A Question From Australia. My comments to her letter are written in BLUE

Dear Dr Zapf

 

You sound too good to be true, and I love the way you write! Thank you. Flattery will get you an answer when many others have failed. It is now 12:30 PM but I loved your letter and couldn't wait to respond.

 

I have just read your page on Neuromas.  I live in Brisbane, the capital city of Queensland, Australia (about a 1 hour flight north of Sydney where the 2000 Olympic Games were held).  In 1983, while at the peak of my career as a professional dancer, my physio diagnosed a Morton's Neuroma in my L foot.  I saw 3 different Orthopaedic Surgeons and they couldn't agree that what I had was a neuroma, so I waited until December 1986 (when the pain was affecting normal standing and walking so badly) before I finally succumbed to the operation to have it removed. That is why God invented podiatrists. Rare is the one who cannot feel quite confident about the identification of a neuroma, as you say straight away. 

 

I pleaded with the surgeon to operate from the top of the foot (following advice I received in a letter from the Orthopaedic Surgeon who operated on the dancers in the Australian Ballet Company) but he refused, saying that he wasn't sure it was a neuroma and there were too many ligaments in the way if he went in from the top, Funny how we approach things. I find no ligaments in the way when approaching from the top. As I said in the section on neuromas the incision is easily made and the approach is simple - just spread the little vessels away and up pops the neuroma. Most times the patients are awake and they expect you to say something like "this is the biggest neuroma I have ever seen" so you say, not to lie, "Wow, this is a big neuroma". It is kinda fun to show it off to everyone in the operating room. .so he made an incision about 3 inches long underneath the ball of my foot. Incisions on the bottom of the foot are horrible - should be only a last resort. They can leave nasty scars that can irritate and bother you for the rest of your life. I save such plantar incisions for the, thankfully rare, recurrent neuromas..  (I was told that this was the best surgeon in Brisbane).  I asked for a local anaesthetic so that I could be informed about what he was doing, but he said that was impossible when dealing with nerves so I had a general anaesthetic, It is rare to have a neuroma removed in the states by a podiatrist under general anesthesia - we tend to have mastered the art of local anesthesia. My anesthesiologist colleagues tell me that it is quite common to be put to sleep when neuroma removal is done by orthopedic surgeons. Local or general makes no difference in the performance of the procedure or the expected outcome. Generals do, however, make one what to, ah, get sick. was in hospital overnight never in the states and spent half the night dry retching (I had nothing in my stomach to be sick with after the pre-op starvation).  This was after I'd been given an injection which was supposed to stop me being sick.  The best part was the cute male nurse who gave me the injection! Ah, the male nurse!  Apparently the Histology report said it definitely was a neuroma pathology reports for neuromas are kind of funny. The pathologist is always on the side of the doctor. If there is just one thread of nerve tissue in a mass of other stuff they still will call it consistent with a neuroma. As a surgeon I say, Bless Them. about the size of a large pea.   I never saw it, for some reason I expected to wake up and see it in a jar beside my bed! I shoe it to my patients. It makes their day.

 

I wasn't given crutches to use the wonders of public medicine, so until the stitches came out I either hopped on my R foot or hobbled about supporting my weight on my R heel. (By the way, my physique is akin to Diane's.  I am 5 foot 2 and weigh around 102 pounds).  The entire foot was numb for about a week after the op. very rare  I was a good girl, went home to Mum (Mom to you guys) and was waited on hand and foot (ha, ha) ha, ha - love those corny foot jokes.  so that I could rest it and give it every chance of the best recovery.  Everything seemed OK when the stitches came out and when my specialist told me about 6 weeks after the op that I could go back to dancing and it was OK to "push it" all my problems started up again!  The scar was so sensitive.  I kept getting pins and needles pain on the site of the scar and it felt as if I had a huge wad of steel wool in my foot where the neuroma was. told ya'!,  told ya'! told ya'!  Every morning I would wake up with the aching, burning pain in my foot, and it would keep me awake at night.  I had physio, tried orthotics (which caused even more pain and after 8 years, the pain lessened considerably after I stopped using them), I was even using a metal scrubbing brush on the site of the scar to try to desensitise it!  Needless to say, that was the end of turning, jumping etc which meant no more dance career!  To do a pirouette on the ball of my L foot caused hot needles like electric shocks and the best way I can describe the pain I felt every day was like being stabbed with a blunt knife and a constant ache, while having pins and needles (like when the circulation is cut off) and burning sensations at the same time.  I would never be able to wear pointe shoes again.

 

In 1993, I tried acupuncture and had an amazing result from my first treatment which took me back to how it was before the surgery.  Subsequent treatments gave me immense relief.  At the same time I started to drive an automatic car which meant that my L foot was no longer constantly getting pressure from using the clutch every time I changed gear.

