Neuromas

What is a Neuroma?

A Neuroma (pronounced new-roma) is a tumor of a nerve branch. When these tumors occur in the foot, they are usually found in the area between the toes. When the nerve becomes irritated, it starts to enlarge. This enlargement is due to the accumulation of a fibrous coating around the nerve as a means of protection from the pressure. consequently, as it increases in size, it gets even more pressure. When we look at the anatomy of the foot and ankle, we see that the larger nerve branches travel behind the ankle and enter the bottom of the foot near the arch. The larger branches then subdivide and the smaller branches extend between the metatarsal bones (the long bones behind the toes) and continue toward the toes. Each branch then further divides into two branches and each goes into a neighboring toe. As an example, the nerve branch between the second and third metatarsal bones divides and one branch goes into the second toe and the other goes into the third toe. The pressure usually occurs between and just behind neighboring toes. This leads to the formation of the fibrous tumor.

As the neuroma develops, the patient will notice a variety of symptoms. Because nerve pain can be unpredictable, the patient will relate symptoms including but not limited to tingling, burning, numbness in the neighboring toes, electric shooting into the tips of the toes, a swollen feeling in the toes, the sensation of walking on a wrinkled sock or a wad of tissue paper in the shoe, the feeling of walking on a marble or generalized achy pain in the ball of the foot. Some patients relate no pain, but have an irritating sensation of a clicking or popping sensation in the ball of the foot. This is caused by the enlarged nerve moving back and forth between the bones.

Conservative treatment of Neuromas are similar to treatments for Plantar Fasciitis, that is, sensible supportive shoes, custom orthotics, anti-inflammatories both over-the-counter and prescription, injections of cortisone, etc. When these modes of treatment fail to bring adequate relief, surgical intervention may be necessary.

Conventional surgical treatment for the Neuroma is to make a one and a half to two inch incision on the top of the foot extending back from between the toes. The tissues are separated and the nerve is visualized on the bottom of the foot. The enlarged section is identified, separated from the surrounding soft tissues and the enlarged section of nerve is cut out. The healing time from this procedure varies from just a few days to as much as six weeks depending on swelling after surgery, type of work and the amount of standing and walking the patient is required to do.

There are now newer procedures to address the problem. The new thought leans more toward nerve preservation rather than permanent destruction. Technological advancement has allowed for nerve visualization through very tiny incisions. Advanced instrumentation is allowing for nerve handling through these small incisions with minimal scar tissue formation and minimal time to full healing. We can now decompress the nerve in the area of compression (a more temporary treatment option). With this procedure, there can be some loss of stability of the metatarsal bones and other symptoms may arise.

Cryoanalgesia(cryo) has a very high success rate (higher than 95%) with most patients seeing complete resolution of symptoms that is usually permanent. It uses advanced Digital Ultrasound guidance of the cryoprobe onto the nerve in the area of injury through a very tiny incision. The procedure is performed under local anesthesia in the office. The procedure takes anywhere from six to twelve minutes to perform. Most patients can resume full activity level in three days. Most athletes can resume running/training within a week or two of the procedure.

Click here to view a presentation of a lecture given by Dr. Rampertab on the risks and benefits of Cryoanalgesia of Morton's Neuroma vs. Open Surgical Excision.

For Heel Pain and Neuroma Pain- Cortisone injection or UltraCryo (Cryoanalgesia)?

Given the extremely high rate of complete pain relief seen in UltraCryo and the ease with which patients tolerate the procedure, Dr. Rampertab offers UltraCryo as an option for treatment early in the treatment course. Cortisone injections have many side effects, especially when there are several injections in the same area. These side effects include but are not limited to loss of fat and fibrofatty tissue, localized bone loss, water retention, hyperactivity, abnormalities in blood sugar control in Diabetics, etc. The loss of fat padding can actually worsen the symptoms seen in Plantar Fasciitis and Neuromas. For more on this, visit the section "What are the side effects commonly associated with cortisone injections?"

In Plantar Fasciitis, the heel pain is actually from the tearing/repairing of the ligament causing localized inflammation. There is an area of inflammatory tissues around the site of injury and this is the source of pain when the patient steps down on the heel in the morning or after sitting for a while. When repeated cortisone injections cause Fat Pad Atrophy, there is less padding around the heel bone. This causes even more pressure on the area of inflamed tissues. Additionally, as we walk the heel bone has a lot of pressure and impact on it with every step. The fat padding around it acts to absorb the shock. When there is atrophy of that padding, there is more shock into the heel bone. This commonly leads to bone pain in the heel and less commonly leads to fracture or stress fracture of the heel bone. These are much more difficult conditions to treat.

As for Neuroma pain, this is due to inflammation of the nerve as it courses between the bones. With inflammation comes enlargement of the nerve. With repeated cortisone injections, we will see atrophy of the tissues between the bones. This leads to less cushioning of the enlarged nerve and more continuous pain.

As one can plainly see, the temporary pain relief of a cortisone injection is not worth the long-term adverse effects associated. Dr. Rampertab tries to avoid these adverse effects by offering real pain relief without bad side effects. At azcryo, Dr. Rampertab has over 97% success rate with UltraCryo. That means that over 97% of patients got complete relief of their original symptoms. This is not partial relief. These patients were not almost pain-free. They no longer had any of their original symptoms. As for the procedure, it hurts as much or less than having a cortisone injection. The only real pain associated with the procedure is the first local anesthetic injection. The second injection does not hurt because the area is already numb. As the procedure (freezing of the nerves) is performed, there is rarely pain. Less than 10 out of almost 4000 patients said they felt any pain from the procedure. There is a very short, uncomplicated post-op period and the patient is back to full activity in 2-3 days. They are back to light exercise in a week. When a procedure is this successful and this well-tolerated, why would anyone deal with the possible side effects of cortisone injections? The answer is plain to see-UltraCryo brings more long-term pain relief than cortisone injections without the bad side effects.