank you that you have probably received many times in response to your blog: "I'm so glad I found your website!" Thank you for presenting your knowledge to people in pain, searching for answers. I wish I lived in California so I could come see you directly and get some help! Instead, I wonder if you'd just tell me what my next steps should be.

I have a Morton's neuroma. I've probably had it already for a year. The first time I went to the podiatrist, she thought I only had a collapsing (hammer?) 4th toe and prescribed the purchase of a soft gel cuff to cut to size and wear on the toe when exercising. This I did. And it did help a little, even though the area still felt numb.

About a year later, I was back, this time the pain having become so acute that I couldn't even walk my dog around the block without hobbling. She did another exam, heard the clicking and pronounced the neuroma diagnosis, and told me that immediate care involves 3 cortisone shots. If that doesn't work, excision or chemical killing of the nerve. So, not knowing any better, I had 2 shots (I don't know one type of cortisone from another, so I'm afraid I can't tell you what it was), each of which relieved the pain entirely for 1 month. At the end of the 2 months, I woke up one day with a pain on TOP of my foot, and a bright red bruise, slightly below the point where the foot bones come together at the top of the foot. For this she took an x-ray because she suspected a fracture -- but she couldn't find any fracture. She prescribed a pressure boot anyway, so I wore that for 6 weeks (!!). Even when she re-x-rayed she did not find any evidence of fracture, but insisted it was not related to the neuroma. Of course everything felt better in the boot because the foot was immobilized, but now that I'm not wearing it, the foot hurts again, this time both the neuroma and the ankle hurt -- I think because of simple weakness.

So now, with that secondary pain healed, we are back to treating the neuroma. Her chosen course of action is immediate surgery.

My first reaction was to say 'no', but of course it is very painful. I happened to mention the condition to an MD friend of mine who is in family medicine and he says he never prescribes surgery first thing but rather starts off with metatarsal support. What?! I asked myself, NOT surgery? He said surgery is only needed in about 20% of cases!

I was surprised, so I began to do a little Internet searching. The first thing I found was that most websites agreed with my DMP's traditional course of treatment -- they describe neuromas more of less popping up out of nowhere (or from high heels, which I don't wear, I wear things like Danskos, Birkenstock, Think, and Nikes, and hiking boots and Uggs in the winters here), and being treated with cortisone or surgery.

Then I happened across your blog and for the FIRST time I read that my neuroma might have other causes that could also be addressed and that I could start first by trying some other things before resorting to surgery. You write that it might have something to do with sciatica or ankle problems... well I had broken both bones in my ankle on black ice (--Minnesota!, in the spring of '05) and have 9 pins holding it together! About a year after that I had some physical therapy for pain in my left SI, which improved a lot after treatment but has never gone away -- I just live with it because it isn't debilitating. Is it possible that the ankle is causing both the SI pain and a neuroma that is also possibly treatable?! Your website was a huge relief to find.

So -- now I come to my questions...

*I read on your site that there are some things I can do first to self-treat -- so first I went out and got a metatarsal support (I could only find one kind at the clinic's shop, there is nothing at Target or Walgreen's, so I may have to go online, but at least I found one pair I can use in the immediate term). That helped quite a bit right away, I tried it on a short walk with the dog and there was only numbness but no burning sensation.

*I stopped going barefoot in the house but now wear my Birkenstock clogs as slippers.

*Should I try alternate warm-cold foot baths even though my injuries are not recent?

*Should I try Neuro-Eze (again, I'll have to order), even though my pain is not constant, but only hurts when walking?

*Tylenol, not Ibuprofin?

*Massage?

*What would YogaToes do for this, anything?

But here's my biggest question: Who do I see to analyze my gait? I don't know if I pronate or supinate, I can't see it. I don't know if my ankle function is harming my nerve- - I do know that when I tried some of your exercises for foot strength, I realized for the first time how small the range of motion/stretching is in my previously injured left foot. Could that be contributing my neuroma and my SI pain?

I guess what I'm asking is if I've already been to a DPM and she insisted that the neuroma had nothing to do with my previous ankle surgery, who can I ask about my gait and who can I get to help me treat the neuroma? I thought I was going to a reputable clinic here, it's large and has a great reputation but I don't know who I would need to see now....and if not a DPM, then who?

Thank you for your time, thank you for your blog! How can I repay you for the hope you have given me that I might be able to get this condition under control and better yet, perhaps even address any underlying cause?!

Sincerely,

June
 
Dear June, 
 
     Thank you so very much for your kind words. Your questions are all valid ones, and most doctors gradually learn all the treatments available for certain injuries (sounds like your doc is early in the learning curve, which is okay and no slight to her, just her reference point right now). In todays medical world, you do have so many choices in treating that surgery should be the last resort.
 
     If you want to try to avoid surgery, and surgery is done on less than 1-2% of our neuroma patients, you need to get 3 or 4 opinions from podiatrists and find one that is willing to team up with you. I do not know where you are at, but asking around for a conservative podiatrist is a start. If you are in the US, you can go to the website of the American Academy of Podiatric Sports Medicine (http://www.aapsm.org/) and check for local members.You need someone to analyze your gait and design orthotics to stablize that gait and off weight the neuroma. Without that, you will need surgery. But the orthotics are more important after the surgery than before for many reasons, so you have to have orthotics even if you are going to have surgery. Shoe stores, running clubs, and physical therapists may give you a recommendation for a podiatrist. And if that fails, start checking into physical therapists and chiropractors that make orthotics.
If you email your city, I can help find a doc if you are having trouble. But, in the end, you will have to go to the appointment and find out if they want to play on your team.
 
     One of the best things you said is that the cortisone shot lasted for 1 month. That really has made the diagnosis of Morton's Neuroma, which can be 1/4 of the battle. Now that you have identified the nerve problem, see a physiatrist or neurologist, to see if the neuroma pain is from a local nerve problem or from your ankle, lower leg, or back. Some podiatrists are good at that, but it is the world of a MD specializing in nerves.
 
    Why do neuromas hurt? They get pinched between two bones and treatment needs to separate those bones. The met pad was great proof of that. Go to http://www.hapad.com/ and order small longitudinal medial arch pads with adhesive backing. See my posts on Hapads. I love them. Have them in all your shoes just behind the sore area.
 
     The irritated nerves hurt more because the body tries to heal them. Your body floods the area with inflammation, and the swelling next to the nerve hurts. Three times a day you should ice or contrast bath over the next month to reduce the inflammation. You will definitely feel better. If you do, keep doing it. Ice 15 minutes on a ice pack, or do the full 20 minutes of contrast bathing. It all depends on your time and what makes you feel the best. Have your primary doc put you on an anti-inflammatory drug 10 days on, 4 days off to rest your system. You may have to go through a few drugs to find the one that makes the nerve feel the best.
 
     So, these are the basic steps right now to get well. You may want to go back to the same podiatrist with this info and just ask 2 questions. Will you help me on this? Or, if not, who can you recommend that will. This is not experimental stuff. So, be confident, kind, and see what she says. The answer may surprise you. Rich
 
  
    

1 comment:

  1. Again, thank you Dr Blake, I will check the AAPSM website - to answer your question, I'm in Minneapolis, MN.
    Your suggestions have already helped, and I will endeavor to find a doc that will work with me now that I know more.

    ReplyDelete

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.