 

I suppose I should tell you that I have flat feet (you know the kind that leave a print on the sand on the inside as well as the outside of the foot) so I probably wasn't meant to be a dancer at all, and my feet are also very flexible, which predisposes me to getting neuromas.  After all those years of dance training, I was able to give myself an instep by using the same muscles we dancers were encouraged to use to prevent "rolling the feet".  The reason I stopped using the orthotics (in late 1996) was that they were so rigid that they prevented me from using the muscles in my feet and the extra pads under the metatarsals seemed to be aggravating the pain.  I kept arguing with my Podiatrist about the rigidity of the orthotics as a general rule podiatrists, even Aussie podiatrists, want to actively control the function of the foot and to do this we need strong (i.e. rigid) orthotics as I was taught from a very early age to "unpeel" my foot from the floor when walking and I simply couldn't walk in the manner I was trained to do while wearing orthotics.  I had a week of readjustment pain when I stopped wearing the orthotics, but after that, the aches and burning pain in the metatarsal area abated and I had a few years which were relatively pain free, unless I wore high heeled shoes which I rarely do!  I even managed to do a couple of ballet classes for ex professional dancers which I thoroughly enjoyed, however they were discontinued last year.

 

Now, I have now quite suddenly developed a neuroma in my R foot and I think I am one of those rare ones who has the talent to grow back a neuroma in my L foot! having a neuroma in the second foot is not rare at all. It happens a fair percentage of the time in my practice.  It is now painful to put my R foot on the brake when driving, and I am getting that electric shock pain in the area of the ball of my foot.  An added complication is an aching pain on the inside of the heel, just around the bumpy bit of the base of the tibia.  I have been researching on the net for other alternatives, as acupuncture, this time around, is not giving the dramatic relief it did last time.  My acupuncturist warned me it could happen like that and he is amazed at how sensitive my foot is.  He had the vibration on the lowest setting and I nearly hit the roof!

 

I have had such a bad experience that your article makes surgery sound like a fairy tale.  Outpatient true local anaesthetic true, again, tiny incision in the top of the foot about 3 cm if that is tiny, less than an hour less than 30 minutes, walk in and walk O,K, its walk in limp out - but you are walking in a surgical shoe on your own power. out, if only it was that easy!  You say you have been doing it for 15 years, my op was 15 years ago.  Were you doing it the same way back then? yes, exactly the way I was trained in 1984. The way nearly every podiatrist in the states does it.

 

As you can tell from my experience, I am not too keen on surgery, so I will be looking into every alternative that there is before I go down that road again, especially as both my feet are affected!  My sister is in a wheelchair so we can't have 2 of us incapacitated in the one family (co-incidentally, the same surgeon botched up a repair to severe multiple fractures of her ankle so she will never walk without the aid of crutches again).  So, from my family's experiences with the medical profession, I can assure you that things do go wrong and according to my research, the failure rate for surgery for neuromas is 15 - 20% bad research. the failure rate is less than 5% and more like 2%. By failure I mean people who are sorry they had it done. yes there aer some of those and every foot surgeon has them but they are rare. and I am living proof of that!  My husband was a dancer too and he had a nasty experience with cortisone injections, as have most dancers I know, so I'm not too keen on injecting foreign chemicals into my body. In my hands, and those of my colleagues, there is virtually no complication with a cortisone injection or two. Occasionally there is a bit of pain afterwards akin to a horse (or mad cow?) stepping on your foot. These "flairs" are infrequent happening in only one in every 20 or 30 injections.   I have been doing Yoga since 1996 which has helped me get over the pain of not being able to dance any more and I believe in the entire Yoga Philosophy.

 

Another alternative I have read about on the net is endoscopic decompression which is supposed to be less invasive than surgery. I have just learned of this too but do not do it. It seems harmless enough and if you can find somebody who does it I do not see the harm in trying it. Just call all your local podiatrists and ask if they do it. I suspect that most have not even heard of it.  Do you know of any surgeon who is familiar with this or your techniques who works in Australia?  As I said I live in Brisbane, but I have family in Adelaide (the capital of South Australia) and friends in Melbourne (the capital of Victoria) and, as we now have cheap airfares to both cities, I am willing to travel if there is someone reputable there.  Unfortunately, travel to California to see you is out of my financial reach. As you know I am a fan of injecting neuromas with a 4% alcohol solution. with a series of 8 injections almost 60% of my neuroma patients have avoided surgery. Other "sclerosing doctors" report a much higher success rate. It is not a hard technique to learn and I am sure that your favorite podiatrist can be instructed in this technique easily.  

 

Thank you for taking the time to read this and for your informative articles.  I am extremely jealous of your fortunate patients!  And thank you for your kind comments, I wish you all the best. 

 

Robyn