Morton's Neuroma
Description
 A neuroma is the swelling of nerve that is a result of a compression or trauma. They are often described as nerve tumors. However, they are not in the purest sense a tumor. They are a swelling within the nerve that may result in permanent nerve damage. The most common site for a neuroma is on the ball of the foot. The most common cause of neuroma in ball of the foot is the abnormal movement of the long bones behind the toes called metatarsal bones. A small nerve passes between the spaces of the metatarsals. At the base of the toes, the nerves split forming a "Y" and enter the toes. It is in this area the nerve gets pinched and swells, forming the neuroma. Burning pain, tingling, and numbness in one or two of the toes are a common symptom. Sometimes this pain can become so severe it can bring tears to a patient’s eyes. Removing the shoe and rubbing the ball of the foot helps to ease the pain. As the nerve swells, it can be felt as a popping sensation when walking. Pain is intermittent and is aggravated by anything that results in further pinching of the nerve. When the neuroma is present in the space between the third and fourth toes, it is called a . This is the most common area for a neuroma to form. Another common area is between the second and third toes. Neuromas can occur in one or both of these areas and in one or both feet at the same time. Neuromas are very rare in the spaces between the big toe and second toe, or between the fourth and fifth toes. Neuromas have also been identified in the heel area, resulting in heel pain.
A puncture wound or laceration that injures a nerve can cause a neuroma. These are called . Neuromas can also result following a surgery that may result in the cutting of a nerve.
Diagnosis
The diagnosis of Neuromas is first made by a physical exam and a thorough history of the patient’s complaint. A skilled foot specialist will be able to actually feel the neuroma which is called a positive Mulder's Sign. X-rays, or CT Scans are not able to show a neuroma. MRI are not good at identifying neuromas and they are very expensive.However, Dr. Parker has a Parus 8.0 MHz Diagnostic Ultrasound  his office to actually visualize and measure the size of the Neuroma. Recent research is changing our thoughts on the wisdom of removing neuromas, and it is becoming more important to test nerves that are compressed in an effort to save the nerve rather than remove it. Our office also has a computerized Neurosensory Testing Unit (PSSD) quantitatively measure the amount of dysfunction of the plantar nerve in gm/mm square and thus determine and measure the amount of dysfunction of the nerve to determine more accurately whether to decompress the nerve or remove it.
Some conditions that may mimic the pain associated with Neuromas are stress fracture of the metatarsals, inflammation of the tendons in the bottom of the toes, arthritis of the joint between the metatarsal bone and the toe, or nerve compression or nerve damage further up on the foot, ankle, knee, hip, or back. X-rays may be taken to rule out a possible stress fracture or arthritis.
If the doctor on his exam cannot feel the neuroma, and if the patient’s symptoms are not what is commonly seen, then nerve compression at another level should be suspected. In this instance, one area to be examined is the ankle.
Just below the ankle bone on the inside of the ankle, a large nerve passes into the foot. At this level, the nerve can become inflamed. This condition is called . Generally, there is not pain at this site of the inflamed nerve at the inside of the ankle. Pain is manifested as burning, tingling, aching in the bottom of the foot or in the toes. This can now be easily diagnosis with the NEW NEUROSENSORY TESTING (PSSD). Neuromas; however, occur more commonly than .
Treatment
Treatment for the neuroma historically consists of cortisone injections, orthotics, chemical destruction of the nerve by injection of sclerosing agents, or surgery excision and more recently decompression of the nerve without removal by new techniques. Cortisone injections are the most popular and generally used as an initial form of treatment. Cortisone is useful when injected around the nerve, because it can reduce the inflammation of the nerve. This relieves the pressure on the nerve. Up to three cortisone injections can be given over a twelve-month period. Cortisone may provide relief for days, weeks or many months, but is usually not a cure for the condition. The abnormal movements of the metatarsal bones continue to aggravate the condition over a period of time.
To address the abnormal movement of the metatarsal bones, a functional can be used. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. The combination treatment of cortisone injections and orthotics can be a very successful form of treatment. If, however, there is significant damage to the nerve, then failure to this treatment can occur.
When there is significant permanent nerve damage, the patient is left with two choices: decompression of the neuroma thru a minimally  invasive nerve decompression technique such as EDIN Endoscopic Decompression Intermetatarsal Nerve or the MIND Minimally Invasive Nerve Decompression Procedure with the Koby ISOGARD, or surgical removal of the nerve. Most of my patients choose decompression of the nerve rather than surgical excision as a first procedure, as this is 80-85% successful.
RECURRENT STUMP NEUROMA OR ENTRAPMENT NEUROPATHY FROM A FAILED MORTON’S NEUROMA SURGERY
Dr. Parker has advanced training under Dr. Lee Dellon, a full professor at John's Hopkins School of Medicine and Director of the Institute for Peripheral Nerve Surgery in Baltimore, in the repair of failed Morton's Neuromas (known as Stump Neuromas or Entrapment Neuromas). He is also a charter member of The Fellowship Group for Lower Extremity Peripheral Nerve Surgery. The subjective outcomes of the society include relief of pain, restoration of sensation and decrease in medication.
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