What is a Neuroma?
It is the job of the nerves in the body to supply the “electricity” and information from the brain to the skin, muscles, and organs. The nerves to the skin allow for the sense of touch, temperature, and pressure. Those nerves to the muscles function to give instruction for their contraction. Nerves are very sensitive and fragile. Injury to a nerve can be painful and lead to loss of function. When nerves are injured, they require more time to heal than most other parts of the body. When a nerve becomes injured, inflamed, and swollen it is often called a “neuroma.”
On the bottom, near the ball of the foot and between each long bone (metatarsal) there is a nerve that supplies sensation to the skin of the toes. At this level in the foot, the nerve will split into 2 nerves, one supplying the skin each adjacent toe. In gait, the toes will bend with each step and these nerves must be elastic enough for the motion. When there is an injury to one of these nerves it is termed “neuroma.” Most commonly this injury is seen between the 3rd and 4th toes, specifically called a Morton’s Neuroma. The damage to the nerve will cause the nerve to become inflamed and swollen. Now that the nerve is swollen and larger, the space around the nerve becomes effectively smaller. The head of the long bones (metatarsals) and ligament between them will begin to compress the nerve, further damaging it. The nerve then cannot function properly to “conduct electricity” to the toes. This then leads to the pain and symptoms of a neuroma. The longer the compression and damage to the nerve continues leads to more failure of conservative treatments. A tear of a ligament on the ball of the foot that serves to join the toes to the foot is often misdiagnosed as a neuroma by other doctors. Dr. Soomekh notes that it is important to make this distinction between a plantar plate tear and a neuroma as their treatments are very different.
A patient with a neuroma will complain of pain in the ball of the foot. Often it can feel as if there is a small pebble or marble under the foot. There can be shocks of electricity and shooting pain into one or two of the toes. As the injury progresses, the nerve cannot supply the proper amount of sensation to the skin, and numbness, tingling, and burning of the toes can be noted. There is usually more pain with activity and with bending of the toes. Positions and activities that require constant bending of the toes (squatting) can exasperate the symptoms. Patients will often notice a clicking sensation under the ball foot with each step, as the swollen nerve rubs between the bones. Some patients notice that there is may be days without pain, yet when there is increased activity, such as running, the symptoms appear or worsen. Shoes without cushion and high heel shoes can increase the pain and symptoms. With time, as the nerve becomes more damaged and swollen, the two toes can begin to separate from one another.
Causes Of a Neuroma
Neuromas can be caused by acute injury or repetitive trauma to the nerve. The following are examples of acute injury: Stepping onto a hard object barefooted or landing on the ball of the foot from a jump. Fracture of the metatarsal bone near the nerve. Activities that demand repetitive high impact to the ball of the foot can lead to a neuroma. A neuroma is often caused by an overuse of the foot and toes from a repetitive motion.
Diagnosis is achieved by the clinical examination. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. The patient’s foot will be held and while palpating between and just behind the head of the metatarsals there can pain and electric shooting into the toes. Squeezing of the foot from side to side can reproduce the symptoms and the size of the nerve can be evaluated as it moves between the bones. Digital radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine any associated bone deformities.
Dr. Soomekh may evaluate the nerve using a state-of-the-art diagnostic ultrasound. This examination can show the size and swelling of the nerve. It can be used as an important tool to examine the degree of injury and the effectiveness of treatment.
An MRI may be ordered in some cases to evaluate an exacting 3 dimensional view of the damaged nerve and the associated tissues. It can also be used to rule out a plantar plate tear that is often misdiagnosed by other doctors as a neuroma.
Neuroma TreatMent Options
Dr. Soomekh educates that early diagnosis and treatment of a neuroma are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for a Neuroma:
Conservative treatments for a neuroma rely on their ability decrease pain, reduce inflammation, and stop the trauma to the nerve. In the early stages of the injury Dr. Soomekh will recommend a strict 2 to 4 week initial home therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the trauma to the nerve while it is trying to heal. A discussion of appropriate shoes and padding will be advised in order to support and cushion the nerve. Dr. Soomekh may recommend a course of visits to a Physical Therapist.
