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Monday, March 12, 2012

Morton's Neuromas: More Email Advice

Photo illustrates the typical place for a Morton's Neuroma between the 3rd and 4th Metatarsals.
Hi Dr. Blake,

Thank you for creating your informative blog. I so appreciate your mission to educate, encourage self-care, treat conservatively and exhaust conservative options before surgery.

I'm writing you because yours is the only info I've read describing the connection between neuroma and possible sciatic nerve involvement.

I'd love your advice on how to proceed (and I'm okay if you want to answer this on your blog).

I've got a neuroma in the 3-4 interspace that is so painful I am miserable and disabled.
(see photo above).

It first became painful/symptomatic 12 years ago when I was dancing tango a lot. At that time the first doc I saw gave me a cortisone injection, which made the pain much worse than it had been, for at least a month. 
Dr Blake's comment: Injections, whether cortisone, local anesthetic, or alcohol, will rarely set off the pain cycle like this, but it does happen. Even though I would not want to give another shot if a patient previously experienced this reaction (one human to another human, and probably throw in some Oath I took to cause no harm), it may be necessary. Reactions like this seem to indicate an severe hypersensitivity of the nerve, more than you would get just from your garden grown variety irritated Morton's neuroma. The question is what is causing this hypersensitivity.


After that bad month, it took about 5 months but finally responded to orthotics and wearing wide, flat shoes. At first I could only be pain-free while wearing hiking shoes, then gradually over time I became able to be pain-free wearing other wide flat shoes. I was never able to go back to wearing any kind of heel, was very limited in my choice of dress shoe, and could not return to dancing tango. (Even in flat shoes, raising up onto the ball of the foot and pivoting produced discomfort/warning signs.) However I was able to hike up to 5 miles, so I was pretty happy with that. By always choosing clunky shoes and usually wearing orthotics, I remained pain-free for a decade.
Dr Blake's comment: I have been happy with Hapads and Budin Splints, and kinesiotaping to change mechanics, and daily use of Yoga Toes if tolerated,  along with 3 times a day ice packs for 10 minutes, during this period of sub acuteness to begin to increase function (like dance) or heel height. The blog is full of info on these topics.


This Budin Splint can be placed over the third toe, the second and third toe combined, or the third and fourth toes combined. It can be worn in most shoes, and can change the pressure enough to ease the stress around the nerve.

These Yoga Toe knockoffs are normally worn for 30 minutes a day while blogging or checking your emails (sitting). They are used to stretch the soft tissue, to relax them, and ease the tension.

Here are Small Longitudinal Medial Metatarsal Pads from www.hapad.com. You can easily move them around, cut them down, trim them, step on them, and they should allow weight transference away from the sore area. They are not to used with Budin Splints. 


Last early December I did test my limits and wore a 1/2 heel while cooking and serving at a dinner party, and flared the neuroma up. It's been shocking how quickly it became excruciating and how nothing seems to be calming it down. 
Dr Blake's comment: In the acute phase of neuoma pain you have many options to calm it down.The gold standard is a removable boot with accommodative padding or orthotics, or whatever it needs to take the pressure off the neuroma. You should feel that you have 0 to 2 pain in this cast. You go to the cast in the first place, if you can not figure out how to take pressure off the neuroma and still function. Crutches can be very useful, and rollabouts for home or office. With nerve pain, you must stop the pain as quickly as possible. Also, icing or contrast bathing three times a day can help. You try these modalities for 2 straight weeks to see if you can get it to work, if not, you try something. Accupuncture, done by the right person, has much more reliable success than physical therapy. Topical NeuroEze, Lidoderm Patches, compounding topical medications like mixtures of ketamine/gabapentin/lidocaine, can prove very helpful. Massage if tough to do right and not have it be irritative, thus the lidoderm patch is helpful. If all else fails, you can titrate up to a good dose of Neurontin or Lyrica, or another drug, it takes an experienced practitioner with these drugs to do it right.


Here a Removable cast is being used on the right foot to stop bending of the toes. An EvenUp on the left side protects the spine, keeping the pelvis level.

Here my niece Kelly many years ago poised for a photo on Contrast bathing. I have a YouTube video on this.



