What Is a Neuroma?

If you’re suffering pain between the third and fourth toes of either foot, you may have a neuroma. This condition is usually caused by the bones on either side of the nerve pressing together to create pressure on the nerve between them. This pinching can cause inflammation and thickening of the nerve leading to pain. At the Foot and Ankle Center of Washington, we have developed a very effective, conservative treatment plan for neuroma to relieve your pain without resorting to neuroma surgery.

What Are the Symptoms of a Neuroma?

Neuromas are also known as “Morton’s neuroma” and usually don’t have outward signs you can see on the exterior of your foot like a lump. Instead, you’ll experience discomfort between the third and fourth toe of either foot that manifests as shooting, burning, stabbing or radiating pain. It may feel like there is an object in your shoe, tingling, numbness or an odd feeling between your toes. Very often the pain from neuroma will recede when you take off your shoes and massage the affected area. 

What Causes Neuromas?

You can be more susceptible to developing a neuroma if you have high arches, flat feet or other biomechanical issues that cause instability around your toe joints. Trauma to the foot can lead to a neuroma as can tight or poorly fitting footwear that compresses the toes like high heels greater than two inches tall. Repeated stress can also cause neuromas – those that participate in sports or occupations that place undue stress on the forefoot may be more prone to this disorder.

What Are the Treatment Options for Neuroma?

Doctors Hale and Huppin of the Foot and Ankle Center can usually relieve pain caused by neuromas without resorting to surgery and feel surgery should be only used as a last resort. We have great success treating neuromas conservatively, with less than 2% of our patients requiring neuroma surgery. Click here to learn more and watch this video to see how to eliminate neuroma pain without surgery. 

The problem we see is that very few patients receive adequate non-surgical treatment at other podiatric clinics. Conservative treatment should include, at the very least, total contact orthotics designed to transfer pressure off of the ball of the foot and that are designed specifically to address neuromas. Other non-surgical therapies include:

  • Corticosteroid injections
  • Sclerosing injections
  • Anesthetic injections
  • Chemical Neurolysis
  • Shoes with a wider toe box

For more information on neuroma therapy, check out these pages on Morton’s Neuroma to learn about the condition in detail, Sclerosing Injections as a treatment for neuroma and how Custom Orthotics can be used to treat neuroma and ball of foot pain.

When Should You Consider Neuroma Surgery?

Neuroma surgery should be a treatment of last resort. Any surgery comes with the risk of complications and can leave you with pain worse than what you had before surgery. Surgery cannot be undone and we have patients come to us after they’ve had unsuccessful neuroma surgery at another clinic and we’ve reviewed their records and can see that non-surgical treatment would likely have resolved their issues. We find that if conservative treatment is done correctly, less than 2% of our neuroma patients require surgical excision of the neuroma.

What Criteria Should Be Met to Consider Neuroma Surgery?

At the Foot and Ankle Center of Washington, we use the following criteria to determine if a neuroma operation is indicated:

  • Your neuroma was confirmed by examination, diagnostic injections and possibly ultrasound or MRI
  • You have tried custom orthotics, prescribed and cast by your doctor and designed to relieve pressure on the neuroma
  • You have tried shoe therapy, including proper shoes for your foot type and activities and possible modifications to your shoes including accommodative padding
  • You have tried injection therapy
  • None of the non-surgical therapies have successfully treated your neuroma
  • Your neuroma interferes with daily activities

Is Cryosurgery a Good Treatment Option for Neuroma?

We have evaluated cryosurgery for neuromas and have decided not to use this as a surgical option for neuromas at the Foot and Ankle Clinic of Washington. There is currently very little research that shows it to be an effective treatment for Morton’s neuroma but, if better evidence emerges in the future, we will consider it at that time.

What Happens During Neuroma Surgery?

The goal with neuroma surgery is to relieve the pressure caused by the enlarged nerve. There are a couple of ways to accomplish this. To our knowledge, no good studies are available that compare these two primary surgical procedures for Morton’s neuroma. The most common surgery is removal of the nerve and we usually opt for this approach as it seems to offer less chance pain will return later.

One surgical option is to simply release the ligament between the metatarsal bones and thereby reduce the pressure that the metatarsal heads place on the neuroma. The advantage of this procedure is that the nerve is left intact and eliminates the possibility of a new neuroma (a “stump neuroma”) forming where the nerve was removed. The disadvantage is that the neuroma is left and may continue to cause pain.

The second option is to remove the neuroma completely (called a neurectomy). The advantage of this procedure are that the enlarged portion of the nerve is completely removed typically leading to a more predictable relief of pain. A disadvantage is that removing a portion of the nerve leaves a numb sensation on a small portion of the toe. 

