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.
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
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.
Seddon's classification for nerve injury
last updated 4/22/15
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