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Neuroma treatments??

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bartypb, Feb 3, 2012.

  1. And finally, before I go to bed, I had a teacher once who told me that just because a patient has a positive Mulder's sign does not also mean that they have a neuroma. It may simply mean their metatarsal pain is being caused by another structure, not a neuroma, and they also have some other soft tissue structure that is mimicking the "palpable click" of a Mulder's sign when the maneuver is performed. If the symptoms are neurologic in nature (i.e. burning, cramping, partial anesthesia in plantar interdigital nerve distribution), then also consider that they have a plantar capsulitis or plantar plate tear that, because of its local edema, is irritating the intermetatarsal nerve enough to cause "neuroma-like" symptoms.

    I just chuck that out there. You know, for fun like.
     
  2. I hate to get involved in this one since you all appear to be having so much fun.:boxing:

    First of all, I agree with Steve that intermetatarsal neuromas are very distinctive and real pathologies that 1) you cannot "burst" by hitting it (they feel rubbery, almost like a small piece of rubber tubing), and 2) the well-trained foot surgeon should not mistake an intermetatarsal neuroma for some other pathology since intermetatarsal neuromas are continuous with the plantar digital nerves distally and the intermetatarsal nerves proximally (i.e. they aren't isolated away from the nerve, they are a thickened portion of the plantar intermetatarsal nerve). In addition, I have never gone in to excise a suspected neuroma and not found an enlarged nerve/neuroma. Intermetatarsal neuromas can be easily palpated once the clinician knows how to correctly perform the maneuver (Mulder's sign).

    That being said, I know of a surgeon who took out a normal nerve from between the metatarsals, the pathologist read the specimen as "normal nerve", then the surgeon called the pathologist on the phone and told him to change his pathology report or he was taking all his surgeries to another hospital or making sure that pathologist was to never do any more of his pathology studies. Amazingly, the "normal nerve" became "consistent with intermetatarsal neuroma" on the new pathology report. True story.

    I try to not do neuroma surgery since I will always try to treat them conservatively at first. However, when I have done intermetatarsal neuroma surgeries, they seem to work quite well about 80-90% of the time. In fact, I had a male patient that came to see me two months ago that I performed left foot 3rd intermetatarsal space neuroma surgery on 24 years prior and he said he never had pain from the neuroma since. That was pretty cool for me to see.......but also had me realizing just how old I am and how long I have been doing this podiatry thing.:cool:
     
  3. Stanley

    Stanley Well-Known Member

    Simon,

    To perform strain counter strain, you first friction (rub) the origin and the insertion towards the center of the muscle about 10 times. Then move the joint to shorten the muscle length and separate the fibers in the muscle belly towards the origin and insertion. To do this just press in with two fingers which are touching each other in the middle of the muscle belly and then separate the fingers. Hold this for about 30 seconds.

    To perform reverse strain counter strain, you first friction (rub) the origin and the insertion away from the center of the muscle about 10 times. Then move the joint to lengthen the muscle length and separate the fibers in the muscle belly away from the origin and insertion. To do this just press in with two fingers in the middle of the muscle belly, that are about an inch apart, and then bring the fingers together. Hold this for about 30 seconds.

    For the plantar interossei involved for a second interspace neuroma, I would work on the plantar interossei on the third metatarsal. The origin is on the plantar medial of the proximal metaphyseal region. The insertion is the medial plantar base of the proximal phalanx of the third toe.

    Regards,

    Stanley
     
  4. musmed

    musmed Active Member

    Dear Peter
    In the world if instant gratification, you will not see any changes. Re look about 4 to 6 weeks after doing your work and see what happens.

    The same thing happens to the abd hall when it has a trigger point. The muscle changes colour and has a cross section reduction of 14% on average. This change took 6+ weeks to be seen.

    Also when you insert a metal object into tissues, nor adrenaline and substance P is immediately deactivated Prof Bogduk Newcastle NSW Uni)

    Regards
    Paul Conneely
    www.musmed.com.au
     
  5. As I said, I'm unconvinced that Mulders sign = neuroma. ;). And the guy who told me that had very nearly as much experience as you Kevin!
     
  6. Peter

    Peter Well-Known Member



    I have re-scanned many pts (and re-injected I hasten to add) after undertaking a US guided intra-lesional neuroma/bursitis injection in the interspace, and still seen evidence of an intact lesion, so with respect Paul, I disagree. How can you deflate a neuroma?
     
