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the foot stuff

neuromas

Causes

A neuroma can occur anywhere in the body. It is simply an irritation/inflammation of a nerve, usually in an extremity and most commonly in the foot. The nerve that gets irritated is generally the interdigital nerve (between either the 2nd and 3rd toes, or the 3rd and 4th toes). This nerve originates in the spine and comes down the back of the leg, passes by the inside of the ankle and dives into the bottom of the foot, eventually splitting into numerous "digital" nerves that pass between the metatarsal heads. This is the location where the nerve gets compressed. There are many potential reasons why a nerve can get compressed. In the foot, it usually has to do with excess motion of the foot (i.e. - too much pronation) which leads to stretching of the nerve. Sometimes swelling can cause irritation to a nerve. The nerves in the feet can be extremely sensitive in some people - this can predispose one to develop neuromas.

Scenario

A patient comes to the office with the following symptoms: severe dull or aching pain in the ball of the foot, occasional numbness or tingling into the toes, symptoms are worse in dress shoes and with any type of weightbearing activity. Occasionally the pain is so severe that shoes must be taken off and the foot rubbed. This usually helps for a short time. The pain may extend back into the foot and occasionally up the leg. It often starts as a mild tingling in the toes and over time progresses to moderate or severe pain in the ball of the foot. The symptoms tend to come and go over time. Sometimes the toes will spread and a mass may be felt in the ball of the foot.

The typical foot type that develops neuromas is a high arch, flexible, pronated foot type. The high arch foot tends to have increased pressure under the ball of the foot and the nerves have to stretch slightly more than they do in an average arch. Also, the flexible, pronated foot tends to create more irritation to the nerves as they get stretched when the foot pronates (arch collapses). Any high impact activity, particular running and aerobics can also lead to excess stress through the ball of the foot and may lead to neuroma symptoms.

Treatment - try yourself

If you've been overactive, try resting. Stop the activity you've been doing, rest your feet as much as possible and do so for a few weeks. When you start up your activity again, do so slowly and watch for recurrence of symptoms.

Try other forms of exercise. This treatment approach can work for any foot problem simply because you are taking stress off your feet to allow the inflammation to subside. Swimming or cycling are excellent substitutes.

Massage the painful area with ice. This may help reduce inflammation. Once or twice a day for 20 minutes can be helpful.

Stretch your achilles tendon. After you've been walking around with pain in the ball of the foot, you will most likely end up with a tight calf muscle (because you will use the calf muscle to redistribute pressure off the ball) In the long run, a tight calf muscle will lead to increased pronation and increased pressure under the ball of the foot which will make the neuroma worse. To stretch the calf muscle, lean against a wall, shoes off, toes pointed in and very gently lean into the wall until you feel a gentle pull on the calf muscle. Hold it for several minutes. Do the stretch midday and later in the day and after exercise. Never stretch by hanging the foot off a stair or pushing the ball of the foot against the wall. This will over stretch the calf muscle and cause further injury (although it may feel good at the time).

Wear shoes with good arch support and heel counter support. Running shoes, hikers and some walking shoes are excellent choices. You will probably have to spend over $100 to get a good quality shoe. Don't shortchange yourself. Stay in supportive shoes as much as possible, especially walking around the house.

Avoid leather sole shoes with heels greater than 1/2" or pointy toes.

Treatment - see a podiatrist

Metatarsal (neuroma) pad - this is a simple approach that involves placing a moderate sized pad under the ball of the foot in a location that can spread the metatarsal heads slightly and create more space for the inflamed nerve. This usually works for minor symptoms only and often can make the pain worse or create new pain. It can be added to an existing orthotic, shoe insole or placed directly on the foot.

Low dye taping - this taping reduces pronation which in turn relieves stress on the plantar fascia. Often, inflammation will reduce immediately and pain will subside. Some people can get better with a series of 6 or 8 weekly tapings. If the taping helps and the pain recurs every time the tape comes off, this is an indication that custom orthotics would be useful.

Custom Foot orthotics - Many people who get neuromas in the feet have an underlying pronation problem. The fact that foot symptoms occurred is your body's way of telling you that something needs to be done. The best thing to do is to address the cause of the problem, which in many cases is over-pronation. The only way to effectively control excess foot pronation is with properly made custom orthotics - made from sitting casts of the feet and by a professional lab. A podiatrist generally provides the most expertise in this area.

If you have orthotics that are not helping, either (1) they were not made properly for your feet and they need to be remade, or (2) they need modifications, or (3) some other type of treatment needs to be undertaken.

Some people who get neuromas do so because of an episode of overuse. This can occur on a long walk, with a new activity or with improper shoes. If there is no underlying pronation problem the symptoms will clear up quickly with a little rest. Orthotics are not necessary in this situation.

Shoe evaluation - Certain types of shoes can make neuromas worse. Generally, leather soles and pointy toes will aggravate the inflamed nerve. Ski boots and any tight athletic foot wear will also make the symptoms worse. Even if your shoes feel comfortable it doesn't mean they're good for you. Generally, a very stable heel counter with a good arch support (unless you're wearing orthotics) and laces is preferable. If you have to dress up for work, certain types of shoes are better than others. Choosing the most effective shoe to wear can be very individual. If you are wearing orthotics to treat your plantar fasciitis, it is crucial that the orthotics fit and work properly in any shoes that you wear for standing or walking more than 30 minutes at a time.

Cortisone injection - As scary as it sounds, some people get immense relief with a steroid injection. This is usually reserved for people who are in intense pain and cannot walk, or people who have tried other conservative measures and had no relief. There are minor risks and side effects associated with any injection - it's worth a discussion with your podiatrist.

Massage therapy - your podiatrist or doctor may recognize the potential benefits of professional massage therapy. When the foot is in chronic pain, the small muscles will go into spasm. This creates tightening in the area of the neuroma. These small muscles can be massaged and this may provide some relief of symptoms. It will not usually alleviate the condition on its own however.

Foot roller - the least scientific and often a very useful daily maintenance approach. A wooden foot roller is used on and off during the day. It provides massage and increased blood flow to the small muscles in the foot and feels sooooooooooo good.

Acupuncture - this approach may be tried. Some people do not respond well. Best to discuss it with your podiatrist or general practitioner.

Surgery - is undertaken only if conservative options do not work. Usually the neuroma has become a large mass that can be felt in the foot and may cause spreading of the toes. Surgery removes the mass and can alleviate symptoms. Whenever nerves are cut, the body can overproduce scar tissue which may result in the same or worse symptoms after surgery. Also, once the nerve is cut, the toes and ball of the foot will be numb forever. This is a decision that must be made with alot of consideration with the help of a podiatric or orthopedic surgeon.

Final Note

Nerve pain can be quite disturbing. Since the nerve extends from the toes all the way up the leg and into the spine, don't be surprised if your symptoms move around alot. Once the neuroma is treated at its source, the symptoms should all subside. If you have high arches or a very flexible pronated foot you will possibly have occasional recurrence of your neuroma symptoms despite wearing custom orthotics and proper shoes. The symptoms should be easy to manage however; usually minor modifications to shoes and orthotics will alleviate neuroma symptoms.