Morton's Neuromas: Which Shots to Get?

  Morton's Neuromas are inflammed swollen nerves in the front of your foot , usually found between the third and fourth metatarsals (as seen in the above MRI), and sometimes between the second and third metatarsals, and sometimes between both. You count the metatarsals from the big toe #1 to the pinky (baby) toe #5. The symptoms from these inflammed nerves are nerve symptoms: burning, tingling, numbness, electrical, radiating, buzzing, sharp, and/or feeling like a rolled up sock. They are abnormal sensations, also called dyskinesias (just to show you how smart I am). But, this pain may be not be from the foot at all. Nerve pain in the foot can originate from nerve irritation at the ankle, knee, hip, or low back. Nerve pain in the foot can also be systemic (from the body) called peripheral neuropathy. So, it can be very challenging to diagnosis the source of pain in many patients, and thus treat it properly. Any workup for nerve symptoms in the foot should look for possible causes other than the foot.

Photo shows typical problem between 3rd and 4th metatarsals.

     One of the mainstay treatments of Morton's Neuromas involves injections. There are three common shots, and other combinations of medications used in injection form. First of all, there is the diagnostic injection of local anesthesia (like novacaine) to see if injecting the nerve gives complete pain relief. It sometimes proves that the nerve the doctor thought was the problem really is not the problem. These local anesthetic injections should be given with medications that last around 5 hours (commonly Sensorcaine, Marcaine, or Bupivacaine) so that the patient can be 100% sure of the relief attained--100%, 80%, 50%, 30%, or 0%. I am a big believer in this method of identifying the right nerve, if it is a nerve at all, since you only inject the nerve and not the tendons, ligaments, joints, etc. Sometimes, even though you are giving an injection which should last 5 hours, since you are blocking the pain cycle, the relief can be much, much longer. Many doctors will give these injections once or twice a week until the severe pain cycle is completely broken down and the symptoms greatly minimized.

     The second most common type of injection involves cortisone. No one knows for sure how much should be given, since that varies from person to person and body part to body part, but I have lived by the rule of no more than 5 shots per year. I can count on one hand how many patients have needed more than 3 per year, so 4 or 5 shots is unusual, but sometimes necessary. Each one of my cortisone shots is 10mg of long acting steriod. Long acting means that some of the medication is still working for 9 months. As the crystal dissolves, there is slowly less cortisone working on a daily basis. Cortisone can allow healing to occur since it removes swelling. Swelling is our enemy. Swelling cuts off the normal circulation to an area inhibiting healing. So it it more than just a bandaid or temporary fix--it can fix the problem!! I find no use for short acting cortisone. It only lasts for 3 days or so. So what? If you think the patient needs cortisone, use the good stuff. I once had a patient come in for surgical consultation after she failed to improve with 10 cortisone injections over a 6 month period. Surgery had been recommended, and I was a simple appointment to verify that this was appropriate. When we found out what the doctor had used in each injection, I was dumbfounded. He was using long acting cortisone, but in a homeopathic dose of 0.1mg per shot. If you do the math, you would realize that it would take him 100 shots to equal the dosage of one of my shots. Oh my!!??!!

     Why am I discussing dose? Because you should know if you are getting a foot or ankle shot, if it is long or short-acting cortisone, and how much? The 5 dose recommendation per year is based on actually getting 50 mg of long acting cortisone in one area. It does not mean that you can not get the same amount in another area of your foot. One smart patient, with one smart doctor, helped me understand that a local cortisone shot can affect the entire body since small amounts do get absorbed into the body. I call this Dorothy's Rule, after one of my patients, that a patient should not get more than 1 shot of long acting cortisone per month for their entire body. I like this rule since cortisone does affect us in many ways. This applies to patients whom are getting cortisone shots for their foot, and at the same time for their knee, shoulder, etc.
    
     When giving cortisone shots the doctor should stay away from the skin, buring the injection as deep as possible, and avoid tendons if possible. Cortisone near a tendon can weaken it, and cause tearing, as it can thin the skin. The skin usually gradually gets healthy, but can take 9 months or longer, and can not tolerate further shots at this time. Cortisone is normally mixed with the long acting local anesthetics to get 5 hours of post shot pain relief. If the patient does not feel any relief after the shot, the shot missed the painful spot. After cortisone, patients are told no running or jumping for 2 weeks (another reason athletes hate cortisone shots). The patients are told to check pain relief in the first 5 hours, at a week, and at the 2 week followup. If the 10mg is not enough (with the goal 80% reduction in pain), a second shot is given and the two weeks starts over again. During these shots, I do not have the patient go to physical therapy, but they can cross train with non jumping and running activities. With many activities like cycling, they have to assess if it has a negative impact on them. During these shots, the patients are told to ice the area 3 times daily (see separate post on icing). At each two week interval, if the patient seems to be at the 80% level (familiarize yourself with a pain chart and read the separate post on the Magical 80% Rule), activity is gradually returned. Hopefully, the doctor and patient have learned what to avoid, what to wear in the shoes, how to tape, etc, to minimize the re-irritatation during the return to activity program. Any cortisone shot after the first shot in the 9 month window of time is considered a booster shot.

