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Monday, September 13, 2010

Morton's Neuromas: Advice for When Pain Becomes Chronic

This is an email with answer from Brian in Florida.

Dr. Blake,
I have read your blog on Morton's Neuroma. I have been suffering with the affliction for over two years and it literally almost killed me.
To start, I'm 52, male, in good health otherwise. Non-drinker, non-smoker. My foot pain started in November of 2007 rather insidiously. In January of 2008, I visited a podiatrist who diagnosed the condition and gave me a cortizone shot.
This shot ended up causing me tremendous pain for over two months. I was ready to cut my foot off it hurt so much.
During this time I researched the condition and learned about all the pitfalls of surgical intervention for the condition. After much research, (MRI, visiting several different physicans) I learned that my condition is caused by foot mechanics. I have what has been described as a hypermobile first ray which directs my weight to the center of my forefoot during walking.
I have one neuroma between 3 and 4 on my left foot. Two on my right foot, one between two and three, one between 3 and 4.
I have spent literally thousands of dollars on shoes, orthotics, two rounds of cryogenic neuroblation, one by a doctor in Tampa (Dec 2008), a second by a doctor in Phoenix, (Dec. 2009). My symptoms have lessened but I can not stand still for more than 5 minutes without pain, and cannot work standing all day without ending up in a lot of pain.
The Cryo really helped my left foot and the neuroma between 2 and 3 on my right foot, but, the neuroma between 3 and 4 on my right foot has really started to bother me again.
By the way, when I said that this condition almost killed me I meant it. I had been taking Celebrex to help manage tha pain for over 1 year. (200 - 400 mg per day depending on pain started in 12/08 after the first cryo). In July of this year I was put in the hospital with a bleeding ulcer. This was an expensive ($60,000) event, along with the 10 day hospital stay. My gastroenterologist feels that the ulcer was from the NSAIDS, as I do not have an H-Pylori infection.
I need to get this problem resolved. I am trying one last pedorthist  for a set of orthotics and shoes that help with my gait. I am considering either one more Cryo attempt, or getting some guts up and going for the surgery.
With the mechanical issues that come with my inherited feet (one doctor told me that I just had bad genetic luck ) I wonder what is my best course of action. I prefer the cryogenic neuroblation over the alcohol shots but I am wondering if it is time for surgery.
In your experience how common are complications from the surgery, stump neuromas, chronic regional pain syndrome, etc. Would you try something else ? The pain from this condition is affecting my life not only at work, but in my relationship with my family and my over all general health as I can't walk, bike or exercise any more.
The possibility of the surgery actually making the pain worse scares the day lights out of me because I don't know if I could take it.
Your blog is very informative and it sounds like your approach is very conservative. You seem to be a talented and compassionate individual. I would appreciate any thoughts you have in this matter.
Thank you for your time.

Brian, Thanks for the compliments and email. There is so much to discuss from your email, and I thank you for allowing me to answer in my blog post.
     One of the main reasons I would not go to surgery now, if you have told us everything, is that you need more workup for the source of the nerve pain. I do not think you can ever be sure that nerve pain has a simple source, like a fallen arch, or a hypermobile first ray. But, great orthotics can help you immensely and must be sought after. There are so many factors when dealing with orthotics and nerve pain that it can take quite awhile to recognize them all and address them all. They include the amount and placement of the metatarsal arch, the flexibility or stiffness of the material around the metatarsals, the accommodation, and exact placement of, for the painful spot, the heel pitch forward, etc, to name a few. Have you been happy with the orthotic people you have gone to, are they analyzing many of these factors? The orthotic support therefore must be as ideal as possible before you venture into surgery, and it may eliminate your need for it. I guess what I am trying to tell you is not to set some arbitrary number on how many orthotics you get before surgery, but to keep trying until at least you feel the guy making them is doing the best for you.
     One of the key aspects of your condition right now is to regain foot strength. Golden Rule of Foot: For every day you are in pain, it takes another day to get the lost strength  back. That is one reason you are on this slow course. Loss of foot strength definitely is allowing the metatarsals to collapse onto the nerves increasing the nerve irritation. You need a skilled physical therapist to triple the strength in your feet over the next year, but the exercises can not increase the nerve pain. Sometimes easy, and sometimes this is a difficult task. Extremely important however.
     One question all patients with neuromas must ask is why do my neuromas hurt, when some neuromas do not. I have MRIed many patient's feet and found non-painful neuromas, at least the patients say that they have never hurt. I have had patients who come in with neuroma pain for 2 weeks, and when we MRI them, they have some of the biggest neuromas west of the mississippi. Why did they just start to hurt? The neuromas  had probably been around for years. The word Neuroma denotes some permanence, a thick scarred swollen tumor. But, inflammation of the peripheral nerves called neuritis, does not show up on MRI, and can hurt just as bad, and require just as much treatment. I think neuritis responds better to alcohol shots, but this is another general rule that may not apply to you. So you need to make sure that your neuromas hurt by themselves and not complicated by tarsal tunnel syndrome, peripheral neuropathy, low back radiculopathy, and other sources of nerve pain. You definitely need a neurologist or physiatrist involved. Nerve Conduction Studies can be very helpful for tarsal tunnel and low back involvement. Nerve biopsy is standard for peripheral neuritis. So, the source of the pain must be identified better.
     I am not sure why cortisone shots help 99% of patients and aggravate 1%. And when it aggravates, called steroid flares, these patients really hurt for a long time, and they never want another shot again. Don't blame them. Sorry it happened to you.
     I have no experience with cryo-ablation, but it sounds like it helped 2 of the 3 areas. Sounds like you respond well to it, what have they told you about it not working if you try it again. Was it very painful? What is the downside in your mind? Please answer any of these questions in the comment section of this post.
     I am alittle unclear if you still have pain in one or both feet. Could you let us know when you have pain during the day, and at what level on the pain scale of 0 to 10? Have you tried a removable cast, with or without an orthotic, on the worse side and does that take care of 100% present of your pain? Have you tried athletic shoes, hiking shoes, clogs, or sandals, and do any of these shoe gear changes help you at all? Golden Rule of Foot: Try alternating shoe gear throughout the day to vary the stresses on the injured area.
     Since all of the nerves involved have been poked on repeatedly, there can easily be a two year healing course that you are presently on, where the pain will gradually get better. I prefer you keep working on the orthotics, get a pain specialist (neurologist or physiatrist) on board for evaluation and treatment recommendations, find ways of being more active ( there has to be a way you can ride your bike without pain) for strength/cardiovascular/emotional health, use Neuro-Eze three times daily or a prescription compound, consider alcohol series for the stubborn nerve,  discover what shoe factors make you hurt more and less, do contrast bathes or warm soaks twice daily, place a removable cast on for part of the day if that helps, use Neurontin or Lyrica to desensitize the nerves for a 6 month trial (must start real low dose to get used to it), play with digital splints and taping if the orthotics reach a limit of what they can do, and consider at least another office visit where the doctor injects your nerves with local anesthetic(see my post on this) and eliminates your pain for 5 hours completely. I hope this refocuses you and I will be following your comments. There is so much to do prior to considering surgery that I will save the surgical questions indefinitely. Rich

1 comment:

  1. I suffered with Morton's Neuroma for many years. I fully understand what you are going through. When it became unbearable to wear shoes I switched to Birkenstocks which have NEVER bothered my affected toes. I was given ultrasound and cortisone injections. 
    Neuromas Treatment


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.