Morton's Neuroma Physical Examination Testing

https://youtu.be/_7qNgYNUrmw

Morton's Neuroma: Excerpt from Book 2 of Practical Biomechanics for the Podiatrist

The following is an excerpt from my book on Practical Biomechanics for the Podiatrist. 

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist1

 

Schematic of Morton’s Neuroma

 

     The basic mechanics of Morton’s Neuroma formation is pretty common knowledge. The junction of the medial plantar and lateral plantar nerves come together between the third and fourth metatarsals possibly making this nerve thicker or more sensitive. The motion of the 3rd metatarsal which articulates with the 4th metatarsal, and the motion of the 4th metatarsal which articulates with the cuboid, can be different enough that the intermetatarsal nerve branch can get irritated with the independent motion of the 3rd and 4th metatarsals. The overall motion of pronation always increases the metatarsal motion adding to the possibility of Morton’s Neuroma pain. If the nerve is already hypersensitive from low back issues or piriformis syndrome, or excessive pronation at the ankle with bowstringing of the posterior tibial nerve at the medial malleolus, or traction from over strengthening of the popliteal nerve with hyperextension of the knee, etc, then the pain can come on easily and with more disability. Morton’s neuroma pain, along with low back issues, etc, is called double crush syndrome. I have patients where triple and quadruple crush were in play with their presenting nerve pain. It is so common to have L4/L5 nerve root issues that cause pain around the 3rd intermetatarsal space with or without a neuroma. You always have to treat the foot, but you always have to be aware that nerves are superhighways to the brain. They get irritated anywhere along the chain from the foot to the skull, and nerve pain can be the worst pain people have to deal with. The opioid epidemic is one aspect that gives us perspective into this complex problem, because with bad nerve pain, patients many times feel they have no other choice. When the nerve pain starts at the foot, or the foot is just part of the picture, it is so important to be successful in treating each area. I tell my patients that the two things I hate the most as a podiatrist are nerve pain and infections because both are treatable, but possibly life changing if I fail.  
     The treatment of Morton’s Neuroma pain must always be 5 pronged (even though we are just focusing on the mechanics in this book): mechanical, inflammatory, neurological, diagnostic, and as a team (physiatrists, neurologists, pain specialists, etc.). The last point on nerve issues that I want to make is that nerve problems present in one of 3 ways: numbness, numbness and pain, or just pain. These 3 presentations are the same process that responds to treatments the same, even though patients respond and react to these 3 situations differently. The treating doctor should respond and treat them the same.

 

Schematic of how foot pain can be caused or heightened in intensity by back problems

 https://youtu.be/E0E60NpOSHg   Nerve Pain Video 

     To tie this into Chapter 3 and 4 on gait and biomechanical examinations, when a patient presents with Morton’s neuroma symptoms, the most important examinations to do in 10 minutes (or 20 minutes) are:

• Gait Findings of Pronation

• Gait Findings of Limb Length Discrepancy that puts stress on low back

• Gait Findings of Knee Hyperextension

• Forefoot to Rearfoot Alignment

• Metatarsal Alignment

• Ankle Joint Dorsiflexion for equinus forces to be reversed

          Other Special Tests
         

• Straight Leg Test for sciatica

• Tinel’s Test for Tarsal Tunnel Syndrome

• Wide Feet (or at least wider than shoes)

 

Common Mechanical Changes for Morton’s Neuroma/Neuritis (with the common ones utilized in RED)

1.  Metatarsal Padding

1. Orthotic Devices emphasizing Metatarsal Support

1. Forefoot Off Weighting

1. Soft Tissue Mobilization

1. Toe Separators

1. Buddy Taping

1. Neural Flossing

1. Metatarsal Doming

1. Standing Strengthening Exercises

1. Rocker Shoes, Carbon Plates, Bike Shoes with Embedded Cleats

1. Budin Splints

1. Sciatic Nerve Advice

1. Skip Lacing

1. Wide Shoes

 

     Metatarsal Padding for support of the metatarsals will stabilize the area and separate the metatarsals so the nerves do get irritated. Its mechanical function is to off weight the sore area, separate the metatarsals for less nerve entrapment (spreading the metatarsals), and transfer weight more proximal back towards the heel when standing. This is explained in the metatarsalgia section above. The main difference over metatarsalgia is that nerves probably can take a little less pressure initially then if there were no nerves involved, and then get used to more, and the placement may be slightly more medial for metatarsalgia. The nerves can be so red hot that they can not take any pressure, and this indicates they need a lot of nerve treatments at this point: orals and topicals, neural flossing, local and spinal injections, etc.
 
