What is a neuroma? How can I treat it?
The following is an excerpt from Those Aching Feet: Your Guide to Diagnosis and Treatment of Common Foot Problems.
A neuroma is an inflamed nerve. It can occur at any point along a nerve, but typically occurs in areas of stress or irritation. In the foot, the most common place for a neuroma is between the third and fourth metatarsals in the forefoot. Most people complain of pain on the bottom of the foot that shoots out to the third and fourth toe. Neuromas can also occur between the second and third toe, as well as on a bunion. The most common neuroma is called a Morton's neuroma. This neuroma occurs between the third and fourth toe. There are many theories for the development of neuromas in this area. First, this area is the place where two nerves merge, forming a slightly larger nerve. It is postulated that this large nerve has a higher chance of being irritated. There are two columns to the foot which can sometimes act independently. The third and fourth metatarsals separate these two columns. Some say this contributes to increased irritation. In some individuals, the two metatarsals are closer together and this aggravates the nerve. Others feel that there is a ligament between the metatarsals that places pressure on the nerve and causes irritation. Although there appear to be many theories for the cause of a neuroma, there is a general agreement that a certain foot type causes an abnormal motion in the foot that leads to irritation of the nerve. Generally, the pain will appear after increased time spent on the feet, but can also appear after an injury.
What you See and Feel
The pain is usually sharp and localized to the ball of the foot. Pain may shoot out to the toes, particularly the third and fourth toe. It may feel as if you are walking on a marble. Stopping, sitting down and rubbing or massaging the foot may help the pain. The foot can remain painful and achy even if there is no pressure is on the foot.
How It's Diagnosed
The neuroma is diagnosed purely by good questioning and a physical exam of the foot by your physician. Pressing on certain areas of the foot will reproduce the pain. A certain test will actually cause a clicking sound that pops the nerve out from between the bones. 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. In some cases the neuroma can be confused with inflammation of the joints at the forefoot. Commonly, both of the conditions exist at the same time. It may be necessary to inject local anesthetic into the area in order to figure out the diagnosis. Other tests are usually not necessary.
What Else Could It Be?
The most common misdiagnosis is capsulitis. Capsulitis is the inflammation of the joint capsule and it can commonly occur in the forefoot. The pain may be quite similar to the neuroma pain. Many times these conditions occur together because the foot becomes over-stressed and many structures in the area become irritated. An injection with numbing medication in the area may be necessary to help distinguish between the two problems. A bursa in the same area may cause similar types of pain.
What You Can Do About It
The first step in treatment is to decrease your activity and impact on the foot. To start the healing, the irritation of the nerve must be decreased. In association with decreasing impact activity on the foot, neuroma pads can be placed under the forefoot. These pads will help decrease irritation to the nerve. Ice will also help to decrease inflammation and so will anti-inflammatory medications. For certain foot types, orthotics may be necessary. 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 no likely a third injection will. More aggressive therapy includes soft casts and the use of crutches.
If the conservative therapy has not helped, surgery is the next option. Surgery involves removing the nerve. It is a fairly simple and short procedure that involves wearing a surgical shoe for 2 weeks afterwards. Crutches are not necessary after surgery in most cases. Full recovery takes 4-6 weeks. Numbness between the toes after surgery is unavoidable. 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. Surgery is only recommended when all of the conservative therapy has been tried.
The Bottom Line: Visit your physician and try the conservative therapy. If you have no relief you may need a steroid injection. Continue the conservative therapy after the injection. If the pain continues, then consider surgery.
More information and illustrations on neuromas.
last updated 4/22/15
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