What Nerve!

What follows is from an article I wrote on (in green italics!) neuromas followed by additional comments on the subject.

Here is a riddle that takes a bit of nerve to ask: what is about the size of a large raisin, is found in the foot and can be so painful that it can bring the great and the small to their knees?

Before I get to the answer I want to tell you about one great and one small. Steve is the large person, and I do mean large. He is a former NFL football player. He stands well over six feet in height and weighs about 250 pounds of nothing but muscle This particular young man makes his living by publicly demonstrating feats of strength. He has a near perfect physique with a waist smaller than most people’s thighs. (My office employees tell me he is also a good-looking guy, but his shape alone is enough for me to hate him.) At the other extreme is Diane. She stands barely five feet tall and weighs so little she almost needs to be tethered in a strong wind.

Both Steve and Diane came to me after experiencing weeks of unrelenting pain in their feet. They both used the words sharp and stabbing in describing the pain. For both of them the pain was centered in the ball of the foot just behinds the middle toes. With any compression of the feet the pain seemed to spread to the toes or up the foot to the ankle.

The cause of their pain is a small nerve in the foot that has gotten so swollen that it can now be called a neuroma. A neuroma in the foot, sometimes called Morton’s neuroma after Dr. Dudley Morton who first described a foot neuroma, is a common condition. An otherwise normal nerve gets itself trapped between the bones of two adjacent toes. The constant rubbing of the nerve with walking and running results in the nerve becoming inflamed and swollen. It can hurt so much that regular activities are no longer possible without constant pain. Patients find them selves removing their shoes and rubbing their feet to get some pain relief. This was the condition of both Steve and Diane when they limped into my office.

Since the pain is due to the inflammation of a nerve, one of the common treatments is to reduce the inflammation using medication or physical therapy. Both Diane and Steve received a cortisone injection designed to reduce the painful inflammation. Cortisone injections for neuromas are neither painful nor risky. Diane was lucky. With just a single nearly painless injection she was back to her regular activities. The nerve may hurt again in the future, but for now she is working and walking without pain.

Steve, on the other foot, received two cortisone injections without a shred of relief. Steve became a candidate for surgery. In an outpatient procedure, under local anesthesia, his neuroma was surgically removed. This was done with a tiny incision on the top of his foot just behind his toes. The procedure took less than an hour and he was back at home the same morning. At his first post-operative check he described his foot as being tight but not painful. He could tell that the disabling neuroma pain was no longer present. He was gratified to be free from his foot pain. Considering his size I breathed a sigh of relief as well.

Neuromas are probably the most commonly encountered neurological problem seen by podiatrists. We have developed very successful treatments for this condition. If you are experiencing a sharp stabbing pain in the ball of your foot, do not be afraid to bring it to our attention. You have nothing to loose but your pain and your nerve will be rewarded.


Dr. Zapf, Since you wrote that article what has changed?

The biggest change is that traditional surgery is no longer required to treat a neuroma. Instead, I have found another way to treat a neuroma: sclerotherapy. Sclerotherapy for neuromas involves a series of injections of an alcohol solution into the nerve. I know this sounds painful, and it is to some extent, but for many people it is preferable to an open surgery.

What are your current thoughts on neuroma treatment?

A neuroma is a benign (but very painful) swelling of a foot nerve. I recommend doing one of two things to get rid of the pain: shrink the nerve or kill it.

How do you shrink the nerve?

Cortisone (corticosteroid) injections work to help your neuromas in two ways. First they stop or reduce the inflammation response. As your neuroma gets squeezed between the metatarsal of your foot it becomes quite inflamed. Injecting a little cortisone around the nerve can halt the inflammatory process, at least for a little while.

Second I can harness the ability of cortisone to destroy tissues and use it against the neuroma. Too many cortisone injections into one area can cause the local tissues to atrophy and shrink. How many is too many? Nobody knows! Certainly 50 are too many. But probably 10 spaced out over 2 years wouldn't be. To be on the save side there is a rule of thumb (rule of toe?) that we only give three injections of cortisone into any one location. I like to space the injections two weeks apart so I can observe the tissues involved and see if there are any visible changes. This Rule of Three is widespread in medicine. Your doctor probably believes in it too. Funny thing is your doctor has no idea where the rule came from. It is not written in any books on surgery, medicine or pharmacology. It is an idea that just sort sprang full-grown in medicine and is thoroughly lodged there. In most instances I abide by it too. But I have been known to cheat with a fourth or fifth in certain circumstances if the patient and I feel the potential rewards are worth the risks.

There is a funny thing about cortisone injections. Sometimes they completely "cure" a neuroma. I tell my patients that I expect about 5% of neuroma patients to be permanently cured of their neuroma forever with the first injection, 5% more with the second and an additional 5% with the third. There is very little risk involved in any of the first three injections. You body absorbs the cortisone and any effect it might have on your system is over in a day or two. The effect on the neuroma can last for a much longer time. Because the injections of cortisone are of so little risk and up to 15% of people can have their neuroma "cured" forever I strongly recommend every neuroma patients try a couple of injections. A number of people have a fear of cortisone but I feel for the most part that these fears are unfounded. If patients refuse, of course, I work around it and do not force them to have one.