Practical Biomechanics Question #245: Nerves can be both helped and irritated by metatarsal pads. Since classic Morton’s neuromas usually love metatarsal pads, what would it indicate in terms of treatment direction if the metatarsal pads proved very irritative and intolerable?
 

Classic Longitudinal Metatarsal Pads for Morton’s Neuroma Pain (Hapad, Inc)

 

     Orthotic Devices emphasizing Metatarsal Support was also discussed in the metatarsalgia section. Its mechanical function is to off weight the sore area, support proximally, spread out the metatarsals to decrease entrapment, shift the weight more proximal while standing, and immobilize the foot somewhat for less motion. Certain feet, if supported well, will give the patient wonderful metatarsal support (like most pes cavus foot types). I find the classic Root Balance technique to be great in general for its emphasis on metatarsal support. Any orthotic laboratory should be able to give you advice on corrections to the impressions that will maximize the metatarsal support, the same as giving advice on corrections for lateral arch stability or medial arch stability. With Morton’s Neuromas, we want to maximize the intrinsic metatarsal support the impression can give us, and when needed, begin to add additional extrinsic metatarsal padding. This improved metatarsal support, especially when it is intrinsically applied, can make an incredible difference in support of the tissues involved. Support means stability or immobilization of the sore tissue.
     This all sounds nice, and is true, but the crowding of the shoe caused by an orthotic device and its added pads, etc, may not be tolerated in most shoes. For each patient, one variable may prove the most important for both helping and producing distress. I have had to abandon more shoes due to Morton’s neuroma conditions than any other problem.

 

Crazy Shoe Searches with Neuroma Pain

     Forefoot Off Weighting is initially applied with ⅛ inch adhesive felt, and then other types of glued material like Spenco, poron, or grinding rubber, to make it more permanent once the correct position for maximum pain relief. Its mechanical function is to off weight the sore area. For most cases of Morton’s neuromas, this will be under the 1st and 2nd metatarsal heads, and the 5th and somewhat 4th metatarsal heads. The process is started at the first visit with the adhesive felt. The patient is given more material with instructions to experiment. Occasionally the position that brings the most relief is not anticipated. If you can find the most sensitive spot plantarly, you can mark it with lipstick and have the patient transfer that spot onto the top of any surface to find the exact spot to float (off weight). When patients present to my office with previous orthotic devices, I always do this to make sure the accommodations are really in the correct spot, which they normally are not. Millimeters count here.

 

This patient with Morton’s Neuroma pain felt relief with this combination of metatarsal pads, off weight pads, and full length pads

 

Practical Biomechanics Question #246: Due to the fact that Morton’s Neuromas do not like tight shoes, every pad must be carefully tested for both positive and negative results. What are some options to help patients when the shoe and insert combination are helpful, but after hours of wear the neuroma starts to hurt due to the crowding?
 
     Soft Tissue Mobilization is an incredible help in releasing trapped nerves. Its mechanical function is to improve soft tissue mobility for less nerve entrapment. I apologize for forgetting the name of the podiatrist that initially turned me on to this twenty five years ago for I owe him a thank you. I not only have patients do self mobilization three times a day with topical nerve creams, like Neuro-Eze or Neuro-One (both L-Arginine based), with the goal to move the metatarsals around, but a prescription for physical therapy for soft tissue mobilization is typically given for 8 visits. At the same time, I have the therapist advise the patient on a sciatic nerve program and teach neural flossing or gliding. Also, instructions for the TENS unit daily program are occasionally given to the therapist.
 
Practical Biomechanics Question #247: How does foot rigidity cause or aggravate Morton’s Neuroma pain?

Soft Mobilization can be with a professional or self directed

 

Toe Separators are a simple, but sometimes very powerful, tool to change the biomechanics of nerve irritation. Its mechanical function is to change the dynamics of the nerve pressures. There are very thin wafer-like toe separators, but I prefer the normal small gel hourglass shaped ones. Since Morton’s Neuromas are typically between the 3rd and 4th metatarsals, these toe separators are placed between the 3rd and 4th toes. It seems like 50% of patients think it is helpful. This was taught to me by Dr. Remy Ardizzone.

