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Neuromas





Morton's Neuroma

Neuroma Illustration of area of pain

A neuroma is an inflamed nerve. A Morton's neuroma causes pain in the ball of the foot that shoots out to the third and fourth toes. The second and third toes can also be affected. The pain is typically is the worst with standing and walking and relieved by rest. Some will complain of deep achy pain, others complain of a constant burning. There can be radiating pain, electrical pain or numbness. Many people will describe the feeling of their sock bunched up under their foot or feeling of walking on a lump or a ball. A "twang" feeling, like a guitar string, is another common complaint. 

Sitting down, taking off the shoe, wiggling the toes and massaging the foot generally gives relief. Constant irritation typically causes the nerve to become inflamed. The nerve can become irritated when the foot is cramped in a shoe that is too tight or too flexible. Overuse can also cause the nerve to be inflamed and activities that generally irritate the nerve include going up and down hills or stairs, squatting and any type of running or jumping.

A neuroma is diagnosed by good questioning and a physical exam of the foot by a physician. Pressing on certain areas of the foot will reproduce the pain. Squeezing the foot together and pushing up under the nerve will, in many cases, yield a positive “Mulder’s Click”. The clicking sound associated with pain shooting to the toes is diagnostic for a Morton's neuroma. An X-ray can be helpful in ruling out other conditions. Rarely does an MRI need to be done.

A Morton's neuroma is generally considered a nerve impingement with neuropraxia and in severe cases axonotemesis. More on nerve injury classifications.

Joplin's Neuroma DiagramJoplin's Neuroma

A Joplin’s neuroma is an entrapment of the nerve traveling along the bottom and inside area of the big toe. The common medical terminology used to define a Joplin’s neuroma is  perineural fibrosis of the plantar proper digital nerve to the hallux. The pain is similar to a Morton's neuroma, but only involves the inside of the big toe. The pain can be sharp, burning, shooting, electrical, tingling or numbing. A thin “cord” can sometimes be felt and may even roll when pressure is applied. A Joplin's neuroma is usually caused by abnormal pronation (rolling in of the foot) and may also be associated with a bunion. Roll over image to see the common area of pain on the bottom of the great toe

Treatment

    1. Decrease activity. Limit going up and down stairs and squatting. Limit any activity that puts stress on the ball of the foot. See tips for decreasing activity (link to page).

    2. Don’t wear flexible shoes. Make sure your shoes are not too flexible. It is very important to wear rigid shoes while healing. For neuromas, the more rigid the shoe the better, picking shoes with minimal flexibility, even at the toes. More on shoes.
      shoe bend comparison

      A flexible shoe places a substantial amount of pressure on the forefoot. The more rigid the shoe the better. One of the best shoes for neuromas, is a Dansko shoe. The Dansko shoe has a wedged heel, which helps to distribute pressure. Although it would seem like a high heel or a wedged heel would place pressure on the forefoot, the opposite (1 1/2" inch heel or less) is actually true. Most people have tight calf muscles which places excess pressure on the forefoot (more on this). The wedged heel lifts the heel, takes stress off of the calf and distributes the pressure more evenly between the heel and the forefoot. A rigid shoe with a rocker decreases the amount of force going through the forefoot during the "push off" phase of walking. More on choosing shoes.
       
    3. Neuroma Pad Placement IllustrationDon't wear narrow shoes. Narrow shoes force the bones of the foot and all forefoot structures together, placing excess stress on an already inflamed nerve. Narrow high heeled shoes causes the greatest problems for neuromas, but many basic work shoes, some cycling shoes and ski boots will also cause problems.

    4. Try neuroma pads. Neuroma pads are small pads, adhesive pads, which are designed to sit under middle of the foot and take pressure off the nerve. The placement of these pads is very important. The pad should not sit right under the ball of the foot. This would increase the pressure right at the nerve and increase pain. The pad should sit right behind the ball of the foot. When stepping down on the neuroma pad, it should feel like it’s more toward the middle of the foot. It should not cause pain. More on neuroma pads.    


  1. Ice the ball of the foot. Ice for 20 minutes twice a day, more if you have time. A simple ice pack is all you need, but you can apply an ice massage to the ball of the foot by freezing Dixie cups with water and rubbing them along the sore area.

  2. Contrast between hot and cold. Alternating between a heating pad and an ice pack may decrease inflammation more than the icing alone. Start with an ice pack and keep the ball of the foot on the ice pack for 5 minutes, then alternate to a heating pad for 5 minutes. Continue alternating back and forth for a total of 30 minutes. If you can do this three times a day, it would be great, but if there are time constraints, try icing daily and contrasting every other day.


Treatments at the Doctor’s Office
A steroid injection will help to decrease the inflammation in the area. No more than 4 injections should be given in the same area in a 12 months period. If two injections have not helped it is not likely a third injection will. Alcohol injections (also called nerve sclerosing) are an option. The typical course of therapy includes weekly injections for 4-7 weeks. See our blog post on recent research on alcohol injections. Other treatments include physical therapy, soft casts and even the use of crutches.

If none of the above therapies have helped, surgery is the next step. Surgery involves cutting the nerve and removing it. An area of permanent numbness will remain on the foot. The surgery is typically done at a surgery center and takes about 40- 45 minutes. The recovery time involves wearing a surgical shoe for 2-4 weeks and typically takes 4-6 for full recovery. One of the more common complications of the surgery is the development of a stump neuroma. The nerve can become irritated at the site where it was cut and cause pain. Even with this complication, the surgery is usually successful. Another surgical option is release of the ligament which places pressure on the nerve. This is sometimes done endoscopically. There are certain indications for this procedure and when performed, the recovery time is shorter and there is no residual numbness in the toes. Extracorporeal shockwave therapy is another treatment used for neuromas. See our blog post on some of the new research on extracorporeal shockwave therapy for Morton's Neuroma.

Nerve Injury

Seddon's classification for nerve injury

  1. Neurapraxia -- temporary paralysis of a nerve with disruption of the myelin sheath generally by compression or blunt trauma.  There may be some loss of motor function and reflexes and loss of vibration and discriminatory touch, but pain and temperature sensation remain impact. Since only the myelin sheaths must regenerate, the nerve can repair itself completely within a few days or it may take a few months, depending on the extent of injury.
  2. Axonotmesis -- the nerve axon is disrupted, but the surrounding connective tissues remain intact. This can be caused by loss of blood flow, exposure to toxins or prolonged compression. The axon can grow down the endoneural tube at a rate of 1 mm/day from the time of injury. Although complete regeneration of the nerve can occur, the further the injury occurs from the end organ, the less likely it is for complete regeneration. This means that an injury near the sciatic nerve which supplies the foot, is less likely to fully repair than a nerve injury in the foot.
  3. Neurotmesis -- the nerve fibers and surrounding tissues are all disrupted. These injuries are usually permanent and are unlikely to be repaired. This is the most devasting type of nerve injury and causes include gunshot wounds, laceration, severe fractures or punctures.

 

Nerve anatomy showing the myelin sheath, axon and dendrites

 

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Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.

last updated 5/10/12