Custom Molded Orthotics
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the nerve. A custom orthotic can reduce the stress and the forces placed on the nerve while walking and increased activity. The orthotics control the amount of motion through the arch during gait, and take on the pressures that nerve would normally incur.
Cortisone (steroid) Injections for Neuromas:
Those patients that experience significant acute pain, or those that are not responding to other conservative treatments may benefit from an injection. Steroids that are used in medicine are catabolic, this means that they break down inflammation and tissue. When there is an acute injury with inflammation to the nerve, cortisone can be used to reduce the inflammation and break down any scar tissue surrounding the nerve. This can reduce the pain as well as aid in a more rapid recovery. Dr. Soomekh may recommend this safe and often therapeutic injection as an adjunct to conservative therapy; it is not meant to replace it. Cortisone injections may be helpful for some patients, and may not work for others. These injections do not “ware off.” If an injection helps the patient, and the neuroma pain returns after some time, it would be because there was a new injury to the nerve, not because the cortisone stopped working. Dr. Soomekh will perform the injection under ultrasound guidance for accuracy.
Chemical Denervation / Alcohol Injection Series
In some chronic cases, where some of the conservative treatments have failed, the nerve can be “shut off” using a special Alcohol mixture. This solution has a special affinity for nerve tissue. When the nerve tissue is washed with the alcohol, it will decrease its ability to transmit electrical impulses to the skin. This turns off the nerve so that the painful symptoms are reduced or eliminated, without the need to remove the nerve.
A series of 6 injection, 1 every 2 weeks is performed. Dr. Soomekh will use ultrasound guidance to deliver the medication over the nerve.
Surgical Treatment for a Neuroma:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when a neuroma becomes chronically painful, activity is limited and other procedures and therapies have failed, surgery may be indicated.
Is Neuroma Surgery Painful?
Considering surgery can be intimidating. Foot surgery including neuroma surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of neuroma surgery is to remove the stress on the nerve, remove the nerve, alleviate pain, allow a return to normal shoes, and allow a return to all activities. Most procedures allow for immediate walking and a return to work while wearing a special walking boot. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
Neuroma Ligament Release
The inter-metatarsal ligament that lies between the metatarsal heads crosses over the neuroma compressing it. In mild cases of a painful neuroma, the ligament can be cut, releasing the pressure over the nerve. The nerve is left intact. This minimally invasive procedure attempts to remove the pressure over the nerve while allowing for continued sensation to the toes. A small incision is made over the top of the foot between the heads of the long bones and between the toes. The ligament is cut at this level. The nerve is inspected. Dr. Soomekh can determine if the damage of the nerve is minimal enough to leave the nerve intact, and the skin is then closed using plastic surgery techniques.
A neuroma with significant damage to the nerve requires removal and resection of the nerve. Although the nerve is located on the bottom of the foot, a small incision is made over the top of the foot between the head of the metatarsals and the toes. This will avoid the chances of a painful scar on the bottom of the foot. The wound is deepened to the level of the nerve as it is examined to determine the degree of damage. The nerve is then cut and removed to the level of healthy nerve. The cut end of the nerve is then tucked into a muscle to protect the nerve during healing. Dr. Soomekh performs this extra step of placing the nerve into the muscle in order to reduce the chance of a stump neuroma and the return of the neuroma. The skin is then closed using plastic surgery techniques. The procedure allows for immediate walking and a return to work while wearing a special walking boot.
Revision Surgery for Recurrent Neuroma (Stump Neuroma)
Those patients that present with a recurrent neuroma from a failed surgery performed elsewhere may require revision surgery. In these cases, the nerve is approached from the bottom of the foot. The damaged end of the nerve is freshly cut to the level of healthy nerve. The cut end of the nerve is then tucked into a muscle to protect the nerve during healing. Dr. Soomekh performs this extra step of placing the nerve into the muscle in order to reduce the chance of a stump neuroma and the return of the neuroma. The skin is then closed using plastic surgery techniques. The procedure requires wearing a special boot while using crutches, due to the location of the incision, and an immediate return to work.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top nerve specialists and nerve surgeons in the Los Angeles area.