Post Sesamoid Removal and Neuroma Care: Email Advice

Thank you for inviting me to email you about my foot trouble.  

     In the middle of February 2015, I was in a car accident in which someone pulled out from a side street across my line of traffic.  I slammed on the brake and tried to swerve but ended up hitting him in the rear driver's side. My left knee got jammed into the dash and by that evening my right foot had started swelling up and got quite painful. 

     I went to walk in clinic to get checked out and they xrayed my foot. (Dr Blake's comment: x rays do not show small fractures ever or it can take up to 4 weeks).  She said she did not think there was a break.  A few days later I followed up with my primary who went by the urgent care's report and said it was sprain so ice and rest it and take a lot of advil.  I did, it was getting no better.  I went back to my primary a week later because both my neck and foot were not getting better so she sent me to PT.  My neck got better, my foot had no improvement.  It was hurting so bad it was waking me up several times a night. 

     After several weeks my PT said he thought it must be broken so  I went back to my primary who finally sent me to a podiatrist.  The podiatrist sent me for an MRI which showed the tibial sesamoid was indeed broken.  The podiatrist said that Urgent Care missed the break because they did not take the xray at the right angle. Now the pain I was experiencing was a sharp pain in the big toe joint area.  Driving was excruciating.  I also had pain between the 2nd and 3rd toes.  It felt as if there was a baseball under that joint, which changed to feeling like there was cotton stuck under there.  Sometimes it felt like it was burning. (Dr Blake's comment: This is nerve hypersensitivity kicking in. It is pain generating more pain by making the nerves hypersensitive inorder to protect you, tell you to get off it). 

    My podiatrist did not really address that concern but regarding the sesamoid he said that my options were to be completely non weight bearing for 2 months but that may not even work, or get the surgery (keeping in mind  by this point it has been about 2 months since the accident).  So on May 5, 2015 I had the tibial sesamoid removed.  After the surgery the doctor told me that not only was it broken but the cartilage between that bone and the joint above was blown out so he had to clean that up a bit. 

Dr Blake's comment: This was good news so you know the surgery was 100% necessary to avoid further injury to the metatarsal. 

    I went back to PT but stopped since it did not seem to be helping.  Last October I went back to the podiatrist because the big toe joint was still really hurting and the neuroma was still really bothering me.  He scanned my feet to make orthotics and gave me 2 cortisone shots at the big toe joint.  At first he was saying the pain was due to a bunion, but after the shot and after the difficult time he had administering the shot due to scar tissue he said the pain could be from the scar tissue.  He still did not address the neuroma.  The cortisone helped some for the pain.  I think it was late December before he gave me the orthotics.

Dr Blake's comment: I love to get orthotics to patients right after surgery, if they do not have them already, since I want them walking with sesamoid area protection. 

     In January, I went back because I just could not take the neuroma and at first he just wanted to pass it off as being because of a bunion but then he actually looked at my xrays and said that no that did not look to be the case so he gave me a cortisone shot between the 2nd and 3rd toe.  It helped take away some of the burning pain I was getting.

Dr Blake's comment: This doctor is just slow at doing good things!!!

     I wear the orthotics consistently in well fitting athletic shoes, but they don't seem to make much a difference. Actually the orthotics are so hard (and I did put a thin cushion on them) that when I get home I want to take my shoes off, but I don't because the doctor said not to go barefoot. My job keeps me on my feet alot on concrete floors.  I do have some antifatigue mats around and use them whenever possible.  But I find that if I have to stand or walk on those floors for even a half hour I can feel that neuroma and it feels like my foot is blowing up like a balloon. 

Dr Blake's comment: It is common to need up to 3 shots to calm a neuroma down. See if you can get the second one soon. 

     The big toe is becoming again painful (a sharp pain on the underside and side), but not all the time.

Dr Blake's comment: The surgery for a damaged sesamoid and undersurface metatarsal bruising can take up to 2 years to feel great. Typically a PT will be the most help getting the range of motion better, reduce the scar tissue, and get the muscles strong. I am assuming you are doing met doming exercises and simple self mobilization. Does spica taping help you?

