Neuroma and nerve impingement

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Neuromas
What is a neuroma? A neuroma technically means a tumor of a nerve which is not what it actually is. A neuroma is actually a localized enlargement of the tissue that is surrounding the nerve which causes a localized compression. The bones (metatarsals) at the base of the toes can pinch the nerve and cause a localized inflamation.  There is a thick ligament attaching the metatarsal bones which the nerve runs beneath. 

Symptoms of a neuroma are as follows:
- Tingling into the toes
- Feeling like you are walking on a pebble under the front part of the foot
- Pain that may be alleviated some by massaging the area.
- Radiating pain in the front part of the foot.

 

Conservative treatment for Neuroma:

- Wider shoes (Narrow shoes will pinch the forefoot together, worsening the nerve impingement)

- Over the counter shoe inserts, or custom made inserts (this may help to allow the bones in the forefoot to spread out and thus take pressure off the nerve)

- Anti-inflammatories (ibuprofen, advil, naprosyn, etc.) can provide some relief

- Topical anti-inflammatories (Flector Patch, Voltaren gel - prescription needed)

- Cortisone injections are often the next recommended type of treatment for this issue.  These are effective because they put the medicine directly in the area where it needs to be.  Cortisone is a very powerful anti-inflammatory and is great for relief when used correctly.  Use should generally be limited to 3-4 injections per year only. 

- When cortisone fails to provide enough relief, or when someone has already had too much cortisone, a dilute mixture of alcohol can be injected around the nerve.  This is generally performed every two weeks until adequate relief is noted.  Within 3-5 injections, there is generally good relief of pain and symptoms.  This injection alters the nerve chemistry and slows nerve transmission.  It "deadens" the nerve to a certain extent.  It does not get rid of the neuroma, but makes it so you do not feel it as much. 

Surgical Treatment:

- If all of the above fail to provide relief, surgery may be considered.

Traditionally, the complete neuroma was identified and resected.  This can result in lengthy healing and also a neuroma can return at some point after this.  This is called a stump neuroma when this occurs and this can require revision surgery.

The prefered surgical technique now is to create a very small incision and to release just the ligament overlying the nerve.  This is called a neuroma decompression procedure. Since the nerve is entrapped beneath the intermetatarsal ligament in the particular webspace, releasing this ligament will generally provide good relief of symptoms.  Generally the nerve pain subsides within 7-10 days after the procedure.  The incision for this procedure can be as small as 7-14mm long.  The incision heals very quickly with minimal scar presentation. 

Originally neuromas were treated with surgical excision.  This is when the nerve itself is completely removed. A rare but difficult complication of excision is recurrence.  This is called a stump neuroma which can be just as painful and necessitate more complicated extensive surgery to treat.  It is certainly preferable to release just the ligament. 

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Bunion Surgery - Questions and Concerns

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Bunions, hammertoes, and neuromas are three of the most common foot issues.  Bunions, also known as hallux valgus, is more frequently seen in women than men but common for both.  Shoes that are ill-fitting generally play a role in making this issue worse but do not usually cause it.  Usually bunions are inherited.  Often a muscle imbalance will increase over time and the deformity may change even with appropriate shoes.  Appropriate shoes have a wide toe-box, adequate length (approx. a thumb thickness between the tip of the great toe and the end of the shoe), and are deep enough shoe to accommodate for any toe deformities.

What can I do aside from shoes for bunions?
Conservative treatment for bunions is limited but there are several options that can be somewhat helpful.  Bunion splints can help to keep the great toe apart from the second toe and can slow the need for surgery.  Splints can also be used to keep an elevated second toe down.  The Darco splint is one that can help with both of these issues. This splint can be worn at night to provide a gentle stretch to the great toe and adductor tendon that is pulling the toe towards the smaller toes. 

 Additionally, a digit wrap can provide stabilization for adjacent toe issues that often accompany the bunion.

 A cortisone injection into the joint may provide relief if there is an inflammatory component to the bunion or some arthritis.  Additionally, a topical anti-inflammatory patch or gel may provide some relief.  These include Flector Patch, or Voltaren gel.  Conservative treatment usually only provides relief for a short period of time, but is certainly worth trying prior to surgical intervention.

How much does bunion surgery hurt?
The amount of pain that one will have from bunion surgery is highly variable, but it is generally painful since bone work is often performed.  The medial bump is usually cut or chiseled away, and the metatarsal bone is usually cut so as to reorient the great toe joint.  At times, the proximal phalanx of the great toe is cut as well.  Bone cuts are usually stabilized with screws or wires.

