Article Emphasizing the Safety of Alcohol Injections for Neuromas with the Need for Mechanical Treatment Also

https://www.sciencedirect.com/science/article/abs/pii/S1067251618300759?via%3Dihub

Alcohol Shots for Morton's Neuromas Instead of Surgery

     This article documents the positive results for 20% alcohol injections to help Morton's Neuroma Pain. My present protocol is one series of 5 weekly injections starting at 10% and ending at 18%. I then wait one to two months, and if there has been a positive help, and less then 80% success, I then do a second series at 20% only. If patients have a bad reaction, it is one in five patients on the first shot at 10%. They will have more pain for 4 days to 2 weeks. I do not give them another shot until this has calmed down. They do not experience more pain with any other injection even with the higher doses. Rich

https://www.ajronline.org/doi/10.2214/AJR.06.1463

Alcohol Shots for Morton's Neuroma: Email Advice

Dear Dr. Blake,

I found your blog several days ago and have found it very helpful and informative. I have been experiencing pain in my left foot since September 2017. This past Wednesday my podiatrist administered an alcohol sclerosing injection in my foot for a Morton's Neuroma. I have a follow-up appointment with my podiatrist next week; in the meantime, I have two main questions about the shot that I was hoping that you could answer.

1. Prior to receiving the shot on Wednesday, I experienced mild to moderate pain on the top of my foot and the ball of my foot. Since receiving the shot, I have experienced intense pain in the arch of my left foot. My podiatrist told me that a sclerosing shot can cause an initial increase in pain; however, is it normal/to be expected that I would feel increased pain in a new area of my foot (the arch?)

Dr. Blake's comment: Yes, unfortunately, I have had patients feel the entire bottom of the foot was hit by a board, and very sore for up to 2 weeks. Unusual, and typically the first one in the series, but definitely a temporary problem. The symptoms can last for 4 days to 2 weeks. All of my patients that had that experience did continue to have the complete series of 5 without other flare-ups. 

2. The pain that I have been experiencing after the sclerosing shot is very intense, and I am not sure that I want to proceed with the series of shots. The original pain from my neuroma was more tolerable, and was also intermittent--this new pain is intolerable and constant. If I were to stop the sclerosing treatments, how long would it take for this new pain in my foot to subside? Also, are there different courses of treatment that I could discuss with my podiatrist?

Dr. Blake's comment: I can sympathize with you. The alcohol works on the nerves and nerve pain, of all the types of pain we deal with, is the most intense. Once this calms down, it is still considered safe to continue, and less likely you will hurt as much. Alcohol is safer overall then cortisone shots. What I do not know is how much volume or what percentage was used, or even if the right technique was utilized to advise you further? I can comment more if you get me at least the information on percentage. 
     When you treat nerve pain, you should be doing the basic treatments of Neuro-Eze topical, neural flossing techniques, shoe selection (what feels better less padding or more, stiff or flexible, rocker or not, etc), icing or other forms of anti-inflammatory measures,  inserts with metatarsal padding and accommodative padding, etc. Let me know what else you are doing. Also, let me know how long it takes to feel better. Good luck. 

I hope these questions are clear. Thank you for writing such a thorough and helpful blog. 

Sincerely,

Alcohol Injections for Morton's Neuroma

     I just got an email from a patient undergoing alcohol shots for Morton's neuroma. She had unsuccessful surgery several years ago for Morton's neuroma, having the same pain after surgery as before. Her insurance company denied my request for another post-MRI since I was not going to do more surgery. I just wanted to know what I was dealing with.  
     When I first started using these injections 4% alcohol to de-sensitize the nerves was common. 50% of the time the relief was good enough that the patients could avoid surgery. But, 50% of those patients required surgery. So, I started upping the dose. Now, I start patients at 10% titrate them to 20% (my max). I definitely have more flare-ups that last 4 days to 2 weeks, but my % percentage of patients needing surgery seems less. I just want to get the most out of these shots. Anyone who thinks injecting nerves with alcohol is simple, it is not. It takes great effort and much patient counsel. You are trying to avoid surgery and it's issues, a noble cause? 
     There are so many other treatments for Morton's neuroma that should be tried first that only 2% of my Morton's neuroma patients need even to consider these shots. Since I am trying to perfect how I use the alcohol, I am trying to prevent the 1% of my Morton Neuroma patients that still need surgery. 99% of these patients never need these shots in their treatment. My patient wanted to know if I had some knowledge of possible side effects from 20% shots so I sent her the link to the article below.

