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Saturday, December 28, 2019

Failed Neuroma Surgery: What Next?

Hi Dr. Blake,

I had stump neuroma surgery ( plantar approach) in November 2018.  For the first 6-7 months post surgery I was able to bike without pain, and hike and walk 5-6 miles with slight pain.  When I got to month 8 things started changing.  I could bike without pain, but with walking the pain increased.  I will also say in month 7 and 8 I was diagnosed with uterine cancer and doing some type of exercise was needed for my mental health.  It ended up they got the cancer through surgery and I did not need further treatments.  Yeah! 
Dr. Blake's comment: I am so happy for you!! 

During months 4-7, I did have some physical therapy and continued to check in with my doctor.  At month 8, I went to another doctor for a second opinion and he suggested that I need softer cushioning under my forefront.  I did this and what he prescribed did not work well with my orthotic. 

Fast forward to month 11, and I return to my foot doctor telling him I am in pain almost all the time and that I feel a lump to the right of the scar on the bottom of foot.  I suggest we do an MRI so he orders it.  Now I know it probably should have been done with contrast...  but it wasn’t.  It showed postoperative scarring within the third web space and within sub adjacent plantar subcutaneous fat and adjacent to the fourth flexor tendon related to the neuroma excision.  They also found a small ovoid T2 hyper intense mass along the plantar margin of the second MTP joint consistent with a small ganglion cyst. 3 by 7 by 3mm.
Dr. Blake's comment: Is this where you hurt? They probably need some diagnostic injections with local anesthesia only. Does it feel like the same pain as before? Hyper-sensitive nerves from double crush (like coming from your back) can involve neuromas, but removing the neuromas does not help always. 

Both doctors did not think anything of the cyst.  And they said the best way to break up scar tissue was with steroids.  My doctor would only give me 1 shot because of my history of steroids in that foot.  I am 5 weeks out from that shot, and have noticed no improvement.
Dr. Blake's comment: I am assuming that you never respond to steroids. Are you some one who scars alot? Do they think you kept entrapping the nerve in more scar tissue. That makes sense from the timing of feeling good for awhile which normally happens in scar entrapment but not double crush. These of course are general rules with exceptions. What happened with the first surgery? Same symptom development months after the surgery?

At this point, my doctor has given me my records and said there is nothing more he can do.  Wow... I was not ready for that.  The other doctor I am seeing  is pretty non responsive.   So in one weeks time, I am discharged from a doctor and then learn they found some more cancer cells on my check up.  It’s been quite a week.... but I am strong and I will tackle this!  My CT scan showed it was contained... so I think a few zaps of radiation will kill those nasty demons....
Dr. Blake's comment: You are inspirational to me!! Go Girl!! You got this!! I have had a patient once similar where the pain was double crush and coming from Stage 4 prostate cancer pressing on the L5 nerve roots in his back. The foot pain made the diagnosis since it made us look at his back that did not hurt. 
     What about alcohol shots to de-sensitize the nerves? This is a very successful treatment. I have a recent post on my protocol. 

So now I am back to foot searching for the answer.  Before having stump neuroma surgery, I had done RFA and PRP with some success.  I reached out to them and they said most likely there are some nerves caught up in that scar tissue that are causing me the pain.  At this point, I can’t do PRP because of active cancer.

I am doing some massage and stretching exercises. I have also ordered a new orthotic with metatarsal support.   Can you think of anything else?  Should I get more tests done.... mri with contrast...ultrasound?  No one seems concerned about the cyst... I guess that is ok?  I am just discouraged about the level of care I have received.  I would have never thought I would be worse off post surgery...
Dr. Blake's comment: 

  1. Make sure no feels this is double crush from the uterine cancer or low back issues
  2. Yes, get an MRI with contrasts which is standard of care for this issue
  3. Be considered for alcohol injections (typically one or two series of 5 injections which each injection one week apart). 
  4. Do the typical nerve treatments which I have not heard you mention: Lidoderm patches, TENS home use 2-3 times daily, neuro-eze or neuro-one topical gel massaged in, other ketamine based compounding medicines, and neural flossing.
  5. Find the local PT member of the Neurology Academy. They look at PT from nerve standpoint. You need to be at least on a Sciatic Nerve protocol as you can be tweaking the nerve by sleeping, sitting, standing, lifting all day long. http://www.neuropt.org/about-us
  6. There are other treatments I have some experience with like Quell for pain control. 
  7. There are tons of oral medications like Lyrica and Gabapentin. These are to drive the nerve sensitivity down, and then maintained with whatever dose achieves that, and then we attempt to wean off.
  8. The goal with all these treatments is to get you fully functional at level 2 pain and hold you there for a year.
  9. New orthotics with perfect metatarsal support is crucial. That task alone can take awhile to do with a good orthotic person who wants to experiment.     


Any advice is welcome.

3 comments:

  1. It is common to attempt to narrow focus down to identify specific areas of symptomatology but that can cause one to miss the underlying etiology. I see a number of patients with forefoot pain in which the underlying cause is biomechanical. The general term I use for such patients is "lessor metatarsal overload." This means that there is repetitive and excess pressure on the lessor metatarsals in propulsive phase of gait.

    Hypermobile first ray, short first ray, forefoot valgus, midtarsal joint oversupination in propulsive phase of gait are all factors in lessor metatarsal overload.

    Focusing on "proximate" causes of pain we see intermetatarsal neuromas, "capsulitis" of the lessor MTP joints, lessor metatarsal stress reactions and stress fractures.

    I have seen few patients with intermetatarsal neuromas who do not display lessor metatarsal overload. So treatment of the neuroma either surgically or injection as isolated treatment does not treat the underlying pathomechanics.

    Most patients who have had neuroma surgery and remain in pain have had the surgery done with adequate technique but with insufficient attention to the faulty mechanics.

    Common orthotic interventions that I will couple with neuroma surgery may include: forefoot valgus posting (when indicated), metatarsal elevation in the shell of the orthotic, metatarsal bar distal to the edge of the orthotic, and first met head/ray cut outs to help induce plantarflexion of the first ray in propulsion.

    ReplyDelete
    Replies
    1. The system listed me as "unknown." Eddie Davis DPM
      eddavis317@outlook.com

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    2. Thank you so very much Dr. Davis. Your comments are very true and very well put! 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.