 

     Buddy Taping of either the 2nd and 3rd toes, or the 3rd and 4th toes, when there was Morton Neuroma pain, seems to work the 50% of the time that toe separators do not. Its mechanical function is light immobilization of the tissues involved. I typically use 1 inch wide Coban or Coflex which sticks to itself and not the skin.

Here the 3rd and 4th toes are Buddy Taped 

     Neural Flossing or Gliding is a way to stretch and relax the sciatic nerve as it comes off the back, through the piriformis, down the hamstrings, splitting behind the knee to go into the back of the calf and side of the lower leg, and finally onto the top and bottom of the foot. Its mechanical function is to gently floss the nerve making sure that there is no swelling or scar adhesions. There are many variations. Some of the variations will excite the nerve more, and some will work better on the peroneal nerve or the posterior tibial nerve. The standard floss is where the patient lies on their back with the resting leg bent at the knee and the foot flat on the ground or yoga mat. The side to be moved starts where everything is flexed as much as possible (toe dorsiflexed, ankle dorsiflexed, knee flexed and hip flexed without pulling pelvis off the table). Then 10 rhythmical rotations slowly and gently are started from flexed to extended (hip extended, knee extended, ankle plantar flexed, and toes pointed), never stopping at either end of the exercise. Nerves hate prolonged stretches and love motion. Neural Flossing is typically done 3 times a day, on a hard surface since you need to have the pelvis and spine as stable as possible. I will talk in a minute about standard sciatic nerve advice.

 

 

Neural Flossing of the Right Leg with the Stable Leg Side Immoble. Here the right leg is already starting to straighten where the left leg is anchored to the supporting surface.

 

Neural Flossing of the Right Side starts with the right hip, knee, ankle and toes pulled up, and then gradually these 4 joints are pointed

 

Practical Biomechanics Question #248: Neural Flossing is 10 slow flexions and extensions. What puts more stress on the sciatic nerve: Knee Straight vs Knee Bent?
 
     Metatarsal Doming was previously discussed in the big toe joint section. Its mechanical function here is to make the foot more stable taking stress off the nerves.

Metatarsal Doming is an Isometric with 6 second contraction 4 second relax

 

     Standing Strengthening Exercises, along with metatarsal doming, will help keep the injured tissue strong. Its mechanical function is to increase stability by strength. We have to avoid toe bend exercises due to the location of the pain (like heel raises, planks, downward dogs, etc.), but the many versions of Single Leg Balancing, and standing poses in Yoga, Chi Gong, and Tai Chi are a wonderful way to maintain strength which avoid toe bending. Other modifications can be done to cardio workouts like staying flat footed while doing the elliptical, or having the pedal in the arch or heel on a stationary bike.

Single Leg Balancing to help develop Intrinsic Foot Strength

 

     Rocker Shoes have been previously discussed in the big toe joint section. You probably should also consider Bike Shoes with Embedded Cleats and Carbon Plates when immobilization seems necessary to bring the pain down between 0-2.

 

Hoka One One Rocker Shoes

     Budin Splints were previously discussed in the hammertoe section. Its mechanical function is to immobilize the motion of the local nerves. For Morton’s Neuromas, they change the biomechanics of the stresses in the area. Typically I use a Single Loop Budin Splint (also called hammer toe regulator) and get equal results by buddy taping 2 and 3 or 3 and 4 with Coban tape. In several cases of Morton’s Neuroma with a really sore 3rd toe, the patients may find the biggest relief over the 2nd toe only, over the 4th toe only, or getting a double loop for the 2nd and 4th toes combined. This is a way to indirectly immobilize the local nerve. Budin Splints are primarily immobilizing the metatarsal phalangeal joints, and you can add metatarsal padding to the bottom of the splint to off weight the sore areas also.

