Neuroma

Neuroma

Neuroma— a neuroma, sometimes referred to as a Morton’s neuroma when found between the third and fourth toe,s is an enlarged or painful nerve in the foot.  It usually causes pain in the ball of the foot with walking or standing which seems to be localized to the pad of the foot in between a couple of toes .  Th most common area affected is between the third and fourth toes, but also frequently found between the second and third toes.  The pain is often described as burning, shooting into the toes, feeling of numbness, and more rarely a painful popping or clicking can be noted when walking.

How do I know if I have a neuroma?

If you’re having many of the symptoms noted above, particularly radiating pain or numbness in between two toes you may have a neuroma.  If you have a neuroma it will probably hurt worse if you push up on the skin on the bottom of the foot just behind the area in between the toes with one hand and then squeeze your foot with the other.  This maneuver will force the nerve up in between the bones and then when you squeeze the foot bones together it will squeeze on the painful nerve and often create a “pop” sensation as it is forced back down again.  If this test perfectly recreates your pain, it’s very possible you may have a neuroma.

Is a neuroma serious?

Many neuromas can be treated effectively without surgery.  In some cases surgery is an option when conservative treatments fail.  They are typically not cancerous and not life-threatening.

Why does it occur?

The technical name for a neuroma is “peri-neural fibrosis”which would denote that it is not actually the nerve that is getting large, rather a thickening of the sheath and tissue around the nerve.  It is believed that bio-mechanical forces such as extra motion within the bones of the foot, also often termed hyper-mobility, may play a role in the development of neuromas.  Sometimes no clear cause can be identified.

Is there anything I can do at home to get better?

YES…there are several things a person can try to relieve neuroma pain….see below.

1. AVOID barefoot walking as this will often irritate the nerve more.

2. Wear supportive shoes as much as possible, ideally a shoe that feels good and has some intrinsic arch support and good shock absorption.  Some shoes with more of a rigid sole and good arch support can also help.  This would be a shoe such as a Danzco clog.

3.. START STRETCHING morning noon and evening! This helps to reduce pressure on the ball of your foot when you stand or walk.  It’s not a quick fix but can help.  You can view and print my Stretching Exercises on the Education and Helpful Printouts page. Read and follow the instructions.

4. Try decreasing your time on your feet if possible….understandably, this suggestion may not be feasible for many people.

What can we do to help get rid of neuroma pain?

there are many things that we can do to help get rid of your neuroma pain, but they all start with a thorough history and exam to rule out more severe problems and evaluate for possible causes of foot pain such as arthritic joints and stress fractures.

Below is list of some of the things more commonly recommended and/or prescribed for patient’s suffering from heel pain.

posterior muscle/ Achilles tendon and plantar fascial stretching

Icing/heat/contrast baths

Modified LowDye strapping and padding of the foot to relieve tension off of the plantar fascial ligament and reduce pressure under the painful neuroma

PowerStep OTC Shoe inserts

Custom molded orthotics or quality shoe inserts can be very helpful.  Some patients can complete resolve their neuroma pain with custom orthotics.

Prescribe oral anti-inflammatory or steroid medications (We typically try to avoid this for neuromas)

Administer neuroma anesthetic and steroid injections to target the painful nerve and reduce pain at its source.

Prescribe physical therapy in difficult or recalcitrant cases.

Sometimes when diagnosis is questionable an MRI can be helpful to determine if a neuroma is indeed present.

Surgically releasing the inter-metatarsal ligament and removing the painful neuroma.  This is reserved for those with significant discomfort who have made a good faith effort to resolve the pain with conservative measures.

What are the risks?

NSAIDS—If you plan to take NSAIDS (non-steroidal anti-inflammatory) such as ibuprofen (Motrin) or naproxen (Aleve) you want to make sure you are healthy enough to do so and this may require consulting with your doctor. It is not totally uncommon for patients to start taking these medicines and then experience the negative side affects such as stomach upset, heartburn, gastric or intestinal bleeding, or liver or kidney problems. They also will affect you if you have high blood pressure, so be careful and never take more than the recommended doses, and always seek medical attention if you are having any concerning side effects.

Neuroma injections—Neuroma injections also have their inherent risks including bruising, pain, infection, fat atrophy, skin atrophy, reaction to the medication, or it just might not work to reduce your pain. Most people tolerate a neuroma injection very well. The skin on the top f the foot is cleaned with rubbing alcohol and/or betadine, cold spray is used to numb the skin and the injection is then given from the top down for minimal discomfort.

Orthotics and arch supports—A popular and frequently effective treatment for neuromas, these devises work to support the foot better and control abnormal forces which can reduce irritation of the inflamed nerve. The greatest risk associated with an orthotic is that you may pay lots of money for it and it may not totally work for you. For this reason I typically recommend a pair of quality PowerStep shoe inserts at first. We price these to be quite affordable and find many people are very happy with them. Nevertheless, in some patients who’s feet are more flat or who’s pain has continued despite OTC inserts, I do recommend custom orthotics. They are more expensive but a quality pair can last 5-10 years with routine use and they do help a lot of people.

What is the prognosis?

The prognosis for a neuroma is fairly good and most neuromas can be effectively treated without surgery.  In some people they may continue to cause symptoms if they are wearing the wrong shoes or walking barefoot.  In patients who have surgery, most do quite well and have less discomfort after the surgery than they did before.  However, surgery is not without its risks including infection, wound healing problems, and recurrence of a painful neuroma called a stump neuroma.  Some individuals will continue to have neuroma pain or stump neuroma pain even after surgery.  Rarely revisional surgery is required.