A neuroma is an inflamed, enlarged nerve. Many problems that end in -oma are tumors but this one is not. Neuromas can occur at any nerve in the body but are very common in the foot, which are the ones I will discuss.
Neuromas are most often found in the common metatarsal nerves of the foot which are the nerves just behind the toes. The job of these nerves is to allow you to feel one side of each of the adjacent toe. For example, the metatarsal nerve between the third and fourth toes allows you to feel the sensation on one side of the third toe and the adjacent side of the fourth toe. These nerves do not connect to any muscles, they are just for sensation.
A neuroma forms when the nerve is pressed upon by the adjacent structures. The four surrounding sides of the nerve are made up of: The two metatarsal bones next to the nerve to the left and right. The top border is a ligament connecting and holding together the two adjacent metatarsals called the ‘deep transverse intermetatarsal ligament’. The bottom structure is the skin and the ground below it.
This space defined above is a small place for the nerve to pass along with tendons. Pressure when walking hurts this inflamed nerve. Most people describe the pain as intermittent and ranges from mild to severe. I often hear it described as pain, numbness and tingling that shoots into two toes. Many people describe an uncomfortable fullness between their toes.
People can have neuroma pain in multiple interspaces and in both feet or just one spot. The most common place is between the third and fourth toes and the second most common place is between the second and third toes. Neuromas are very rare in the the first and fourth interespace.
Neuromas between the third and fourth toes are called “Morton’s Neuromas”. Dr. Morton named this neuroma after himself because they are so predominantly found between the third and fourth toes. The reason for this is that the third interspace nerve is naturally larger than the others and is more likely to become inflamed and painful.
People with arches that collapse (pronate) or flat feet are more likely to get neuromas. When the foot pronates and the arch collapses, the foot moves slightly toward the side, toward the little toe. This puts horizontal forces on the metatarsal bones pushing them together.
Women who wear heels are more likely to get neuromas because the high heels tilt the foot forward putting more direct pressure up on the nerve. People who wear tight shoes in the forefoot also get neuromas as the shoes push the metatarsal bones together.
So now that we have described what neuromas are, why we get neuromas and neuroma symptoms, let’s discuss treatment for neuromas.
The first line of treatment is anti-inflammatory measures in order to decrease pain and make the enlarged, inflamed nerve smaller. This first line of treatment includes prescription and over the counter anti-inflammatory pills, icing, and corticosteroid (‘cortisone-like’) injections.
Often, I will give an injection on the first visit. Injections work very well and very quickly to get rid of neuromas. Unfortunately, there are side effects of steroid injections. Usually one injection will not have adverse effects but I have seen it happen. These adverse side effects of steroid injection include local atrophy (weakening) of soft tissues such as ligaments and tendons. Weakening can lead to injury and rupture of these structures. I do not like to give more than three steroid injections in the same spot within twelve months. Other side effects of steroid injections include fat atrophy where a small indent forms between the bones where the injection takes place because the natural fat below the skin atrophies. This can be permanent or temporary. An additional side effect of steroid injections is loss of pigment in the skin. This can happen just in the area of the injection or it can travel along the lymphatic and vein structures causing a streaking effect. This usually only effects people with darker skin and more pigment.
Again, these are side effects that rarely happen but can occur. I discuss these with patients prior to injecting. Due to these potential problems, I try not to perform injections on the first visit and try alternative treatments first. With that said, I do perform these injections regularly on the first visit. I do them when the patients are in severe pain and want quick relief from the pain they are suffering from as the injection is the quickest and one of the most effective ways of getting rid of painful neuromas.
In my experience a majority of the people that are treated with icing and oral anti-inflammatories return for an injection on the subsequent visits.
The next line of treatment involves a longer approach to eliminating the forces that cause neuroma. This is done with custom or over-the-counter orthotics. Sometimes just a pad alone in the shoe can reduce the pressure by pushing the metatarsal bones apart and off the nerve, but a custom orthotic does this as well as addresses the collapsing arch.
