Dr. Mark H. Tompkins ● 4402 Vance Jackson, Suite #146 ● San Antonio, Texas 78230
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MORTON'S
NEUROMA
(INTERDIGITAL NERVE TUMOR)
by Dr. Mark H. Tompkins
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Morton's neuroma (MN) is an abnormal growth pattern that occurs within the
digital nerve(s) that run(s) between the third and fourth toes in either foot.
(Neuromas can occur between any toes with either foot, but most commonly occurs
between the third and fourth toes, and is referred to as a Morton's Neuroma.)
This abnormal growth leads to an enlargement of the nerve and is caused by many factors; including but not limited to, abnormal foot motion, abnormal growth patterns within individual foot bones, increased pressure from concomitant foot deformities (i.e. bunion, hammertoes, etc.) or weight/shoe factors, previous injury or pathology. This enlargement of the digital nerve that runs between the bones just behind your toes (metatarsal bones) causes irritation of the nerve tissue and a variety of symptoms occur. These symptoms may begin simply as a feeling of having your 'sock balled-up in your shoe' or something 'stuck between your toes'. The symptoms usually progress to periodic numbness and tingling and then, most commonly, burning pain between the toes. Untreated, the symptoms become more episodic in nature and lead to severe burning or shooting pains into the toes that occasionally can be relieved with removing the shoe gear and massaging the area. The pain associated with MN can become disabling, but more importantly, can alter shoe gear or gait patterns which can lead to other foot, knee, hip, and/or back problems.
Treatment for Morton's Neuroma Many/most patients with MN can be successfully treated with a combination of altered shoe wear, insert therapy, and cortisone injections. The key to successful treatment is early diagnosis and intervention. Many people with MN wait numerous months (and sometimes years) before seeking professional treatment. During this time, the nerve tumor increases in size and usually severity. Once the MN becomes at least 2-times its normal dimensions, many of the standard conservative treatments are not successful. Altered shoe wear varies from more supportive shoes such as tie vs. slip-ons, and athletic/walking-type shoes, to prescriptions shoes recommended/prescribed by a foot specialist. The men's and/or women's casual/dress shoe manufacturer I recommend most often is SAS (San Antonio Shoes).for more information visit www.1st-in-footwear.com/49/antonio-san-sas-shoes-texas.html . I refer patients to Roger Solers Sports for recommendations regarding athletic/running/walking shoes. For more information, visit www.rogersoler.com . These types of treatments are fairly successful in relatively mild cases of MN. Insert therapy can range from something as simple as an otc (over the counter) arch support to very expensive prescription orthotics. The type of insert necessary depends on the severity of the MN, the duration with which it has been present, and individual patient's needs. This type of treatment is fairly successful in relatively mild to moderate cases of MN. Cortisone-type injections have been the cornerstone of treatment for MN for many years. There are various combinations of corticosteroids and local anesthetics used for injection therapy. My preference is a combination of lidocaine, marcaine (local anesthetics) and either dexamethasone or triamcinolone (or both). I typically give a series of from one to three injections over a variable course of time depending upon individual patient response. This type of treatment is fairly successful in moderate to severe cases of MN, if patients get to a foot specialist within a reasonable period of time after the onset of symptoms. A relatively new and exciting treatment for moderate to severe cases of MN is Sclerotherapy. I recommend this type of treatment for moderate to severe cases of MN, which have been resistant to the aforementioned treatments or in cases where significant symptoms have been present for a number of years. Sclerosing Injection Treatments for Mortons Neuroma A new treatment protocol offered by Dr. Tompkins as of January of 2004. Sclerotherapy is a procedure which involves the injection of a sclerosing agent (causes scarring) into a particular area/site of the body. Sclerosing injections have been used for many years in the treatment of varicose veins, and also in the throat and liver. The adaptation of using a sclerosing agent in the treatment of MN was introduced by Dr. Dockery in 1999. The treatment involves a series of injections into the area proximal (in front of) the area of the actual nerve tumor itself. Sclerosing treatments for MN involve the use of a mixture of a local anesthetic called marcaine, and anhydrous alcohol. These two ingredients are combined to create a 4% alcohol solution. .5 cc's (one-half of a cc) is injected into the nerve a few centimers proximal to the tumor. The 4% alcohol solution creates sclerosis (scarring) within the nerve tissue which chemically inactivates the nerve. This prevents the transmission of the pain sensations that are associated with MN. There are a number of different protocols used in sclerosing treatments for MN. The protocol I currently utilize is a series of 5 bi-weekly injections. At the end of the 5th treatment, if the patient has had any noticeable improvement, anywhere from 7 to 10 (total) bi-weekly injections are given, depending on individual patient response. If there has been no improvement or response after 5 sclerosing treatments, I do not recommend any additional injections. These patients can either live with the pain/disability of the MN, or can contemplate surgical excision. The injections are given with an extremely small bore (27 gauge) needle into an area on the top of the patient's foot. Most patients find the injections are only minimally painful, with little to no side-effects. Occasionally (25% of injections) there can be a bit of bruising and/or some discomfort the next day or two. I typically put a special pad on the bottom of the foot after each treatment and ask the patient to do only normal walking for the next 48 hours. Since incorporating Sclerotherapy into my treatment regimen for moderate to severe cases of MN (Jan of 2004), I have been able to significantly reduce the number of surgical excisions necessary in my patient population, with very limited side-effects or complications. Sclerotherapy is not for every patient with MN, nor will every patient respond to this type of treatment. However, with the choice of either living with the pain and disability of MN, or electing to undergo surgical excision, I find this type of treatment to be an excellent alternative. If you feel you might have this very treatable podiatric problem, it is imperative that you seek professional treatment as soon as possible to ensure a successful outcome.
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