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.
Neuroma Photographs
I recently too some very Up Close and Personal Photos of a
neuroma. To see them just click this hyperlink -->
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 se 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.
For more information on sclerosing see; -->
For Karen's thoughts about sclerosing see -->
For more information on my "painless" injections see --->
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. In 14 years I have probably excised 100 neuromas.
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.
Becky
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. I have not yet had this happen to me, I don't think, but I have only
practiced for 15 years. It can take dozens of years for them to become
symptomatic. My time will come, I suspect.
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.
AND WE GET LETTERS
From a
patient who ended up with a stump neuroma after neuroma surgery:
Hi
Dr. unfortunately my Dr. never game me the alternative and he perform a
neurectomy. I have developed a stump neuroma and the pain is worse than before.
I have pain in my entire foot know. I was wondering if I still have a chance of
getting better and being free of this problem. I have another neuroma in my left
foot and a stump on the right and I cannot do anything that involves walking.
This problem have taken over my life. I will thank you for any information or
advise you could provide.
Jennifer from Los Angeles.
Dear Jennifer, Every
once in a while, perhaps 1 in 50 neuroma surgeries results in a terribly painful
stump neuroma. Unfortunately for you that "1 in 50" is 100%. This rare but
problematic side effect is why I encourage patients to try sclerosing injections
before undergoing traditional surgery. I know that 8 visits to the doctor seems
like a lot of time but, in retrospect, wouldn't you rather have taken the time
then than have the pain now? I have had some success getting rid of stump
neuroma pain with sclerosing injections. Your job is to find a local doctor who
will be willing to work with you and try to inject this one (and the other foot,
for that matter) with the alcohol solution.
... Dr.
Michael Zapf
And another question about neuromas
I wrote recently
about foot pain which was found to be from bilateral Morton's neuromas. I
know you mostly answer questions for your patients, but I'm going to try to
bug you again because I am miles away in Tennessee and trust your advice
most. You have me curious about the sclerosing injections, but I have only
found one podiatrist here who does them, and not many patients here want
them. I doubt he uses all of your methods for easing the injection pain, but
I am still thinking of trying this. If it weren't eight weeks of injections,
I would be tempted to fly out to your office! Do Morton's neuromas ever
resolve without injections or surgery? What do you feel is the success rate
of the alcohol injections? Do you try cortisone first? Do you advise still
being careful with athletic activities and shoes after injections and
surgery? I know you are busy, but it is so scary out here where I can't be
your patient.
Thank you,
Dear
Kathryn, Sclerosing injections using a 30-gauge needle and a 1CC syringe
should not hurt much at all no matter who does them. I encourage you to let
your local doctor give them a try. He or she can even call me for any advice
if desired. Morton's neuromas can frequently become quiescent, especially
after a cortisone injection or two. I encourage my patients to try one or two
cortisone injections first for just this reason. If the neuroma were to come
back - we cal always sclerose it later. I find
that the alcohol injections relieve enough of the neuroma pain that more than
90% of my patients never opt for the traditional surgery. I do not advise any
special precautions after surgery or alcohol injections. Successful treatment
for neuromas should allow you to do everything your "sole" desires. Good
Luck,... Dr. Michael Zapf
Read about Robyn from Australia's sad tale of neuromas -->
From
the web site: www.zfootdoc.com ©by Dr. Michael Zapf