  7. When it is not a neuroma
     
  8. By calling it a cyst. :-?
     
  9. Good point :rolleyes:.
     
  10. Peter

    Peter Well-Known Member

    I didn't intend to call it a cyst, but used the phrase as a potential alternative Dx pre histopathological examination. I should engage my brain more before typing on a keyboard.
     
  11. Thanks Stanley. Just not sure how you can do this to the plantar interossei when they are deep to so much more anatomy and only palpable at their insertions?
     
  12. So, do you ever get pathology reports which state normal adipose or normal fatty tissue when you send off a neuroma?
     
  13. Stanley

    Stanley Well-Known Member

    Simon,

    This all depends on the pathologist at the hospital. Some can only tell malignancy from non malignancy.

    I once had a path report come back as Morton's neuroma. The only problem was I took out a mass from the dorsum of the foot overlying the middle cuneiform.

    On the other hand at another hospital, i get more accurate reports.

    Regards,

    Stanley
     
  14. drsarbes

    drsarbes Well-Known Member

    Mulder's sign:

    Is it pathognomonic?

    Perhaps the confusion arises in that there are "clicks" and palpable "snaps, crackles and or pops" when one performs a test for a Mulder's sign that may not be a neuroma.

    OK.

    That being said, I will go on record here (is someone taking notes?) that to an experienced clinician these NON neuroma "clicks" are quite distinctive and easily distinguished from a neuroma.

    Sometimes I feel these threads regress with subsequent postings rather than moving forward.
    The histology of neuromas is well established.
    The diagnosis "should" be relatively easy.
    Treatment...that's another thing.

    Are we artists or scientists?

    Steve
     
  15. I agree with your sentiments Steve to your question I would answer a fair bit of Both
     
  16. I read something quite amusing the other day.

    Sometimes its helpful to take a look back over what we think we know. Bear with us Steve. Some of us are not so accomplished as you and like to work up a notch at a time:drinks. Its a biomechanical mindset thing I think. My biomechanical understanding is obliterated and born anew every few months.

    Out of interest, what were your thoughts on the study I cited?
     
  17. Having done foot surgery now for some time now, and knowing that many of you are not surgically trained in excising intermetarsal neuromas and have not seen a neuroma from the vantage point that one has when surgically excising them, there is something to be said for surgical experience when treating pathologies, such as intermetatarsal neuromas.

    What do I mean by surgical experience? I mean that you have closely observed the anatomical variances that occur with intermetarsal neuromas, their different shapes, sizes, and positions relative to the metatarsals and deep intermetatarsal ligament. It means that you are able to actualy see the neuroma pop up from between the metatarsal heads/digits when plantar pressure is applied to the plantar interspace area (reproducing the Mulder's sign). It means that as a surgeon you have been able to pick up the neuroma and feel its rubbery consistency between your fingers.

    All of these observations, especially when made on a regular basis year after year, will give the podiatrist that does foot surgery a certain level of confidence in diagnosing and understanding the biomechanics of these entities that would probably be difficult to obtain without the experience of seeing these pathologies on an "up close and personal" basis with surgical excision.

    Unfortunately, too much confidence from a surgeon, just because he/she is a surgeon, can also be a negative factor when surgical methods of treatment are given as first choice for the patient treatment rather than more conservative methods of treatment....but that's a whole other story.:drinks
     

  18. And therein lies a nice little prospective study... do we have any data regarding the validity, reliability or sensitivity of the Mulders click test? How frequently does a surgeon open up a foot to find that there is no neuroma to excise? (Hence we get lumps of fat being biopsied) This must have been relatively more frequent prior to the more widespread use of diagnostic ultrasound and other modern imaging, but its got to still happen today... hence my question: how many times do you get a pathology report that says "normal fatty tissue"? If you've opened it up, I suppose you might as well remove something.:rolleyes: I know what I saw with my own eyes: a whole stack of pathology reports for neurectomies and an awful lot of them saying "normal fatty tissue". We can blame the pathologist, but I don't believe for one minute that all podiatric surgeons sensitivity to spotting a neuroma is/ was 100% via the Mulders click test. There had/ has to be some false positives. Unless of course the Mulders click test is 100% sensitive. For the record (and please take notes), it isn't.

    Here we have 2% that didn't have positive Mulders click but did have a neuroma http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=247481&postcount=10 How many do have a positive Mulders click but don't have a neuroma? Show me the biopsy results from that study...