When all the above treatments fail, my next treatment is physical therapy. Physical therapist perform anti-inflammatory ‘modalities’ to try to reduce the inflammation of the nerve.
When all the above and PT fail to treat neuromas then we discuss a little more invasive procedures. Surgery for neuromas is the last resort. There are some newer procedures that we call minimally invasive procedures for neuromas. Please do not confuse this with minimally invasive bone surgery of the foot which I discussed in detail of the perils of it, in my previous blog.
There are a few minimally invasive procedures for neuromas:
My favorite procedure is called ‘Radiofrequency Ablation for Neuromas’. I have been doing this amazing procedure for a few years and I have close to one hundred percent success with it. This involves inserting a radiofrequency probe into the foot right at the inflamed nerve. Once it is in the perfect spot, I heat up the tip of the probe to ninety degrees Celsius, just below the boiling point of water. I repeat this process at three areas of the neuroma, all through one entry point through the skin. This pin point spot of heat denatures the proteins off the nerve and stops the transmission of the pain fibers.
Occasionally, there is a result of numbness or decreased sensation in the two adjacent toes, but that is rare and when it does happen, people have always told me that a tiny amount of numbness is better than pain.
Radiofrequency ablation for neuromas is a relatively painless procedure that requires just one or two injections that hurt less than a typical steroid neuroma injection.
Recovery after radiofrequency ablation for neuroma is pretty easy as well. Healing time is very short as there are no incisions to heal. Patients do not need to worry about keeping a foot dry for this reason, and can get it wet and shower immediately after the procedure. Additionally, I only recommend patients stay of their foot the night of the procedure and rest only if there is discomfort for one to two days after. Most people report mild soreness or throbbing for one to two days after. Many people have no discomfort at all afterwards.
After radiofrequency procedures I tell patients that they may see immediate relief of the neuroma pain within one to five days. I also inform them that some people require up to three months for the procedure to work. I do not call it a failure until three months have passed and the pain is still the same as prior to the procedure. When people report no relief at two months, I will repeat the radiofrequency procedure at that point. If they have some relief I tell them to wait a full three months. If they still have some or all of the pain at three months, I repeat it then. I have done one, two and three procedures on people so far and have almost a perfect record.
Other minimally invasive procedures for neuroma include a series of seven to ten sclerosing alcohol injections, cryosurgery for neuromas, and a nerve decompression procedure often called a ‘kobygard’ procedure. I’ve done them all in the past and prefer the radiofrequency over them all. The alcohol injections did not work very well with only a handful of patients having any relief. The cryosurgery procedure worked okay but people had significantly more post procedure pain than radiofrequency and no where close to the success rate. Cryosurgery for neuromas is also done in the hospital or surgery center while radiofrequency is done in my office. Lastly, the kobygard procedure had a better success rate than the cryo or alcohol but not as good as the radiofrequency. Kobygard decompression is also done in the hospital or surgery center and is more invasive requiring a small incision between the toes and suturing. This means you need to keep the foot dry for twelve days after surgery. Patients also experience much more post procedure pain than the radiofrequency as well.
The last option is surgical removal of the neuroma. This is a great procedure when it its needed but as you can tell since I’ve started doing the radiofrequency procedure I have not had to do many open surgeries. This surgery involves an incision on the top of the foot and dissection down to the nerve below the ligament. I then remove the enlarged area of nerve and close up the foot.
When I do these surgeries, the nerve is very enlarged. To give you an analogy of what it looks like, a normal nerve looks like a piece of spaghetti’s thickness. A neuroma looks like the size of a jelly bean attached to the nerve. Depending on the severity it ranges from a Jelly Belly small candy to a traditional large jelly bean in size.
Okay, that’s about it for neuromas today. To summarize, neuromas are enlarged nerves caused by mechanical irritation. They can be very painful and annoying. We’ve discussed conservative, non surgical treatment as well as minimally invasive treatment and finally surgical treatment of neuromas.
As always, I hope this help and feel free to comment. I will do my best to reply in a timely manner.
Dr. Silverberg
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