Dr. Blake's response to her email: 
     Thanks for the email. I had to try to find the article on 20% that made me go above 4% years ago. I think it is well written. I have also read various patient blogs. Some get poor results from these shots. With a percentage of patients going to surgery, no surgeon has ever told me that there is damage. Wish I could be 100% confident, but I believe it is rare. I think if you get the shots, and something goes wrong, you should be ready for the surgery you are trying to avoid with the shots. A true quandry!!. But, it does make me soul search, as I never want anyone hurt. That is why I try to read and go to seminars, etc. Here is the article, and we can talk some more before I give you any more shots. Rich

https://www.ajronline.org/doi/full/10.2214/AJR.06.1463

    The only issue I have with alcohol injections in my practice is that I do not use ultrasound. I have been giving these shots forever into the nerve, and know where to inject. Yet, I do know there any variations of nerve alignments, so how close do you have to be? I feel secure that our surgeons, and MRI imaging, has never found damage post shots to my knowledge. And, for this topic, I always look or always ask. Rich

See several of my articles on Morton's neuromas attached:

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

http://www.drblakeshealingsole.com/2011/05/evaluation-of-possible-mortons-neuromas.html

http://www.drblakeshealingsole.com/2015/01/mortons-neuroma-general-principles.html

Followup on Alcohol Shots for Morton's Neuroma: Email Advice

Hello Dr. Blake,


Well, after 8 shots with the alcohol my MN still remains. I started at about an 8 on the pain scale (10 being really bad) and I am around a 4 right now, sometimes it goes to 6.

Strange thing is that on shot #7, when administered, it was NOT painful and I felt relief very quickly. Then 2 weeks later when my podiatrist gave me shot #8, it really hurt when he administered the shot and of course it made my MN hurt more afterwards. 

Throughout the course of my alcohol shots, it kinds of was the same way. When he administered the shots, if they hurt during the administration, then my MN hurt for that week. When the shots didn't hurt, my MN improved. He used an ultra-sound during each injection to help guide the needle. My theory on this is that he somehow was getting "too close" to the nerve and injured it during the injection and this caused more nerve damage. Of course this is only my unprofessional theory on it.

At this point I am in a waiting pattern to see what I will do next. I have the foot inserts, met pads, and I wear slippers with met pads while at home which helps a lot with the pain. If I go bare foot, especially on tile, it starts to hurt. I am going to try some cold laser therapy, although I know this is not promising, it's worth a shot. I don't want to do the surgery but living in constant pain every time I walk is no fun either. 

Thanks,
Paul (name changed)

Dr Blake's comment:

     Thanks for your feedback on the alcohol shots. You want the shots to hurt during to know that you are at the nerve layer. Your gradual reduction in pain is a good sign. Stop the series at 10 shots, give yourself 1 month off, and try another series of 5. I believe you told me that you were only getting 4%, so try to beg for 6 or 8% for the next round. When you did not feel pain, he/she was missing the nerve and you were only getting the numbing effect of the local anesthetic. Even though this feels good, it is guaranteed not to help you in the long run. Rich

Tuesday's Question of the Week: What % of Alcohol in the Shots for Morton's Neuromas

Dr. Blake,
Thanks, what do you think of the alcohol injections for Morton's Neuromas? Do they work?

Sam (name changed)

Dr. Blake (this sent one month later when I did not respond), 
I am looking to try the alcohol sclerosing for my MN. It will be a 0.25ml ultrasound guided injection with 4% alcohol. The podiatrist is looking to do 5-7 shots at 2 weeks apart. 

What is your take on the alcohol shots and are there any side effects or concerns?

Thanks again Sam

Dr Blake's response:

Sam, I typically try alcohol shots only after failure with the cortisone shots, orthotics, daily icing, etc. I like to get an MRI before doing the shots if possible. If the MRI shows a large neuroma, I only get 30% or less success with the alcohol shots. When you are considering the alcohol shots, you have to consider that you may need up to 3 sets of 5 shots. It is alot of shots. A back specialist should also be ruling out referred pain from the back, neck, or peripheral neuropathy. Rich

Dr. Blake,

Thanks for the information. I think my podiatrist in Arizona ordered the 4% solution and wants to start them and space out the shots every 2 weeks with a limit of 7 shots total. Is it necessary to wait 2 weeks between shots? You do them weekly with no adverse results. Why do some wait 2 weeks?

Does the higher alcohol content (6-8%) have better results?