In addition to the bone work that is done, there are many other things that factor into the amount of pain one will experience.  Some people are naturally more sensitive to any type of stimulus which will make this surgery more challenging.  Also, individuals taking pain medicine, anti-psychotics/anti-depressants, and sleeping pills will most likely need much stronger medicine after surgery and may benefit from a pain pump where local anesthesia is continually infiltrated around a large nerve for 3-7 days after surgery by a very thin catheter.

How long does it take to heal?
Generally the skin incision will heal in about 10-14 days, and the bone is healed in 6 weeks.  Most of the time you can walk immediately after bunion surgery in a bandage and surgical shoe.  The surgical shoe is usually used for 2 weeks until the bandage is no longer needed.  After 2 weeks you can usually return to a sneaker or running shoe.  After 6 weeks full excercise is generally allowed.  Full exercise means starting with a very low impact activity like a stationary bicycle, then progressing to more traumatic activity as tolerated.  Running and jumping should be the last activities attempted.  You need to increase activity in a stepwise fashion!

The soft tissue will take 3months to a year to loosen up.  The great toe joint will be stiff for quite some time.  If the incision is made dorsally (on the top of the joint), you will often have difficulty flexing the great toe down for some time or perhaps forever.  With a medial based incision, you will not have this difficulty and the scar will not be as visible.  You may need two separate incisions if it is done this way.  The second incision would be made in the webspace between the first and second toes to release a tendon which may be necessary depending on the deformity.

What are the most common complications?
Bunion surgery usually has a fairly high success rate but can be quite painful as mentioned above.  Infections can occur as with any surgery... frequently a pre-operative antibiotic is administered.  Wound healing issues can occur, especially in smokers. Smoking affects all small blood vessels which are critical for healing.  Not only will the skin and soft tissues have a much longer time healing or may not heal, the bone work will take 50-100% longer to heal than in a non-smoker.  The bone work may even go on to a non-union (where it never bonds back together as it is supposed to.). If you smoke, you should strongly consider stopping completely at least 14-23 days before the surgery to prevent these complications, or even not have the surgery.  A smoker who undergoes surgery is set up for failure or revision surgery.

There are specific post-op instructions which need to be adhered to in order to obtain the best result.  There will be restrictions in the type of foot wear needed (post-op shoe, sneakers, etc.), the amount of activity you are allowed, bathing.  These instructions are given so that the most predictable and best outcome is obtained.  If you deviate from these, healing and positional issues will occur that will give you less than a desired outcome or even beget revision surgery.

Often the surgical site will be stiff for an extensive amount of time, up to 6-12 months.  Full muscular strength after surgery usually takes 3-6 months. Although you are often able to bear weight immediately and results are predictable, there is a significant healing phase and you must be patient. The surgery usually takes 45-60 minutes but the healing is the difficult part.


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Cipro Side Effects:

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Ciprofloxacin is an antibiotic which is in the fluoroquinolone class.  Although fluoroquinolones are great drugs and are extremely important in eliminating dangerous infections, they are not without side effects, just like any drug.  One of the most common side effects is tendonitis and tendon rupture. This is a rare occurrence estimated at 0.14% to 0.4% of healthy patients. In the renal transplant population, an incidence of 12.2%–15.6% is reported, compared with 0.6%–3.6% for transplant recipients not receiving fluoroquinolones. The risk of tendonitis and tendon rupture is further increased in patients over 60, those taking corticosteroid drugs, and those with kidney, heart, or lung transplants. Risk is also increased with strenuous physical activity, renal failure, and previous tendon disorders such as rheumatoid arthritis.

Symptoms will usually be swelling, pain, and limitations in activities.  Tendonitis or rupture is usually seen in the achilles tendon most frequently.  This can also be seen in the shoulder or upper extremity/wrist, but with much less frequency.  It is suspected that the mechanism is one that inhibits tenocyte migration and activity which helps tendons maintain health and heal minor trauma.

Generally the tendonitis is self resolving with discontinuation of the medication and immobilization with a walking boot or a cast.  Occasionally complete rupture is seen and this will generally require surgery.

Although this is a rare complication of Ciprofloxacin use, it can be quite disabling or even devestating.  Most importantly is letting your doctor know about the above risk factors if you do need this antibiotic, or letting your doctor know immediately if you start to have any abnormal reaction.


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