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.
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