    Experience is everything Kevin, but how does one gain the experience? Via trial and error.:drinks The days of pretending surgeons don't make mistakes are long since over, at least here in the UK. I used to have a sticker on one of the grinders in the orthotics lab at the University which came from the magazine "Loaded" http://en.wikipedia.org/wiki/Loaded_(magazine) . It had Dr Mick http://en.wikipedia.org/wiki/Mick_Bunnage saying: "malpractice makes perfect". It was stuck on the grinder for a reason. But that was in the days before an anatomy lab was deemed unnecessary because you could "learn it via models and computer simulations". Never mind.
     
  19. Or indeed if a "normal" nerve removed from a control foot has the same histological appearance as a painful one, what use the reports?

    Whatever.

    I suspect Kevin is right, having a rummage around inside someone is bound to give you a better understanding than not. But I also think it is naive to assume
    And thats what worries me about the idea that 100% of feet opened have neuromas.

    I bet if we opened up all painful heels, we'd find spurs...
     
  20. Yep, that'll throw a spanner in the works. Like to see you get that one past ethics though...

    You've got about as much chance of finding Harry Rednapp guilty of tax evasion, when he has set up bank accounts in the name of his dogs and had tens of thousands of pounds transferred there, with the verdict being delivered two hours after the manager of England resigns... Never going to happen. The man is clearly not guilty as was found by the jury.

    Dr S. K. Spooner (cursed with cynicism)
     
  21. And if we opened up unpainful heels we find....

    Best thread on here for ages by the way, and not a barefooter in sight.
     
  22. Simon:

    I have seen my share of people where the "neuromas" should never have been excised by surgeons. I suspect that neuroma excision surgery is overutilized by many podiatric surgeons and when this surgery is done incorrectly, then the patient may have more pain after surgery than before surgery. This is why I won't do any neuroma surgery unless sufficient conservative management is tried for some time before surgery is contemplated.

    In addition, just because the Mulder's sign is present, doesn't also mean that the neuroma is symptomatic and should be removed. There are plenty of enlarged intermetatarsal nerves that create a positive Mulder's sign that are asymptomatic. Another clinical test I use is to evaluate the light touch sensation between the plantar digits of the affected foot. Invariably, if the light touch sensation between the adjacent plantar digits of the suspected neuroma site is decreased, then that gives me increased confidence that there may be a neuroma in that site.

    And by the way, for all the intermetatarsal neuromas I see, I only do surgery on about 10% of them. Most of them become asymptomatic with appropriate conservative therapy and a change in shoes. However, for those that I do surgically excise, patients are generally very pleased with the results of the surgery. And, for all the neuromas I have excised over the past 28 years, I have never seen a pathology report come back that wasn't a neuroma.
     
  23. And ladies and gentlemen... that's why he's a star.
    :drinks

    But, I got to put this one to bed, since I remember reading these reports from a podiatric surgeons neurectomies which were frankly left lying around and have carried them as a concern ever since: how many of your biopsy reports come back saying normal adipose tissue, Kevin?
     
  24. Ian Harvey

    Ian Harvey Active Member

    I use positional release techniques followed by PNF for "neuromas" (which have been diagnosed as such by someone else). If this isn't successful I try acupuncture into the met space followed by PNF. This is almost always successful. The success of this approach tells me that a neuroma is probably not the cause of the pain, and my results support what other people are saying about using soft tissue techniques to cure "neuroma" pain. Sorry I can't supply stats on these claims, I just do it and it works most of the time.

    I suggest that a lot of "neuroma" pain is referred from intermet trigger points. This would explain why those using soft tissue and acupunture techniques have good results, and explain Clairoo's 87% success rate.

    Just an opinion based on experience.

    Regards,
    Ian.
     
  25. Can anyone refer me to a study where a "trigger point" has been identified on MRI scan, or any type of imaging, please?

    I do seem to recall a study published in Manual Therapy which noted that different clinicians couldn't agree on the location of "trigger points"... I'll see if I can find it.

    Maybe I was thinking of this one... http://www.sciencedirect.com/science/article/pii/S0304395996032484
     
  26. Ian Harvey

    Ian Harvey Active Member

    Hi Simon.
    I agree that "trigger points" is a term that is used a bit loosely. and perhaps I should use another term. Perhaps it is more accurate to say that a tender point exists between the mets, which it is possible to relieve by soft tissue techniques. If we can agree that tender points within muscles do exist, and that they can sometimes refer pain, then do you think that they would show up on imaging?

    I see possibly one presentation per month with neuroma like syptoms which have been diagnosed by another practitioner as a neuroma. Every so often the patient says that a scan has revealed a neuroma. Soft tissue techniques appear to work quite well. That is mine and others experience.