I am unable to walk without limping and without extreme pain, unable to do most of normal life (shop, cook, etc) and cannot be on my feet to work (I do bodywork). My pain level is about 7-9 when stepping on the foot, and 1-4 when I'm not on the foot. Anything touching the foot is painful so I remove my shoes most of the day while sitting/lying, and use a foot cradle in bed. It's so painful to touch I can't even really allow a doc to examine it. I did have swelling (which I'm told is rare with neuromas) but contrast baths seem to have reduced that to a minimal level.
Dr Blake's comment: With this level of pain and disability, I would be on crutches and working with a pain specialist to reduce the pain via pain killers, drugs like Lyrica, Lidoderm patches, get a physiatrist or neurologist good with the back and foot connection to evaluate you. Is this pain so intense at your foot since it is being irritated at the back?

An MRI with contrast described the neuroma as 7mm x 10mm, and showed no evidence of other issues like bursitis, stress fracture, ganglion (which we wanted to rule out because of the swelling.)


Here is a non-contrast MRI showing a possible neuroma in the third inter metatarsal space.


Here are all the things I'm doing:

I am exclusively wearing a very wide, cushioned running shoe with a deep toe box (Saucony Hurricane). I have one pair to which a cobbler added a slight rocker sole, and another pair that is unmodified). Dr Blake's comment: I have not had luck with the rocker sole, but it is worth a try.
No barefoot walking or standing at all.
My doc made me new orthotics that encourage slight pronation, to reduce the weight on the lateral sides of the feet.  (I have overly flexible feet, high arches, and am a mild supinator, but no bunions or other issues.) Dr Blake's comment: This sounds great since lateral weight bearing due to supination would be terrible for this syndrome, and terrible on your back anyway (even if it has nothing to do with it).
I am using Hapad met cushions (they seem to move the pain proximally, but don't make the pain any less). Dr Blake's comment: Try to get the longitudinal medial arch pads and attach to shoes and/or orthotics. Just a bigger surface area to redistribute the weight. 
I am taking Celebrex (200mg/day) and Neurontin (1800mg/day).
Dr Blake's comment: Neurontin is to be gradually built up to possibly 2400mg to drive the day to day pain level to 0-2. Since you are not there, do you think it is working. If so, increase to 2400mg gradually. If you do not think it is working, spend 6 weeks weaning off the Neurontin so you can try Lyrica. Lyrica is a similar drug but for many patients much better (and others not as good).
Dr Blake's comment: The Celebrex is a half dose, so you can increase to 200 mg BID, or discontinue to try other of the 8 classes of anti-inflammatories. One of those 8 classes may be better for you. 
I had been applying a topical cream, compounded Neurontin/Ketamine; since reading your blog I have switched to BenGay, which I actually like better. I can order some Neuro-eze if you think that would be better.
Dr Blake's comment: NeuroEze can be used at the same time as BenGay and is totally different. I definitely would be using Neuro Eze three times per day.
I've done contrast baths three times daily for 4 weeks (but have recently stopped--it almost began to seem that the cold and heat were each irritating the nerve).
Dr Blake's comment: This was the right thing to do if something seems irritative. Nerves tend to want you to stop irritating them. Try 20 warm water bath alone to see if it helps. 
I'm doing PT twice a week to stretch the plantar fascia, and have had 8 sessions of iontophersis with dexamethasone.
Dr Blake's comment: You are doing so many great anti-inflammatory measures with little results, so you are probably just dealing with a very irritative nerve at the moment.
I'm also doing foot movement exercises like toe waving, toe scrunching, slowly gently drawing the alphabet.
Dr Blake's comment: This is so crucial to find ways to keep your foot strong while you are rehabilitating. Bravo!!
I've recently started acupuncture (I felt some pain reduction after the first session but then have not experienced relief after 3 subsequent sessions).
Dr Blake's comment: I love acupuncture for this, ask the therapist if changes in the approach taken may be useful. 
Dr Blake's comment: In situations like this you perfect every possible modality to see if you can get ahead of the symptoms.You are doing a wonderful job!!

I've been wanting to avoid a cortisone injection because 12 years ago it increased my pain for over a month. But It's becoming clear to me that I'm not making enough progress despite all my conservative measures.
Dr Blake's comment: Very understandable!!