 

Here a Budin Splint is placed over the 3rd toe for Morton’s Neuroma pain with a small Hapad metatarsal pad. This is ideal for using the previously discussed lipstick marked on the sore spot to find the exact location of the pad

 

     Sciatic Nerve Advice is needed for any nerve condition you treat including Morton’s Neuromas. Its mechanical function is to find ways to decrease the stress on the nerve like various positions. Nerve irritation affecting the foot can come from anywhere. The nerve can be irritated from the exhausting long hours the patient sits. The nerve can be irritated from a bad mattress. The nerves can be irritated by the lifting or torqueing at their jobs. A simple prescription to a physical therapist for a sciatic nerve program should be all you need. However, tests including straight leg, Tinels, intermetatarsal nerve sensitivity on exam, can be retested for improvement evaluation, and point to how high the nerve tension is on the body. I try to discuss what is nerve sensitivity with the patient, so they know what to report. Nerves can hurt for sure, but also give symptoms of burning, itching, buzzing, tingling, prickling, sharp stabs, and numbness. I want to know where and when they have any other nerve symptoms called dyskinesias, even if it is the upper extremity, since I am looking for patterns or overall neural tension in the body. We all know that we must bend our knees when we are picking up something. The worst stretch on the sciatic nerve is when the ankle is bent (dorsiflexed), the knee is straight, and the hips are bent forward. Even having 2 of these together can be a problem, especially straight knees and dorsiflexed ankles. What position are we in when lowering our heels off a stair? Or doing the downward dog? These are positional questions you expect a good physical therapist to know and change as they evaluate a patient’s routine.
     This is a good time to remind the reader that Physical Therapists do have a subspecialty in nerves. There is an Academy of Neurologic Physical Therapists. Have your patients with nerve pain see if various offices have therapists specializing in the nervous system.
 
Practical Biomechanics Question #249: Nerve pain, like that of Morton’s Neuroma, has many mechanical treatments. Name 4 mechanical treatments for intermetatarsal nerve pain.
 
     Skip Lacing is a common way to take pressure off an area, even when the pain seems all plantar. Its mechanical function is to decrease compression across the sore area. Nerves hate compression. Typically I will remove the lacing from the distal eyelet,  but occasionally two. 

 

2 eyelets are removed to reduce pressure temporarily across the metatarsophalangeal joints

 

Wide Shoes really produce the same effect as the skip lacing. Its mechanical function is to prevent medial to lateral compression forces on the intermetatarsal nerves. New Balance was the first company for me that really helped with their variety of shoe widths. Now other companies at least have several widths per size. Then there are shoes that just run wide like Keen, Lems, Altra, etc.

 

Practical Biomechanics Question #250: Any foot nerve pain should be assumed that the symptoms are at least partially coming from higher up the chain. If a patient presents with Morton’s Neuroma pain, but presents with numbness on the top front half of their foot, where does some (or all) of the problem arise from?

     I will close with a copy of my Nerve Pain Algorithm for treatment options for peripheral neuropathy, Morton's Neuromas, Tarsal Tunnel, Baxter's Nerve Entrapment, etc

 

Correspondence Related to Left Neuroma, New Orthotic Devices custom made, and some Right Foot Symptoms

Hi Dr. Blake,

Very interesting wearing shoes for the first time since Aug. 2019, and wearing orthotics for the first time ever.

I delayed my “2 week report” because things were so different everyday, and I couldn’t figure out how to describe it in email.

Now that it has been 3 weeks, here’s a brief report. I’m hoping that we can talk on the phone, as a prelude for meeting up in person so that you can see my gait and consider tweaks.

I have pasted a table below my signature showing my 3 weeks of wearing time. I only counted standing/walking time, of course. I have managed to get up to slightly more than 7 hrs, but discovered on the way there that normally I am on my feet 5-6 hours per day. 

Overall things were surprisingly good until I got close to 7 hrs, then some bunion pain, and foreshadowing of corns arrived. 

I have gotten used to the new way my feet balance, and my usual tight IT band aches and pains have disappeared. My ankles, knees, and hips feel like they are much better aligned. I had shin splints for 4-5 days, but they went away.

I am wearing the orthotics with a pair of New Balance 860 running shoes, and with a pair of New Balance clodhopperish walking shoes. The clodhopper walking shoes are probably better. Both pairs of shoes were essentially new, and not broken in at all. (I bought them in my search for shoes that might work with my neuroma a good year before I first saw you.) I haven’t worn the Chaco sandals in at least 2 weeks. The orthotics don’t work in the other 2 pairs of shoes, due to neuroma pain.

I ice my feet at night, and use NeuroOne every morning, and often also at night. I also do nerve flossing.

