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Thursday, October 2, 2014

Morton's Neuroma: Email Advice

Hi Dr Blake,

I am 71 yo male with a long history of running, backpacking, etc..  Ran 80 miles per week in my 30s, ran 40 miles on my 40th birthday, 2:51 marathon at age 38, and etc..   Had successful meniscus surgery on my right knee (minor shaving via arthroscopy) 2 years ago probably due to XC ski injury.  Have since stopped any running but still like to do backcountry backpacking, hill walking, etc..  I carried a 40 lb pack for 10 days over 50 miles/ 1000s of ft in July, mostly without foot discomfort except for substantial MN (Morton's Neuroma) pain in left foot on 3000' descent the final day.

Have custom orthotics made by DPM in Orinda, California, per referral from my primary care doc in Oakland. Diagnosis and foot treatment was covered by HealthNet Seniority Plus but I paid out-of-pocket for the KLM orthotics. 

For a few years I have classic Morton's Neuroma (MN) symptoms in my left foot.  The podiatrist confirmed diagnosis with the 2 tests you show on your video.  However, he doesn't seem to have focused on approaches other than cortisone, alcohol, and surgery -- except for his orthotics onto which he seems to have placed a pad too far away from the ball of the foot and without much interest in getting the lateral placement right.  Also, he has not ordered an MRI for confirmation of the diagnosis and location of the neuroma.  [PS: I was first aware of these symptoms when I was wearing XC ski boots which were probably too narrow.]

My goal is to be as aggressive as possible, initially using non-invasive methods.  I would like to find someone knowledgable to teach me how to do self-massage or to find a good Bay Area PT who can do this for me and teach me the right stretches, etc..  I would also like to find the correct Neuroma Pads or Metatarsal Bars as well as something to spread my toes if either would be a good adjunct to my existing orthotics.  (If necessary, I would consider replacing my new orthotics.) 

I recently found your blog and have studied all your website postings and videos on this subject.  I also just called your Ctr for Sports Med and learned that an initial visit with you would cost around $280.

So, if you are willing to take the time to answer, here are some questions:

1.  Can I assume there's no relationship between suspected Piriformis Syndrome in my RIGHT buttock/thigh and my MN symptoms in LEFT foot.  [I ask this because one of your blogs mentioned the ways in which the sciatic nerve can produce pain that could be misinterpreted as MN.]
Dr Blake's comment: No, there can be a direct correlation between the two. A central bulge of L5/S1 nerve root can give you your exact symptoms of right piriformis syndrome and left morton's neuroma. This is why it is a no brainer to do MRI with contrast dye for the foot,and see a neurologist or physiatrist for the low back/piriformis. Try neural flossing as shown on my blog three times a day on both sides and record what symptoms it helps or irritates. 

2.  Since I am not suffering these MN symptoms during most activities (often am painfree for weeks at a time), might I resolve these issues with a combination of massage, pads, etc.?
Dr Blake's comment: Definitely, you have just begun non-surgical treatment. From a podiatry standpoint, the right orthotic devices to achieve protected weight bearing and the right shoe gear that does not irritate, it the gold standard starting point. You are not even at the starting point in this area. A look see at the nerves above your foot to see if there is a double crush phenomenon going on, and appropriate treatment. The nerves are giving you clues, but we must interpret. Doing minimal nerve desensitization (Neuro-Eze and neural flossing) and anti-inflammatory (icing and contrast bathing) on a daily basis is also very important. Definitely avoiding anything that seems to aggravate is crucial. Try Sports and Orthopedic Specialists in Oakland as a good source of PT advice on massage, etc. 

3.  If I came to you, what might I expect to pay and how might I get my insurance to cover some of it?
Dr Blake's comment: It really depends on what we do. I do try to keep to the KISS principle. I do not take HMOs, only straight Medicare, so you would be a self pay. The $280 for my consultation and the hospital charge combined sounds about right. 

Thanks in advance for your reply,

Ron (name changed)

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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.