    I am not saying that painful neuromas don't exist, far from it, merely that mine and other's experience demonstrate that acupuncture and soft tissue treatments often work. These techniques are quick, simple and conservative and can be done in most clinics with a little training. I am surprised that they aren't the routine first choice of treatment for most neuroma like presentations.

    Regards,
    Ian.
     
  27. musmed

    musmed Active Member

    Dear Ian
    Here here!!

    Dr. Spooner, everyone has a CT, X-Ray MRI because of pain!
    No one has seen it yet because pain is made in your head.

    Regards
    EXtremely wet here
    100mm in 1 hour last night

    Paul Conneely
    www.musmed.com.au
     
  28. bob

    bob Active Member

    I would say never Simon. Mulder's test may be very sensitive, but I have some doubts about its specificity. Actually, that is not quite true. I believe that positive Mulder's clicks indicate an interdigital perineural fibroma (neuroma), but I can not be 100% sure that this lesion accounts for every bit of each patient's pain/ pathology. We remove a nerve (whether it is partly responsible for the pain, wholly or not at all) from a painful area and this generally results in a pain free area post-op. Is this because we have removed the only pathology (a neuroma) or is it necause we have removed innervation of another pathological area? I do not know. Ultrasounds scans and Mulder's clicks make me think that the thickened nerve is the problem and when I take them out the patient is more comfortable, so I assume the neuroma was the problem, but I am assuming x+y=z to an extent.

    I can not think of any false positive neuromas with Mulder's click. However, I have removed neuromas from patients who did not have a positive Mulder's click. I have never and have never seen anyone opening a foot up, finding nothing and removing a bit of adipose tissue. I have seen 'spacectomies' performed and this may account for your previous experience of these types of results.

    As far as histopathology reports showing adipose tissue - personally I have had a few, but never purely adipose tissue. As others have said, it will depend on your pathologist. It will also depend on your dissection. I dissect the nerve out as (I think) Steve said above. Occasionally, I may have excised some surrounding adipose tissue and dropped it into the pot along with the neuroma and the report comes back as neuroma & adipose tissue, but never adipose tissue alone.

    These things are easier to discuss on direct visualisation of the tissues. It would be worthwhile contacting your local podiatric surgery unit to spend some time seeing the anatomy. Cadaver dissections are OK, but I do not feel they are as helpful for seeing live anatomy as the real thing especially when looking at the intermetatarsal space. Steve's photo above is helpful, but if you can scrub a case it would be better to see and feel the click in action.
     
  29. Simon:

    Not a single one of my biopsy/pathology reports have come back saying "normal adipose tissue" after neuroma excision surgery. They have always said "diagnosis consistent with Morton's neuroma (intermetatarsal neuroma)".

    Careful dissection is required to do good neuroma surgery and I really can't see how any surgeon who knows what they were doing would be excising adipose tissue and thinking that it was a neuroma. I have yet to see adipose tissue that was connected to two interdigital nerves distally and one to two more proximal intermetatarsal nerve branches.

    Three other keys to successful neuroma surgery that I learned from Wilfred Laine, DPM, during my surgery residencey at the Veteran's Administration Hospital in Palo Alto, California in 1983-1984 and from Steven DeValentine, DPM, during my years of working with him in the late 1980s and early 1990s at Kaiser Hospital in South Sacramento are as follows:

    1. Cut the proximal intermetatarsal nerve as far back proximally as possible so that the end of the cut nerve is more under the midshaft level of the metatarsal, in a relatively non-weightbearing area of the plantar foot, so that the likelihood of nerve stump irritation is minimized postoperatively.

    2. Do meticulous dissection, avoiding the vascular structures in the area and, then before closing, let the tourniquet down for about 5-10 minutes to make sure that all bleeders have been coagulated or tied off before the incision is closed.

    3. Have patient keep foot elevated above their heart for the first 48 hours after surgery to minimize postoperative bleeding into the surgical area to minimize the risk of postoperative scarring around the nerve stump.

    Thank goodness I had good teachers in my early years foot surgery.
     
  30. blinda

    blinda MVP

    Now, I`m no surgeon. But, I saw that big ass VP pre and post excision by Robert, and it was Hooooge. I was incredulous that surgery had been scheduled for this lady when the source of pain was so obvious.

    Something that a few orthopaedic surgeons could do well to consider, IMO

    Agreed. Thank you everyone :drinks
     
  31. Stop me if I'm being blonde here, but isn't that what this study showed?

    Or am I reading the abstract wrong.
     
  32. Kevin
    Indeed it doesn't mean that the click is present its caused by a neuroma. Could be another soft tissue structure mimicing it I suspect...
     