Left Foot (the foot with the initial neuroma issues)

• Neuroma pain comes and goes, as it did with the Chaco sandals. It is never worse than the worst days with the Chacos, and is often more comfortable than the Chacos. Intermittent bristly or mildly burning pain, sometimes aching. Clicking in the first few minutes when  I first start out walking in the morning.

• Some of the pain might actually be from that callus that you have worked on in the middle of the ball of my foot.

• Today i began to feel the foreshadowing of a corn on my little toe. See Right Foot notes for more on corns.

• Something to talk about real time: I noticed that the neuroma pain has decreased as my orthotics wearing time has increased. Would tweaking the orthotic with the neuroma in mind help, and/or will wearing them longer without tweaking help more? (Part of the reason that I waited to report in was that the neuroma pain was coming and going so much.)

Right Foot (lesser neuroma issues, tailor’s bunion)

• Neuroma pain mostly gone.

• Initially, there was no bunion pain. Bunion started to hurt as my time on my feet passed 6 hrs. The little toe bunion sleeve you recommended definitely helps, but it still hurts some. Definitely hoping to nip this in the bud, so it doesn’t get worse. 

• Started to get whispers of a corn on my little toe. Many years ago I had some shoes that gave me corns on my little toes, and I still have some Dr. Scholl’s small corn cushions, which solved the problem back then.  Turns out that Dr. S no longer makes this kind of small corn cushion. Everything on their website is bigger, and a different shape. I only have 13 of the antique-style corn cushions left, so I could use your help with finding a solution. The corn “foreshadow” is hurting now, as I sit here typing.

• I have a touch of intermittent sciatica in my right hip that started with wearing the orthotics. 

• Something to talk about real time: I also get some pain along the “rim” of my right foot. Is it possible that the orthotic is tipping my foot a little to far over, so that the little toe, bunion, and “rim” of my foot hurt? 

There you have it. Email definitely does not seem like the best way to discuss this stuff, but I am hoping that this message will serve as a good outline for a real time discussion.

Many, many thanks. It is oddly thrilling to be wearing shoes again, I just wish it were a tiny bit more comfortable.

Best,

Date (June 8-29)	# of hrs/minutes standing/walking in orthotics
8	1 hr
9	“
10	1 hr 30 mins
11	2 hrs
12	2 hrs 40 mins
13	1 hr
14	2 hrs 55 mins
15	“
16	4 hrs
17	4 hrs 30 mins
18	“
19	5 hrs
20	3 hrs 45 mins
21	5 hrs 40 mins
22	“
23	2 hrs 35 mins
24	5 hrs  35 mins
25	6 hrs 40 mins
26	7 hrs  5 mins
27	1 hr 50 mins
28	6 hrs 25 mins
29	7 hrs

Dr Blake's comment: One of the ways you get to understand how the body works is by making a change and seeing the response. I sure wish all of my patients could be as great in looking at the pros and cons of my new orthotic devices. The left Morton's Neuroma has dictated that she wear wide shoes, which can be inherently unstable if too wide for the foot. Her symptoms are improving both footwise and up the leg. The right sciatica and rim pain are signs of slight over correction, so I will have to adjust that soon. Rich 

Adding Stiffness to the Front of an Orthotic Device

https://jmsplastics.com/product/j-suede/

     The image above was taken after I applied a very thin piece of suede leather. This is stretched before tacking down to stiffen the bend across the metatarsal heads. This is a very useful technique when trying to treat metatarsalgia symptoms, Morton's neuroma symptoms, hallux limitus and rigidus symptoms, and all without adding alot of bulk in that painful area. 

Nerve Pain: Where Does It Come From?

     This image is of a T1 MRI section across the front of the right foot. Above my sensor marker, there is an obvious Morton's Neuroma that may be the complete cause of this patient's pain. Remember, we need to always ascertain if the pain is mechanical, inflammatory, neuropathic (like Morton's Neuroma), or a combination of these 3 factors. 

     In this foot, the section shows a typical low lying 4th metatarsal head with a very thin fat pad. This allows these plantar nerves on the bottom of the feet to get beat up too easily. The Morton's Neuroma can develop from this constant abuse over years. Why they begin to become symptomatic, when they are fairly large, is anyone's guess? 

     The onset of MRI technology now 35 years ago did teach us an incredible thing: Not all Morton's Neuromas hurt as they were found in patients where they never had nerve symptoms. Therefore, it is important, even in the face of an obvious MRI documented symptomatic Morton's Neuroma, that we make sure that the pain is completely driven by this enlarged nerve.

