My best practices for neuroma pain (part 3 of 3)

Neuroma and Forefoot Pain  (Heel Pain)      Part 3  of   3

What about my heel pain?

The treatment of heel pain with cryo-neurolysis is also becoming more and more popular. This is because of the common involvement of a small branch nerve that comes down the medial aspect of the heel and runs directly under or adjacent to the heel spur. This is commonly referred to as Baxter’s nerve. Involvement of baxters nerve can be due to the swelling of the surrounding tissues from a chronically inflamed plantar fascia.  To diagnosis this condition, I simply press on the inside of the heel, attempting to locate an area that is tender, and occasionally creates a radiating burning sensation. It is interesting to note that oftentimes patient’s that are nonresponsive to conventional plantar fasciitis treatments have this  additional condition that goes undiagnosed.   Diagnosis is easy,  after palpating the nerve,  I inject as little as 1/4 cc of lidocaine directly over the nerve on this side of the heel and wait approximately 30 seconds.   A conclusive test is when patient is able to actually stand up and say there is no more pain.

In regard to plantar fasciitis and Baxters neuroma I am often surprised at the reactions of my patients when I tell them that these inflammatory conditions are often the cause or the effect of other inflammatory conditions within the vicinity of the inflammation. For instance, as I said before, a neuroma of an interspace (forefoot) can often create or be seen with a capsulitis of the metatarsal head forming near that interspace.  A capsulitis or even a stress fracture can be the result of compensation / inflammation from an existing neuroma.  The point here is that the foot is a weight bearing structure and when one problem exists, another may also exist in the same location.  This can be due to compensation (walking differently) or simply inflammation of anatomical structures that are functionally related or simply exist near enough to the original problem to create additional problems.

In the case of heel pain, we do a similar chicken egg question.  What came first, the fasciitis or the neuritis?  The important concept here is that everything is not always cut and dry when it comes to your feet.  But if I can explain to you the variables and you understand these, then we can work together and solve your problems quickly, efficiently, and comfortably.

Before you consider having conventional neuroma surgery or  getting conventional conservative neuroma treatment which often involves the use of cortisone shots and bulky padding with extensive periods of convalescence, I invite you to review  the above concepts.   After your review,  weigh all of these options  against my initial promise of finding the best ways to treat common problems with the least amount of pain and surgical risk to see which best fulfills that promise.

Dr. H

My best practices for Neuroma Pain (part 2/3)

Neuroma and Forefoot Pain       Part 2  of   3

Here’s what’s going on youtube: http://www.youtube.com/user/drmilo1121?feature=mhum#p/a/u/0/TIaC1ugEV8U

I was never very happy about the historical approach to neuroma, which is to surgically remove the nerve.  For years I used decompression techniques which involved releasing the ligament connecting the metatarsals which is responsible for most of the pressure on the nerve. Release of this ligament was successful without cutting the nerve.   Decompression or release of the nerve is also finding popularity in the treatment of diabetic neuropathy where literally all of the  major nerves  to the foot are examined and carefully decompressed. So ligamentous decompression, performed with a very small incision, has been a great option that’s been successful for years.  You might be asking:  What is the effect of cutting a ligament that joins the metatarsal heads?  The answer is, usually only a small increase in the distance between the two metatarsal heads.  But why change the structural anatomy of the foot if you don’t have to?  So we next need to look at treating just the nerve itself.

Approximately 5 years ago,  techniques directly treating the nerve proximal to the actual neuroma started to become popular. One such technique is the sterile alcohol injection. This injection is performed with a 4% sterile alcohol solution  in Marcaine. Repeated injections are utilized and have a lasting effect on the myelin sheath of the nerve. The success of these injections  are even more well-documented  when a diagnostic ultrasound is used to guide the injection medication directly adjacent to the nerve. As with any injection technique, practice and refinement of technique are invaluable tools to keep patient’s comfortable and happy. To make these injections very comfortable for the patient,  we used a small anesthetic block prior to the injection.  The number of injections given is variable but usually between  5 and 7 and occur 2 weeks apart. Additional injections  are considered if the patient(’)s response is encouraging but not complete. Additionally, raising the concentration of the percentage of alcohol from 4% to 8% or even 12% can be helpful.

My personal success with sterile alcohol injections is well documented in a  book of success stories that we’ve been keeping for a number of years.   The one  problem with these injections is that it may take  3 or 4 injections before patients obtain relief. For this reason, I commonly implement a single additional procedure that is performed early in the treatment called  cryo  surgery.