     I went for a second opinion who said he had very little time, just said he recommended a couple more cortisone shots at that neuroma. 

Dr Blake's comment: What a comment!!! I apologize for the sacred profession of medicine. 

 I would like to get back to a normal life but if I try to walk too much, or run I pay dearly.  And I am not sure what to do.  Any suggestions would be greatly appreciated.  I can send you xrays if that helps.  Thank you so much for your time!

Dr Blake's comment: So, I would have the doc do at least one more neuroma shot with cortisone. Read on my blog about neuomas to see if there are other suggestions, like metatarsal pads. Get referred to a PT known in your area for feet and see what they say about the big toe joint and the neuromas. Keep me in the loop. Get a new MRI 2 weeks after you next shot. I would be happy to see the images. Just email me them by taking photos of each frame. What shoes or qualities in shoes have you found helped the most. 

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

9/13/10
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
    
    
    
    
    

Morton's Neuroma: Treatment Options

Morton’s Neuroma: Treatment Options
Morton’s Neuroma denotes a swollen inflamed painful nerve classically between the third and fourth metatarsals, radiating into the third and fourth toes (toes are numbered one for the big toe and 5 for the pinky toe). It can also be between the second and third metatarsals, or between both the third/fourth and second/third just to make diagnosis more difficult. The nerve symptoms created can be more like numbness, tingling, buzzing, burning, sock rolled up sensation, etc on one side on the spectrum, to sharp, radiating, and electrical pain at a level 8 to 10 on the pain scale. One of my unfortunate patients described it as lava flowing in her foot!! One third of all patients only have numbness as the chief complaint, one third have a combo of numbness and some pain, and one third have only pain (lucky them!!) The pain can be so bad that the differential diagnosis could only be a broken bone, however the history of onset of pain does not match up with a fracture, and there is no swelling. Neuromas rarely have swelling.


When a patient presents with symptoms of Morton’s Neuroma, the treatment plan should address 8 areas. These are:


Mechanical support behind the metatarsal heads to off load the sore areas immediately in any shoes which produce pain (see post on Hapads)

Mechanical support of any over pronation affecting the ankle (see posts on biomechanics)

Shoe gear changes to minimize daily aggravation (various factors affect each case—amounts of cushion, heel lift, flexibility, tightness, stability, arch support)

Changes in digital (toe) motion with taping or Budin Splints

Tightness in the ligaments and other soft tissue around the toes and metatarsals

Anti-inflammatory measures to reduce the inflammation around the nerves (see posts on icing and contrast bathing)

Nerve stabilizing methods (see post on Neuro-Eze)

Diagnostic testing to determine where the source of the pain originates, whether or not there are classic neuromas present (MRI best)

Luckily, less than 10% of patients do I consider for surgery to remove the nerve if their symptoms do not improve well, but the other 90% can have a rocky road getting their symptoms under control. Remember, first and foremost that this is a nerve problem. Nerve problems hurt more than any other injury. There are more nerve endings on the bottom of your foot per square inch than any where else on the body. Nerve pain goes straight to the brain and is quite intolerable by most. The treatment should be aggressive and multi-factorial. It takes about 1 year of treatment in the recalcitrant cases (slow ones) to decide that surgery should be done. If you are in the unlucky 10% requiring surgery, 50% of you will heal quickly, and 50% will take up to two years to really feel somewhat better (if at all). So, 5% or 1 out of 20 patients with nerve pain still have nerve pain to some degree 3 years after I start treating them. So, try your hardest to be in the 95%.

Remember that nerve pain makes nerve pain by itself. So, the cycle of nerve pain spiraling out of control must be stopped. Golden Rule of Foot: Treat Neuroma/Nerve pain aggressively, or it will decide to stay around. When I first feel symptoms of numbness or pain in the front of your foot, seek immediate help (like reading this blog). But, there are so many aspects of treatment that the patient can only do like icing, shoe gear changes, add Hapads, start Neuro-Eze, limit pain producing activities (if there is pain), doing daily self massage, etc. When I first got into practice 29 years ago July 1981, 50% of all neuromas diagnosed were surgically removed. Now, less than 10% are surgerized (my own word!!) so medicine is moving in the right direction on this one.



Neuroma or nerve pain in the foot must be treated at the foot, but it can be caused by irritated nerves from back problems, ankle problems, sciatic nerve problems, and peripheral neuropathies (nerve diseases) from diabetes, B12 deficiencies, etc. Even with our most sophisticated workups on nerve pain, the nerve pain can occur 5+ years earlier than the diagnosis. These are some of the neuromas removed, and yet the patient feels little or no improvement. Medicine has to get better in this area.