  33. Ian Harvey

    Ian Harvey Active Member

    Sounds like the neuroma contained the nerves which "witnessed" the actual pain, and the witness has been killed. Now the patient might still have whatever caused the pain, but simply can't feel it. Which suggests that conservative techniques should have been tried first.

    Podiatrists without surgical qualifications might defer to the orthotic option, but I suggest that other techniques like soft tissue and acupuncture make a lot of sense, and can be quicker and cheaper.

    Regards,
    Ian.
     
  34. Good question to ask - doesit hurts less when barefoot ?

    Ouch thje door hit me on the way out
     
  35. What is the definition of a "trigger point" and why should they be invisible?
    This is a close as i can find: http://www.ncbi.nlm.nih.gov/pubmed/1514891

    Edit: here is a nice review paper, if a little dated: http://terapiamanipulativa.com.br/Myofascial trigger points.pdf
     
  36. No seems you are right Robert, was that study performed in Sweden?;)
     
  37. bob

    bob Active Member

    You could be right Ian - this is something I have considered for years and have mentioned in my posts above. It is also possible that more than 1 local pathologies coexist and that by removing the pathologic nerve you are getting rid of pain in both.

    Just for clarity, I do not know of a single podiatric surgeon who offers surgery as a first line treatment for neuromas. The range of conservative options in the NHS is varied and does not extend to acupuncture in my area at least. 'First do no harm' is always the approach and orthopods are supposed to abide by this.

    Mulder's click forms part of making the diagnosis. It is not the only sign. Like every presenting pathology, a thorough history and physical examination and relevant diagnostic test(s) helps to form a reasonable diagnosis and treatment plan. There are few other structures in that part of the foot that would mimic a Mulder's click other than a fibrosed thickened nerve. If any of the surrounding anatomy was pathologic the patient's symptoms and your exam and tests generally indicate that it is not a neuroma.

    In my ever dwindling memory I can think of one case that had a click that was not a neuroma. Having said that the feel of the click was different to the usual Mulder's. The patient had seen the local podiatry department and orthopaedic unit for years. Their pain differed from the normal in that the foot was occasionally painful at rest, episodic localised swelling, some pain when barefoot, the usual burning radiating pain to the toes, a general feeling of 'fullness' and pain on squeezing the dorsal and plantar aspects of the right 3/4 intermetatarsal space. Mulder's click did not feel positive to me - sure there was a click, but the usual flicking feeling under your thumb when applying plantar pressure to the space was absent. The patient had tried a variety of shoes, orthotics, multiple injections by the othopod and ultrasound guided injections by his radiologist friend who also thought it was a neuroma on his scans. She had a very obvious Churchill sign on standing. Eventually she sought a second opinion and it didn't add up for me. I requested some bloods after doing a history on her and requested an ultrasound guided biopsy. This came back as a possible rheumatoid nodule and she had a positive anti CCP. When I excised and sent it off the pathologist reported that it had macroscopic and microscopic features of a rheumatoid nodule, by which time she was already booked to see rheumatology.

    I'm quite happy that the above turned out good for the patient and for me, but there will equally be cases where I may have miss-diagnosed pathologies myself. This is always a concern and motivates me to question a lot of the accepted wisdom that does not always equate with common sense. As said before - cutting what I believe to be a painful pathologic nerve out will deinnervate it's distal course where other pathology might coexist.
     
  38. blinda

    blinda MVP

    :butcher: You can go off a person, you know.
     
  39. Love those crazy swedes. Published in Oz, but I don't have the full text so don't know.

    I think this sort of thing could be called "doing a Tim" after THAT JHAV study. Bit of a fart in the jacuzi isn't it!
    Umm....

    LOOK, A SQUIRREL!!!
     
  40. G Flanagan

    G Flanagan Active Member

    In my experience the 3/4 IM space neuroma (true mortons) seem to do a lot better following surgery than the 2/3. I think many referrals for 2/3 neuroma's are actually adjacent mtpj capsultis +/- neuroma which seem to settle with treatment of the capsulitis.

    Many surgeons do indeed jump straight to surgery which is ridiculous, as Kevin mentioned, the majority will settle with APPROPRIATE conservative care.

    I think i've alluded to this years ago in a post but our path lab reports tend to come back as the following
    Fibrofatty tissue containing nerve fibres including Pacinian Corpuscles

    always found that odd as they are mostly present in skin?

    Never had them come back saying just adipose tissue as that would have meant that you would have missed the nerve completely when excising which i'm sure only a blind surgeon could do (i hope)
     
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