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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