I will have another post which will be a checklist of all the treatments you should have tried and failed before surgery is performed. But for now, let us focus on what should happen in the first 2 or 3 visits (probably over a 6 week period) with a doctor whose diagnosis is Morton’s Neuroma. These are:



Begin a program of anti-inflammatory measures, which is done daily, and could involve one or several cortisone shots (see post on cortisone shots)

Begin to change from all shoes that aggravate the symptoms (take each shoe separately since you may be surprised what feels okay)

Avoid barefoot walking

Begin some evaluation of the possible source of the nerve pain (low back evaluation at a minimum with straight leg raise and Tinel’s test at ankle)

Add some Hapad or other metatarsal arch support to all shoes that have adequate room

Begin some exercises that relax the tissues around the inflamed nerve (like toe waving exercises)

Begin some massage to desensitize the nerve with Neuro-Eze, some heat lotion (i.e. Ben Gay), or warm face cloth wrapped around foot as long as the massage doesn’t irritate the nerve

Begin controlling pronation if the ankle mechanics could cause pulling on the branch at the ankle (in what they call the tarsal tunnel)

Discuss the timing of possible MRI, Nerve Conduction Test, alcohol injections, course of cortisone injections, possible casting in removable boot



See you and your health care provider have some work to do. Work on shutting off the nerve painlessly, and as quick as possible, before the symptoms get worse.

Athletic Injury Rehabilitation: The Law of Parsimony

Deception Point

The Law of Parsimony: When multiple explanations exist, the simplest one is usually correct.

This is my first post being inspired by the Mediterranean Sea along the coast of the Italian Riviera (this time from Diano Marina, Italy).

As I watched the Mediterranean Sea and read Dan Brown's Deception Point thriller, on page 238 he mentions the Law of Parsimony. This is a common law utilized in medicine; a good starting point in the treatment of injuries. I will use the Law of Parsimony in this post to describe the common starting point of treatment based on the commonest cause for several injuries listed below. If you have one of the injuries mentioned below, make sure that your treatment is addressing this issue.

• 
  
  Achilles tendinitis--tight achilles tendons
• 
  
  Plantar Fasciitis--inadequate arch support
• 
  
  Recurrent Ankle Sprains--weak peroneal tendons
• 
  
  Chondromalacia Patellae or Patello-Femoral Dysfunction--weak vastus medialis
• 
  
  Ilio-Tibial Band Tendinitis--tight Ilio-Tibial Bands
• 
  
  Morton's Neuromas--tight front area of your shoe or boot
• 
  
  Posterior Tibial Tendinitis--excessive pronation
• 
  
  Bunion Pain--tight front area of shoes
• 
  
  Metatarsal Area Pain--development/increasing of hammertoes (see post on Budin Splint)
• 
  
  Peroneal Tendinitis--lateral instability in shoes
• 
  
  Generalized Arch Pain--weak intrinsic foot muscles

These are great starting points to treat these injuries. In many cases, it will take awhile to get weak areas strong, tight areas flexible, and correct biomechanical and shoe issues. Other treatments will be used to address anti-inflammatory concerns, and less common causes of the same injuries at the same time to hopefully sped healing along. See the post on Tips for Bunion Care as a good example. Thank you Dan Brown and the Mediterranean Sea for this inspiration. Now off to a great pasta or seafood dinner.

Morton's Neuromas: Nerve Pain in the Front of Foot

This is going to be a reader (are you guys out there?) based post on various topics. But I want the focus to be POSITIVE NEWS. Emphasize what has worked for you. Do not emphasize what has not worked for you on this site. If you can relate in 1 to 6 sentences at most what was HELPFUL in your treatment, you will help hopefully 100’s who read the post (eventually!!). I will comment occasionally and will initially try to have my own patients generate a lively conversation. I am very sure that we all will learn a lot from those who post comments. With most injuries, it takes 2 to 5 treatment avenues (for example, icing, stretching, inserts, physical therapy, etc.) to completely get better and prevent reoccurrences. STAY POSITIVE for the reader. With all the negativity in the news and on the web, and when a patient is dealing with pain, they need a POSITIVE HEALING message. Pain is negative, let your comments be positive. POSITIVE NEWS brings HOPE and hope allows for HEALING. Please be a part of the HEALING PROCESS. I will place this paragraph at the top of each of these Reader Speak Outs.

Question for the Reader(s): If you have had pain in the front of your foot that has been diagnosed a Neuroma, what 1 treatment do you think was helpful/most helpful? If you have more than 1 you would like to discuss, please do a separate post.