     The 3 sources of pain: mechanical, inflammatory, and neuropathic, also come the 3 avenues you can treatment patients symptoms: mechanically, anti-inflammatory, and nerve desensitization. So, we begin treatment with mechanical off-weight bearing pads, icing and contrast bathing, and neural flossing or acupuncture, etc. And, we follow these simple treatments with others based on the patient response and subjective feeling on what is helping. 

     Morton's Neuromas, as well as other nerve conditions like Tarsal Tunnel, have the added caveat that the majority of symptoms do not originate in the foot. This implies, and is very true, that treatment alone of foot nerve pain at the foot may not be successful. You typically should include in any Morton's Neuroma workup and treatment getting consults on the low back and spine in general. Think about the concept of Double Crush, where the nerve is only painful when irritated at least in two places, with no symptoms if you remove one of the two areas of irritation. 

     

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.

Foot Massage: More Than Just Feeling Good

     I wish all my patients could get a good foot massage on a regular basis, but even their significant others do not seem motivated. I am sure it is in the delivery, since I have never had one myself. But, countless of patients with Morton’s neuromas, general foot pain, or post sprains have told me time and time again how important it is. Loosening up a tight restricted foot, as long as the pain level is respected, can only help as our feet slowly tighten up over time

Morton's Neuroma: Email Advice

Dear Dr. Blake,

I am very excited to have found your blog. I am super impressed with all the information you offer. I've been suffering from a Morton's neuroma on my left foot for the past 7 months per the diagnosis of my Podiatrist upon physical examination. In the past 7 months I have tried multiple treatments. I had completed 3 months of physical therapy prior to seeing my podiatrist where I had been getting treated for a form of tendonitis. I have tried four treatments of acupuncture, which only worked for a day or two. I wore a shoe my orthopedic  doctor gave me for six weeks, his diagnosis being Metatarsalgia. For the past 8 weeks I have wore a pad my Podiatrist gave me and an insert I had  purchased upon her recommendation. Also, I have been wearing shoes with a wide toe box  since mid-September. I ice daily and use essential oils such as lavender, peppermint and rosemary every night. I stopped going to the gym which was very difficult as I enjoy martial arts which involves a lot of pivoting ( down and in) and weight bearing on my left foot. Although  the super intense pain  has improved somewhat, still alot of pain is present. I will be completing an MRI on Monday, January 21st. Hopefully, I will be receiving my first cortisone shot on January 28th. Do you administer alcohol injections for Morton's neuromas with or without guided ultrasound? I'm just trying to think of my next step if the cortisone shot or shots do not help me. Thank you in advance for your time. Is truly appreciated.


Dr. Blake's comment: I was trained way before ultrasound and have had no trouble finding the nerve without. But, some doctors prefer it, so it is a personal call with the one responsible for your health. Today is the 21st of January so send me the report and any observations made and I will attach to this same post as a continuation. Morton's neuroma pain is in essence nerve pain. It is the L5 nerve coming off your low back. I mention this because evaluation should always consider if the pain is only local to the foot, or coming from higher up, or both (called Double Crush Syndrome). Also the treatment should always be mechanical, anti-inflammatory, and neurological. The metatarsal pads, shoes, wide toe boxes, orthotic devices are all mechanical changes. This blog is full of things that sometimes help any individual. Cortisone shots are anti-inflammatory along with the icing. Nerve treatments which help are acupuncture, TENS, topicals like Neuro-Eze or Neuro-One, compounding prescription meds, neural flossing, alcohol shots, oral nerve meds, and possibly low back treatments. Make sure you are always addressing your problem using these 3 treatment areas. Good luck. Rich

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

Oral Cortisone for Nerve Pain with Inflammation

Dear Dr. Blake

I wonder if you would be able to answer a quick question for me?  I'm here in the UK and have been suffering from neuromas in my feet (2 in each foot) for around 17-years.  The right foot was operated on in 2012 and now I have 2 stump neuromas (both >1cm).  The neuromas in the LT foot are also >1cm.

In an attempt to avoid further surgery I have had radiofrequency ablation, cryosurgery, alcohol injections, steroid injections etc.  None of which have really worked that well, though the steroids do help a bit.  The surgeon I have been seeing is reluctant to offer any more steroid injections because he is concerned about foot pad atrophy (he is not the surgeon who operated on the RT foot). 