If shrinking a neuroma doesn't help, how do you kill it?

You can kill a neuroma either by surgically cutting it out or with a series of alcohol injections, called sclerosing.

Tell me about sclerosing.

Sclerosing involves 8 weekly injections of alcohol into the base of the neuroma. Each injection involves putting in about 1/2 a CC of a 4% alcohol solution into the skin, moving the needle to the neuroma and depositing the small quantity of the solution. The needle used in the smallest made, a 30-gague, and the syringe is a tuberculin syringe with produces very little painful pressure. To do the injection you put the needle in and move it around the nerve until the patients says something like "Doc, you have found my neuroma."

Sclerosing seems to have no complications except that it sometimes does not work.

One patient's comments on sclerosing:

 From Jane B. She returned to my office for an unrelated problem but had her neuroma "sclerosed" 6 years before. She noted that she had no pain whatsoever from her neuroma since she has the treatment. She made the following note; "I will always choose an alternative method to surgery first and Dr. Zapf's special Zapping method for neuromas, sclerosing, really worked for me!"

What is involved in regular neuroma surgery?

Neuromas can be surgically removed in either the office or the surgery center. The advantage of the surgery center is the use of sedation, which can relax the patient while I am playing with their big, fat foot nerve. Through an incision on the top of the foot the nerve is carefully dissected and removed from the foot. There are a few sutures to close the wound and we are done. Patients return home in an hour or so and need to remain with their foot elevated for three days. During these three days they can walk to the bathroom and go to the kitchen for juice or toast but should not stand to cook, clean or work. After three days they can be as active "as their foot will let them" and within reason. Pain is minimal and usually only a few pain pills are ever taken (after all the nerve that transmits pain signals is sitting in a bottle.) After two weeks of wearing a surgical shoe the sutures are removed and "regular" shoe wearing and regular bathing can be performed.

How successful is regular neuroma surgery?

If by "regular surgery" you mean the traditional procedure whereby a two-inch incision is made on the top of the foot with the removal of the surgery, it is very successful.

Most are like Michelle S. who said" After suffering with stabbing pains through my toes for years, I decided to do something to change the situation. After several injections of cortisone and sclerosing injections I still had pain. I decided to pursue the surgical treatment. I can't tell you how easy this procedure was! A couple of hours at the SurgiCenter with very professional people, a weekend with my foot raised and the pain was gone! Why did I wait so long? I highly recommend the surgery with Dr. Zapf. I felt I was in very capable hands!"

And Becky who said: "I went into the SurgiCenter early in the morning and was home before I knew it.  I have had no pain; really I have had very little discomfort (the worst thing is the surgery shoe that doesn't match anything in my closet).  Dr. Zapf and his staff have been great and the staff at the SurgiCenter was also great.  It is two weeks since the surgery and I am doing fine.  If I had known it was going to be so easy I would have had both beet done at the
same time.

What can go wrong with regular surgery?

Complications from the surgery include the usual things like complications or allergic reactions to anesthesia, infection of the wound, slow healing of the wound and more pain than expected. In addition there are some things that are specific to neuroma surgery.

There can be an unusual swelling in the space where the neuroma was removed. This is thought to be from the blood that can accumulate in the space where the neuroma used to reside. If there is a lot and early this "hematoma" can be squeezed out, usually with a little anesthesia. If it just a tightness in the area after surgery it can be injected with a bit of cortisone to shrink the tissues. Sometimes just "tincture of time" takes care of it.

The most feared complication is stump neuroma formation. This occurs when little sproutlets of nerve from the cut end of the nerve start to grow trying to heal itself. These sproutlets can grow into a ball that hurts like (or more than) the original neuroma. Rarely these sproutlets seem to grow across the entire neuroma site and reform a neuroma. I say this because a few times I have had the opportunity to go back into the foot to remove a so-called recurrent neuroma and found an entire intact neuroma. This is not supposed to happen if the nerve was properly removed the first time. In some cases i knew of the doctor who did the first neuroma excision and he or she has a great reputation. I am sure that they would have seen a neuroma and would have entirely removed it. So it must have grown back.

In short I believe that only 2% of the time are people worse off after neuroma surgery. I explain that that is not a reason to avoid the surgery. My belabored analogy:  it is like planning an outdoor June wedding in California. There is a 2% chance it will rain. If it rains you are worse off. The fact that it rained did not mean you made a mistake in planning an outdoor wedding. You played the odds and had bad luck. If you want to minimize your odds of something going wrong, don't get married. If you planned an indoor wedding you might get an earthquake (this is California, after all). Then again, single people have shorter lives and more sickness, so pick you poison. In other words, don't let a small chance of a complication ruin an otherwise good decision. If you are really worried about your neuroma surgery and do not want to face the 2% consequence, try sclerosing first. It may not help but it cannot hurt. Then at least if you are a 2%'er you can say you did all you could to minimize your risks.


The pictures below show a neuroma removed form its favorite hiding place, the "3rd interspace" which is the area between the third and fourth metatarsal bones. The pink "Y" shaped object is the neuroma and the yellow glob hanging on by the bottom is some of the fat that usually sticks to a neuroma.