Cryo-Neurolysis

Cryo-Neurolysis  is the process of freezing a nerve branch in order to desensitize the nerve. This process  has been in use for decades and has documented success. With the use of a good diagnostic ultrasound machine, the probe conducting the cryo-neurolytic agent, usually CO2 or N20  is placed directly adjacent to the  pathologic nerve. I commonly perform these procedures on patients with Morton’s neuroma that are undergoing a series of sterile alcohol injections. The reason that I like to perform BOTH of these procedures is because the cryo-procedure is consistent and works  quickly, but the anesthetic effect is sometimes not lasting due to the fact that cryosurgery does not permanently damage or destroy nerve tissue. I often like to paint a picture of going outside in minus 50 degree temperatures and touching  your tongue  to a metal pole. Of course your tongue  will freeze to the pole until there was a thaw.    After  the thaw,  your tongue  would actually lose sensation and ability to taste on the portion that made  contact with the pole.   So in essence, cryotherapy provides a fast way to obtain relief of very painful Morton’s neuroma without a very large incision or the risk of  stump neuroma.   In fact, the incision is so small that you don’t even need a stitch.  What’s even more encouraging is that patients actually go on hikes the day after the procedure and are completely pain free.  While this is not always the post op course, it is fair to say that you can work out the very next day in over 90% of the cases.  When we follow this with a series of sterile alcohol injections, we can complete the process and create a lasting cure.

My best practices for Neuroma Pain (part 1/3)

NEUROMA AND FOREFOOT PAIN      Part 1  of  3

Based on my opinion and professional experience.

Everybody wants solutions that are fast, painless, and have a high success rate. This statement is true regardless of whether or not we are talking about a medical problem, a social problem, or even a mathematical problem. One of the reasons  I am excited about this blog, is that for the first time, I can address a large number of people with what I believe are the latest and greatest solutions for painful foot problems.

As you read this blog,  I know you’ll find one reoccurring  theme, and that is, what works for you more than likely works for me too.   I am constantly putting myself in my patients “shoes”,   and asking myself just how I  would like to be treated by a Podiatrist given the pace of my life, my time commitments and my desire for great, lasting results.

During my 25 years as a DPM, I have noted there are two types of patients.  The first type is extremely body conscious and will see a  doctor  for just about any ache or pain. The second type of patient would no sooner go see a doctor than sit on a cactus. The second group usually wait until the pain is intolerable and it is often too late for  conservative treatments and additional convalescence.   Patients hate to miss workouts and are often unwilling to use crutches or wear walking boots.  My goal is to consistently provide  treatments that not only get patients better at a low cost and without pain,  but to follow up these cures  with usable programs and advice  that will keep them healthier than before they saw me.   If this sounds too much like propaganda,   then I invite you to take a look at my program for strengthening feet using minimalist footwear.    Ahhhh  but that’s another talk I will save for next week.

So lets talk about your neuroma (nerve pain).

It seems like there are more cases of neuroma pain lately.  This is possibly due to more  people getting active,  changes in footwear design,  or even a higher consciousness of the problem.  Regardless of why people are seeking treatment for this common foot problem, I am sure people are interested in what the latest treatments are for these painful nerve conditions.

What is a neuroma?  Well most people don’t know that a neuroma is simply a benign nerve tumor caused by pressure of the surrounding soft tissues.  A swelling of the nerve will lead to aching, numbness, tingling and shooting pain that often radiates into the toes.

Pushing the nerve and squeezing the metatarsals can create a click or pop as the thick nerve is attempting to find space.  If pain accompanies this “pop”, we refer to this as a positive mulders sign and this helps with the diagnostic process.  Diagnosis gets trickier when multiple problems are occurring in the foot at the same time.  For instance, a neuroma can occur with another inflammatory forefoot condition called capsulitis.  Capsulitis is an inflammation of the joint capsule surrounding a metatarsal head.  So diagnosis is often the key to getting the treatment right.

In a few days I will post what I promised  – How I treat neuroma pain.  This is information that you can use if you have forefoot pain OR heel pain.

Dr. H

Having foot pain? Ask the Podiatrist.

Welcome to my new blog! My goal is to be a resource for your foot problems, from bunions and hammertoes to those discolored nails. I want to help, post your questions or concerns.

Thank you,
Dr. Michael Horwitz