Are There Different Options for the Neurectomy Procedure?

One consideration is where the incision on the foot should be made. Neuroma surgery can be performed either from the bottom of the foot or from the top. Surgery from the bottom of the foot (plantar approach) is a more direct approach. The downside to the plantar approach is the possible pain that can occur from having a scar on the bottom of your foot.

The other option is to use an incision on top of the foot. This technique is considered better for most patients because it avoids problems resulting from an incision on the bottom of the foot such as a scar.  Our preference is usually to perform the dorsal (top of foot). The only time we recommend the plantar approach is for patients that have had return of a neuroma after a prior surgery.

What Happens After Neuroma Surgery?

Many studies state that patients can walk immediately after a neuroma operation as long as they use a protective post-op shoe. But we have found that patients experience less pain and swelling if they protect their foot in the first weeks after surgery. For best results and the least pain, we recommend being non-weightbearing (using crutches or a knee-walker) for one to two weeks after neuroma surgery. After that, we recommend a walking boot for two to four more weeks. 

Most patients can then usually move into a regular shoe but may still have some discomfort until the area completely heals and tissues remodel. We find that patients often do better long-term if they wear total contact orthotics in shoes after recovery from neuroma surgery. The orthotics decrease pressure under the surgery site on the ball of the foot. This is particularly helpful during the first months after surgery when some healing is still taking place.

What Complications May Result from Neuroma Surgery?

Every surgery carries the risk of complications. Even if the surgery goes off without a hitch and the patient does everything perfectly right post-op, some patients will still develop complications. These can include pain, infection, stump neuroma or slow healing. Other complications, more specific to neuroma surgery, include:

Numbness – This is common and will usually occur on the sides of the toes adjacent to where the neuroma was removed. Most patients will not notice this in day-to-day activity. There may also be some numbness on the bottom of the foot near the site where the neuroma was located.

Callus – In rare cases, patients can develop a callus under the ball of the foot after neuroma surgery. This is likely due to changes in the way you bear weight while recovering from surgery.

Continued or Return of Neuroma Pain – Patients who chose the decompression surgery may continue to have problems if the size of the neuroma causes ongoing irritation. 

Development of Another Neuroma – Patients who opted for neurectomy may develop a stump neuroma (a second neuroma that forms at the surgical site) that may be even more painful than the original problem, can be difficult to treat and may require another surgery if it doesn’t respond to non-invasive therapy.

Metatarsal Pain – This can result from removal of fat in the surgical area during the procedure.

Pain from an Adjacent Neuroma – If you have more than one and only had one operated on.

How Should You Choose a Physician to Perform Your Neuroma Surgery?

Some foot surgeons are exceptionally skilled at neuroma surgery, some are mediocre, but most are somewhere in-between. To ensure the best possible outcome, you should choose an experienced and skilled neuroma surgeon. Click here to see our page on bunion surgery and check out the section on “Who Should Perform Your Surgery?” for tips on identifying good surgeons and those to avoid. 

Contact the Foot and Ankle Center of Washington Today 

If you have been told you need neuroma surgery, make an appointment to see Dr. Hale or Dr. Huppin as soon as possible for alternative, non-invasive neuroma treatment. Even if you’ve been told by another doctor that neuroma surgery is your only option, you should get a second opinion from us, as our treatments have been proven as an effective alternative to surgery.

For more than twenty years now, our alternative treatments for neuroma surgery have proven effective for the vast majority of patients we see. If you come see us for a second opinion, please be sure to bring any shoes and orthotics you wear regularly. Contact the Foot and Ankle Center of Washington today to schedule an appointment to address your neuroma pain as soon as possible. 

Click here for conservative treatment options for neuroma

References

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  2. Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. Mosby-Year Book;1999.
  3. Thompson FM, Deland JT. Occurrence of two interdigital neuromas in one foot. Foot Ankle. Jan 1993;14(1):15-7. [Medline].
  4. Levitsky KA, Alman BA, Jevsevar DS. Digital nerves of the foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot Ankle. May 1993;14(4):208-14.[Medline].
  5. Thomas JL, Blitch EL 4th, Chaney DM, Dinucci KA, Eickmeier K, Rubin LG, et al. Diagnosis and treatment of forefoot disorders. Section 3. Morton’s intermetatarsal neuroma. J Foot Ankle Surg. Mar-Apr 2009;48(2):251-6. [Medline].
  6. Mulder J. The Causative Mechanism in Morton’s Metatarsalgia. J Bone Joint Surg Br. 1951;33:94-95.
  7. Rout R, Tedd H, Lloyd R, Ostlere S, Lavis GJ, Cooke PH, et al. Morton’s neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians. Qual Prim Care. 2009;17(4):277-82. [Medline].
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