What is it:
A neuroma is a painful condition, also referred to as a "pinched nerve" or a nerve tumor. It is a benign growth of nerve tissue frequently found between the third and fourth toes that brings on pain, a burning sensation, tingling, or numbness between the toes and in the ball of the foot. The nerves that supply the sensation to the lesser toes originate on the bottom of the foot. They travel between the long bones of the foot, metatarsals, and at the head of the metatarsal the nerve will divide into 2 nerves, one going to the adjacent 2 toes. In the area where the nerve is about to divide, a ligament crosses between and attached to the metatarsal heads and perpendicular to the nerve. This ligament is called the deep transverse intermetatarsal ligament. When there is an over use injury or injury to the nerve, the nerve can become swollen. This enlarged nerve then can become pinched between the metatarsal heads and compressed by the ligament crossing the nerve. This then causes pain and discomfort. A Morton's neuroma is classically described and most often affects the nerve that supplies sensation to the area between the 3rd and 4th toes and is actually located between the metatarsal heads. Although this is the most common area, it can occur between any of the toes.
A neuroma is often caused by an overuse of the foot and toes from a repetitive motion which can lead to repetitive compression of the affected nerve. It can also be caused by blunt trauma to the forefoot or direct insult to the nerve. The continued and static compression of the nerve over time will cause more severe damage to the nerve and lessen the success of conservative treatments.
Biomechanical deformities, such as a high-arched foot or a flat foot, can lead to the formation of a neuroma. These foot types bring on instability around the toe joints, leading to the development of the condition. Trauma can cause damage to the nerve, resulting in inflammation or swelling of the nerve.
Improper footwear that causes the toes to be squeezed together is problematic. Avoid high-heeled shoes higher than two inches. Shoes at this height can increase pressure on the forefoot area.
Repeated stress, common to many occupations, can create or aggravate a neuroma
When there is persistent inflammation of the nerve, this will lead to patients describing numbness, burning, tingling or shooting pains in the 2 adjacent toes. There can be a feeling of walking on a pebble or a rock on the ball of the foot. Others describe the sensation of a sock curled underneath their toes. Some patients can feel or hear a clicking as the nerve rubs over the bones during gait. Often the symptoms can be reproduced in a squatting position with only the ball of the foot and the toes on the ground and the toes flexed.
- Pain in the forefoot and between the toes.
- Tingling and numbness in the ball of the foot.
- Swelling between the toes.
- Pain in the ball of the foot when weight is placed on it
Clinical evaluation of the foot is the most important way to evaluate for a neuroma. Palpation of the foot between and just behind the metatarsal heads will elicit pain and often electric shooting into the toes. Squeezing of the forefoot from side to side can reproduce the symptoms as well. Plain x-rays can show if there is any bone involvement that many contribute to the damage to the nerve. Special neurosensory examinations (PSSD) may need to be performed in order to evaluate the extent of the nerve damage. Ultrasound examination and MRI can also demonstrate the enlarged nerve and amount of inflammation in severe cases.
In the early stages of a neuroma, conservative treatments are often successful. Removal of the causing deforming forces and activity that triggered the inflammation is important. In acute cases, a period of immobilization in a special shoe or boot may be needed. Physical therapy is a very effective treatment for neuromas that are in the early stages. Also, in acute cases the use of steroid injections (cortisone) can be very helpful in reducing the pain and symptoms and help to cure the neuroma. The cortisone works by reducing the amount of inflammation in the nerve, thereby reducing symptoms. Custom molded orthotics with special padding is an important part of treatment and lessens the chance for the neuroma to return. In more severe and chronic cases that have failed conservative therapies there are 4 main more invasive treatments available including alcohol sclerosis, cryotherapy, nerve decompression and nerve excision. Each treatment has pluses and minues and treatment is customized to the patient's needs.
Alcohol Sclerosis : A special alcohol solution can be injected into the enlarged nerve. This solution has an affinity only for nerve tissue. It will slowly over several injections, deaden the nerve. The loss of the nerve can then leave the patient symptom free. Patients usually require 6-8 weekly treatments.
Cryotherapy: This is the method of freezing of the nerve. A small incision is made over the area of the nerve. A wand from the device is then inserted into the wound and placed over the nerve for a set time to freeze the nerve. This allows the nerve to no longer transmit a nerve signal and therefore reduce symptoms. Most patients respond well to the treatment which is office based and done under local anesthesia. In certain cases, the procedure does not fully treat the nerve pain on the first attempt and a second treatment may be necessary.
Nerve Decompression : The most recent advance in neuroma therapy is nerve decompression. It is thought that, in many cases, the nerve is pinched by the overlying ligament that connects the metatarsal heads together. A simple surgery with a one centimeter incision allows the release of this ligament resulting in decompression of the nerve and relief of pain. This surgery leaves the nerve intact and allows continued sensation to the toes. Patients are able to return to sneakers afer two days.
: The most traditional treatment for neuroma pain has been a nerve excision. This procedure allows for removal of the nerve from the metatarsal head region as well as its branches into the toes. There is a risk of the remaining nerve growing again and the build-up of scar tissue, but with proper technique, the risk is minimal. The physicians at OC Foot and Ankle perform this procedure under a sterile and controlled surgical setting with proper and clean anatomic dissection resulting in minimal blood loss and scarring.
Remember, treatment options vary with the severity of each neuroma, and identifying the neuroma early in its development is important to avoid surgical correction. Podiatric medical care should be sought at the first sign of pain or discomfort; if left untreated, neuromas tend to get worse.
Your Feet Aren't Supposed to Hurt
Remember that foot pain is not normal, and any disruption in foot function limits your freedom and mobility. It is important to schedule an appointment with your podiatric physician at the first sign of pain or discomfort in your feet, and follow proper maintenance guidelines to ensure their proper health for the rest of your life.
- Wear shoes with plenty of room for the toes to move, low heels, and laces or buckles that allow for width adjustment.
- Wear shoes with thick, shock-absorbent soles and proper insoles that are designed to keep excessive pressure off of the foot.
- High heels should be avoided whenever possible because they place undue strain on the forefoot and can contribute to a number of foot problems.
- Resting the foot and massaging the affected area can temporarily alleviate neuroma pain. Use an ice pack to help to dull the pain and improve comfort.
- For simple, undeveloped neuromas, a pair of thick-soled shoes with a wide toe box is often adequate treatment to relieve symptoms, allowing the condition to diminish on its own. For more severe conditions, however, podiatric medical treatment or surgery may be necessary to remove the tumor.
- Use over-the-counter shoe pads. These pads can relieve pressure around the affected area.