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Tuesday, July 23, 2013

Morton's Neuroma: Email Advice



Hello Dr. Blake,

      I recently came across your blog while trying to better understand my diagnosis of Morton's neuroma in my left foot. I noticed you are in San Francisco and was hoping to set up an appointment with you, since nothing I've done seems to help the pain.

      I began noticing a strange sensation in my foot last September, but didn't take any measures to treat it until December 2012, when it began to feel significantly worse. In summary, I had 3 cortisone shots but still experience a lot of pain and would like to find out if I am a candidate for surgery, as much as I'd like to avoid it.

      For a very detailed account, here are the steps I've taken so far:

 1. I went to see a chiropractor first, since my mom thought it might be similar to her foot pain, which he treated by working on her back. With minimal observation, he thought perhaps I had a metatarsal sprain or pulled tendon and suggested daily ice an massage.

 2. One month later when the pain got worse, I set up an appointment with a podiatrist and got an x-ray to rule out a stress fracture. When I saw her she confirmed that it was actually Morton's neuroma, and suggested 3 cortisone shots over the course of 3 months in addition to wearing only shoes with orthotics.

 3. My first cortisone shot was on Feb 13th 2013, and after about 48 hours I estimate that it felt about 30% better. Actually, she injected two shots - one between the 3rd and 4th metatarsal and one between the 2nd and 3rd. She said the injection included Marcaine (0.25% plain), Kenalog 40, and Dexamethasone 4 mg/ml.

 4. On March 20th, I had my second round. Again, I noticed a 30-40% improvement, so I really felt like I was on my way to recovery.

 5. On April 22nd, I went back for my third round, but she decided not to give me the third shot, suggesting that it would go away on it's own.

 6. A month later, when I still felt some slight discomfort, I made another appointment because I was afraid to resume my normal activities or wear other shoes without orthotics. On May 21st, she gave me a third round of shots. However this time, it seemed like the injection made it worse and it seemed like almost a week before I could put equal pressure on both feet.

 7. When I told my podiatrist that I was still in pain, she ordered an MRI, but I declined because I have very minimal health coverage, not to mention that I was very frustrated with how casual she was about the treatment. She said it was very common and very easy to treat.

 8. Since June 4th, (this email was received July 21st) I have been going to regular acupuncture appointments twice a week. I definitely seems to help with pain management, but it does not feel like a solution. The pain now seems to vary day to day, depending on what activities I am doing. All this to say, I feel pretty desperate for your help because I don't know what else to do besides surgery, and I would like to avoid it at all costs! If possible, please let me know if I can set up an appointment with you. Many thanks, Susan (name changed)

Dear Susan,
     Thank you so very much for your email. With your health insurance issues, I will try to minimize visits. You can call the office any day at 415-353-6400. But first, here are my thoughts for your to think about. 
1. You have definitely had adequate cortisone, which each last for 9 months, so are in there working right now. 
2. What does cortisone do? It controls swelling around the nerve that is all. So, even though the cortisone is working, you can still have nerve pain which is not inflammatory. 
3. Continue to work on any remaining inflammation however by putting your foot on an ice pack for 10 minutes 3 times daily.
4. What can be the cause of the residual nerve pain? Typically it is mechanical pressure and nerve irritation from above the foot. 
5. How do we work on the mechanical pressure part of the nerve pain? You change the weight bearing on that part of the foot. Here we are only limited by our imagination. We have so many choices, and you need to find out what excites the nerve and what does not.
6. Part of the mechanical fix is always inserts/orthotics which are carefully designed to take pressure away from the sore area. This insert is the staple of the treatment. But, staying away from tight shoes, too high heels, shoes with poor padding, and shoes with too much flexiblity should be done. 
7. Many times I will use a removable boot for awhile, with an EvenUp on the other foot, to rest the area while allowing the patient to walk. You can get the Anklizer at Amazon.com relatively cheap. 
8. Avoid barefoot for sure, find a clog or sandal or slipper that does not irritate you at home. 
9. Check my blog and online for Hapad Adhesive Felt Longitudinal Medial Arch Pads. I use the Small size on most patients, and there is an art to applying and adjusting. However, if you are not afraid of making mistakes, you can move them around, thin them, cut them shorter or narrower, to individualize the design for each shoe. I love these. They can be put in any shoe that orthotics do not go into, even heels and sandals, and may even be better than the orthotic you have.
10. I do love Acupuncture for this syndrome. Acupuncture works at the nerve layer of this injury, and can be very helpful. 
11. For your money, I would see a neurologist/physiatrist next. You really need to get their advice on whether this nerve pain is coming off your back (even if you have no back pain), and if they recommend nerve drugs (oral or topical) to help you. I would at least understand the concept of double crush--type into the search engine on this blog. 
12. Definitely get a bottle of Neuro-Eze. For $30/bottle, you rub a small amount into the area on top and bottom of your foot for 1 month, along with everything else. It is homeopathic, a concentration of L-Arginine, a natural amino acid. 
13. Take this one month at a time. So few patients need surgery that you are not close to that right now. I hope this gives you some focus for the next month or so. 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.