My neuromas are causing me a lot of problems at the moment, though I can still cycle (which is a great passion of mine).  Later this year I plan to ride from Moscow to London, then at the end of the year, proceed with surgery.

My question is whether you think a course of oral prednisolone might be worth a try, just to get me through this exacerbation of symptoms/

Thanks so much for your help

Kind regards

Dr. Blake's comment: A 6 to 8-day course of oral cortisone to drive down inflammation is okay. Remember no strenuous activity for the duration of the meds and another equal time, including cycling! It can only be done once every 6 months! Rich

Two good articles:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737790/

This article above is great in cautioning it not to be used in skeletally immature athletes and limiting the total dose under 400 mg. But, there is no mention of not exercising while on it or for the next 6-8 days. This helps prevent bone problems like osteonecrosis, stress fractures, etc. From what I have read, these tips are anecdotal but an important precaution. One rheumatologist believes that any form of cortisone should be limited to once per month, with oral once per 6 months. The article below talks about the prednisone burst dosage and how wired people feel the first 4 of 8 days. Rich

http://www.drblakeshealingsole.com/2010/12/oral-cortisone-king-of-anti.html

This I wrote this article 8 years ago, I would add not to be used if you have Vit D deficiency or Low Bone Density, or any problems that cortisone may affect (slight Adrenal Insufficiency). 

Morton's Neuroma: Email Advice

Hello,

     Today I was diagnosed by my orthopedic doctor with morton neuroma, after initially being diagnose with sesamoiditis from my sports medicine doctor. He noted that while there is some inflammation in the sesamoids, in my MRI, my symptoms do not correlate with sesamoiditis and definitely don't warrant 6-8 weeks of an aircast boot & NWB. He also said even though my MRI didn't exactly show a morton neuroma, he said the nerves are hard to show up on MRI.

Dr Blake's comment: This is very true at times. You can have Morton's nerve pain that hurts like a neuroma. The irritated nerve does not show up on an MRI. You are supposed to get contrasts to rule out a neuroma in an MRI, so the MRI if done without contrasts may have to be repeated down the line. Hopefully not!!

     I don't have the big toe pain, he thoroughly examined my foot, where the pain is near the middle of the top of my foot, feels like I have something under my foot when I put pressure on it.

Dr Blake's comment: It would be helpful if you sent a photo with you pointing to the area. but it is not where you get sesamoiditis. 

     I have burning stinging pain in the ball of my foot, with off and on toe cramping. Which is all why he came to the diagnose of morton neuroma. He recommended cortisone pills for 5 days, to begin slowly walking again after 3 weeks of inactivity and good supportive shoes with wide toe box as well as custom orthotics. He said if after a a week my pain doesn't lessen, he recommends cortisone shots, which I've heard horror stories and am scared to get. What are your thoughts, is it possible to have MN and not have it show up on an mri ? 

Dr Blake's comment: It all sounds right, but a little rushed. Could you use 600 mg ibuprofen three times a day for 10 days? During this time add daily ice pack to the bottom of your foot for 15 minutes twice daily. Then you could avoid the cortisone pills for now. Try a small longitudinal Hapad arch pad as a metatarsal arch instead of initially going to orthos. I have plenty of photos in my Morton's Neuroma posts. And, yes, you can have the symptoms of a neuroma, without the findings on MRI, and without MRI evidence of a neuroma, surgery is probably not warranted unless you are a rare case. The cortisone shots can be irritative, but horror they are not. I have no problem giving an occasional cortisone shot, and usually the patients are happy. Read also my posting on Double Crush, in case the nerve is referred. 

Also are orthotics worth it, or can I use the metatarsal pads to offset weight on the MN? I've heard success stories of the alcohol injections, is there any good doctors in the Denver area?  I would sincerely appreciate a response, though I know you are extremely busy. 

Dr Blake's comment: Try Dr William O'Halloran in Denver. Great guy. Yes, off weight with Hapad first. Do a diagnostic local anesthetic shot first to see if they can find the right nerve to inject. Good luck!!

Thank you very much. 

http://www.drblakeshealingsole.com/search?q=Morton%27s+Neuromas

https://youtu.be/_7qNgYNUrmw