Thanks,
Sam

Dr Blake's response: 

Sam, I mix my own, so typically now make 6% for the first series of 5 once per week. Based on the patient's feedback, I have been recently going with the second series of 5 (when needed) to 8%. Have not seen any problems (even post MRI imaging), but the shots are always irritative when given. Try to ice for 20 minutes post shot, and then another time that evening. And based on the article below from London, I am going to increase my percentage higher. But, not sure how much.  Rich

http://www.dailymail.co.uk/health/article-537748/The-shot-alcohol-cures-foot-pain.html

Dr. Blake,

The alcohol solution is on back-order here in Arizona (1-2 month wait). How do you make your own? It's basically diluted alcohol, right?

Thanks,
Sam

Dr Blake's response:

Use a 10 ml vial of 0.5% Sensorcaine (or equivalent) without epinephrine and withdraw 0.6 ml and discard. Take a 1 ml vial of denatured alcohol and draw up 0.6 ml. Inject this 0.6 ml back into the 0.5% Sensorcaine for your 6% alcohol soluation. Change amount based on % required. Rich

Morton's Neuromas: Success with Alcohol Shots

Excellent article about Morton's neuroma which has plagued me for six years. Had some success with alcohol injections, but my podiatrist moved to Kansas before completing series of shots. Replacement podiatrist doesn't believe in their value. Can you recommend another doctor in Wilmington, NC? The pain is severe after 45 minutes of hiking which is my passion.  Prefer NO surgery.  Also, your search function on my iPad keeps taking me back to the same article when I try to access potential treatments you recommend.  Thank you for any help with identifying a doctor who,shares your values and expertise.  

Dr Blake's response:

     There are the podiatrists in North Carolina from our national Sports Medicine Academy--AAPSM. They are normally the best place to start.  

Christopher J. Gauland, DPM		2140 West Arlington Blvd. Ste. D	Greenville	NC	27834
William J. Johncock, DPM - Fellow	828-327-3029	419-B 2nd St. N.W.	Hickory	NC	28601
Robb A. Mothershed, DPM		3057 Trenwest Dr.	Winston Salem	NC	27104
Jeremy Thomas, DPM Website	919-851-3435	204 Ashville Ave Ste 40	Cary	NC	27518

There are some of the other articles on Morton's Neuromas, but many more throughout the blog. Sure hope this helps. Rich

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

http://www.drblakeshealingsole.com/2011/05/evaluation-of-possible-mortons-neuromas.html

http://www.drblakeshealingsole.com/2010/08/mortons-neuroma-treatment-options.html

Neuroma Injections: Questions regarding Alcohol shots

Hello Dr. Blake,
I have a neuroma in my right foot. Had three cortisone injections and they did not work. I will be getting my fifth alcohol injection this afternoon. The pain is about 75% gone. What would you recommend I do next if today's injection doesn't get me to 100% relief? And how long should I wait to judge the overall effectiveness of the alcohol shots?
Thanks very much.

Dr Blake's comment: 

     Thank you so very much for your comment on my blog. Whereas cortisone shots are typically done as sparingly as possible (three is a good number to try), alcohol shots are done in series of 5 one week to 10 days apart. The goal of the alcohol shots are to decrease the nerve sensitivity and hopefully destroy the nerve (in this area you only lose a small amount of sensation between the toes and no motor function loss). 

     The goal of any treatment modality (and this applies here) is to reduce the pain 80% where the pain level can be maintained day to day between 0-2. 80% better is where you can increase your activity gradually. You still need protective inserts to off weight the nerve (some form of orthotic device or one of the many variations of metatarsal pads). It sounds like you are probably there, or close enough. I would continue icing 3 times a day for 10 minutes each, and continue not to go barefoot. Give the month of June 2013 as a test to see what really happened with those 5 alcohol shots while you gradually increase your activity and give the tissue injected a rest. 

     When you go through the month, you should also consider Neuro Eze or another compounding gel to massaged 3-4 times daily to keep the nerve calm. By 7/1/13 you will have an idea where you are at. If you are alot better overall, but the pain level has gradually increased, you are a candidate for another series mid July to late August--lucky you. In my practice, when I am using alcohol 50% need a second round, and 10% need a third round. And, the bigger the neuroma on MRI, the less likely the shots will work totally--but I would always do before considering surgery. 

     I sure hope this helps. Rich

Alcohol Injections for Nerve Desensitization for Athletics

I just saw a patient whom I am using a series of 5 injections spread over the next 5-6 weeks to desensitize a very sore Morton's Neuroma to enable him to compete at a national level in Sprint Cycling. I may get permanent nerve anesthesia, but I am hoping and should get over 1 year of significant less nerve pain. Several years ago this procedure worked well for him. Dr Rich Blake See my original post on injections for Morton's Neuromas which talks about cortisone vs alcohol injections.