The last twist to this is that I am also having what feels like sciatica in the same leg. After the neuroma pain began in the forefoot, it spread to the ankle, then the lower leg, and now includes the back of the thigh along the route of the sciatic nerve. I've mentioned this to two docs (a podiatrist and a physiatrist) and both brushed it off as muscle soreness due to my limping/compensation. But I think it could be that the entire length of the nerve has become progressively irritated, and reading your blog validated this hypothesis. 
Dr Blake's comment: Yes, when one nerve is sore for awhile, others nerves begin to become hypersensitive to protect you. Your nerves are annoying friends, but still friends. 

I do not have any pain in my low back, and did not have sciatic pain anywhere in the leg prior to this recent onset of neuroma pain in the foot.

How would you suggest I proceed? Should I go back to the physiatrist and request a workup on this? What would that look like? Emg? Or ask my PT to evaluate? In truth, the sciatic pain is very minimal compared to the foot pain, but I am wondering if the nerve cannot heal at the foot because it is irritated at multiple points along its path. Just not sure how to proceed here.
Dr Blake's comment: You definitely need a neurological workup to decide if this is limited to your foot, or part of a bulging disc/radiculopathy problem. You would want the same doc to experiment with the Neurontin or Lyrica or Cymbalta, possibly pain meds, in an attempt to get these symptoms under control. Spreading nerve pain is something to be even more aggressive in treating, but no one would argue with your persistence.

I"m also thinking it's time to proceed with a cortisone injection, and I have a dilemma. 

My podiatrist wants to do a series of 3 injections, 3 weeks apart, of short-acting cortisone. My physiatrist recommends an injection of long-acting steroid (Kenalog). Can you compare the benefits and downsides of short-acting and long-acting steroid?Does the long-acting drug have a greater risk of steroid flare? 
Dr Blake's comment: Steroid flares should be avoided with increased nerve pain. For this neuroma, a fairly large one at that, I would recommend Kenalog or nothing, and would opt for nothing at this time. Irritative nerves do not like to be injected. We all try it once, but when that fails, and conservative medical management is not working, surgical removal should be given full consideration. 

Another question is that one doc recommends using ultrasound guidance to place the injection, the other doesn't. Do you believe there is benefit to the guidance? Are there studies that demonstrate more positive outcomes with guidance?
Dr Blake's comment: I have no experience with this, but if the one you trust to give you a shot wants to use guidance, I would do it without thought. 

Thank you so much for any advice on this, and for all the good you are doing in the world. 

Warm regards,
Karin 



Dr Blake's comment: Over the next 3 months the decisions do 2 things: 1) Get a neuro workup with attention to your sciatic nerve as a possible aggravating factor, and have the same doc analyze the Neurontin question. 2) Do all of the other conservative things we mentioned above and see if that makes a significant difference. Then get back to me in 3 months with your progress report. Good Luck, and thank you for all your kind thoughts. Rich Blake

2 comments:

  1. Thank you for all your information. I am anxious to try several of your suggestions with my neuroma. I am looking to order the Hapad metatarsal pads. If I only have the neuroma in my left foot, should I just order for the one side, or should I get the pair? My goal in healing is to end with as little needed "devices" as possible. I don't want my right foot to become dependent on the pad when it is perfectly fine already.

    I am a stay-at-home mom and I tend to go barefoot a LOT. I am actually surprised that you recommend avoiding barefoot walking as other natural foot doctors I have read online suggest the opposite - those in favor of being barefoot all the time. Please expand on this.

    And finally, what are your thoughts on the Yoga Sandals with build in separators? I am wondering if they would be helpful for me.

    ReplyDelete
    Replies
    1. You can wear hapads on only one side as long as it feels comfortable that way. Probably 80% of my patients just wear on the side they need it for. Avoiding barefoot is only when the problem is acute and you need the extra padding and protection of the shoe. In this case, you wear shoes 2 weeks longer than you need to , and then reintroduce barefoot walking at home to see how it goes. The nerves on the bottom of your foot are very exposed the higher your arch, so some of my normal to high arched patients can never go barefoot. But this is variable. Yoga Sandals which separate the toes change the position of the nerve to bone. It would make some patients very sore, and improve others. You would just have to try. You could try wearing small gel toe spreaders between your toes for several days to see if it helps. You would place them between the 2/3 toes and 3/4 toes in general. Hope this helps. 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.