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Neuroma Modifications. Domes or cutouts?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Sep 25, 2008.

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    I have been working, of late, with a Pod Surgeon who has a rather different take on the treatment of neuromas.

    Their approach is to apply a 14mm scf medial heel wedge to pre met and a 14mm cavity pad under a freelan around the painful area (offloading it) for all clinically diagnosed neuromas.

    This is somewhat contrary to what i have been using and comes with no particular rationale other than that he has been using it for many, many years and claims around a 95% success rate with it (anecdotally). A big claim.

    He is very keen that i adopt this method for all neuromas where we share care. I have significant misgivings! is this something anyone else has used / come across in your travels?

    Your thoughts are appreciated!

  2. Atlas

    Atlas Well-Known Member

    Don't you love the recipe book?

    Patient has this problem. Go to page 15 and there is the solution.

    Whilst conceding that clinical patterns exist, musculo-skeletal conditions from the neck to the foot can appear similar, but in fact respond to very different interventions (episode to episode; patient to patient).

    No harm in trying it I guess, and the ultimate pudding-proof will be patient function and symptoms; not what you, or I, or the pod surgeon thinks.

    Physiotherapist (Masters) & Podiatrist
  3. NO:mad:

    I always treat the neuroma as the symptom and vary the prescription depending on the cause!

    But like you say, i'm willing to try so long as i don't think it will do harm. Because 14mm is a LOT of rearfoot posting!

  4. Admin2

    Admin2 Administrator Staff Member

  5. Griff

    Griff Moderator

    Hi Robert,

    It may just be because its friday afternoon, but I am struggling to visualise this design - any chance of a Smith-Kirby-esque doodle of it or maybe a digital photo? Am I right in my understanding it is a 3/4 length varus wedge of 14mm, with a 14mm cavity pad ontop of this and sub symptomatic region??

    Many Thanks

  6. Jeremy Long

    Jeremy Long Active Member

    Although this design may have a history of success for this provider, it certainly sounds awkward. To me, there are considerably more efficacious options available that will permit greater flexibility in associated footwear.
  7. Robert,
    A 14 mm pad from heel to forefoot applied unilaterally sounds like a recipe for limb length discrepancy to me. In my experience the vast majority of neuroma's are associated with excessive lateral compression from footwear, if we put a 14mm pad + the Frelan insole (do people still use these?) into the shoe is this likely to cause more or less compression of the forefoot from the shoe upper?

    In the past, I've tinkered with various orthoses modifications for neuroma, some of which appeared to work some of the time in some of the people. As a side note, I was around the Northampton School of Podiatry when Tim Kilmartin did a trial of cobra pads versus reverse cobra pads in the treatment of Morton's neuroma, as I recall it didn't make any difference to outcome- but I can't recall if this was ever published???

    To be honest, at the moment I tend to advise on wider footwear and send them for a steroid injection from my friendly neighbourhood extended scope physio- £14 GBP :cool:. Outcomes so far are probably better than I've obtained from orthoses therapy in isolation ££££? Patient happy = me happy.

    I'll try and find a reference for that Kilmartin study.
    Last edited: Sep 28, 2008
  8. Thanks Simon! interesting information.

    I'll snap a picture this pm and get it up on forum tomorrow hopefully.

    I really can't understand the prescription. I like to have either deductive evidence or inductive evidence for anything i use and it troubles me that i have neither here!

    However we shall see.

  9. pgcarter

    pgcarter Well-Known Member

    Sometimes you can trigger pain with particular forces, giving you a hint about what you need to limit or enhance with your underfoot device.....have you tried that? They are not all the same and do not all respond the same........so what logic is there in using the same treatment all the time?
    regards Phill
  10. Robert:

    My treatment of intermetatarsal neuromas consists of a few therapies that tend to work quite well for most patients:

    1. Make certain the patient is wearing no shoes that compress the metatarsal heads and digits from medial to lateral. This means, don't believe your patient when they tell
    2. Use over-the-counter or preferably a custom casted foot orthosis with a metatarsal pad on the dorsal orthosis plate with the free end of the metatarsal pad hanging 15 mm off the anterior edge of the orthosis.

    3. Use 1 to 3 cortisone injections around the area of the neuroma to reduce inflammation and scarring around the neuroma.

    4. When #1-#3 fails, I perform neuroma excision surgery from a dorsal approach that is very successful in nearly all patients.

    Unfortunately, most women wear shoes that do not meet the criteria of #1 and this is quite a difficult monetary and psychological battle to get them to understand that unless they stop wearing their tight shoes that their neuroma pain will not resolve. I take time to explain to them that their neuroma is a space-occupying lesion that becomes sensitized by excessive compression forces acting on their sensitized neuroma from their tight shoes or abnormal foot biomechanics.

    Many times I simply tell them that should wear running or jogging shoes to work (and I write them a prescription to their employer to allow them to do so) and at home for two weeks and will offer them nothing else for treatment just so that they can see how much mechanical effect their improper shoes have on the production of their neuroma symptoms. Even though most of them are sceptical at first, nearly all of them are "singing my praises" after their two week trial of running shoes that have given them 75+% relief of their neuroma symptoms.

    Hope this helps.
  11. David Smith

    David Smith Well-Known Member

    Ah! Ron, Now your talking :good:

    Regards Dave
  12. Saw the thing in situ today. Actually made a kind of sense. The medial wedge extends to just pre met and the forefoot pad overlaps it. The forefoot pad is only 2-5 mets. So what it amounts to is a met dome which is higher behind the mets with quite a small cutout directly under the painful area.

    Still have doubts about a 14mm heel wedge though!

    Interesting other replies. Re steroid injections, which are obviously effective in some cases, how does that work if it is a neuroma? Obviously the neuroma is still present. Does this imply that the pain with a neuroma is caused by inflamation around the neuroma? Will the neuroma cause pain again when the steroid wears off?

    I'd also be interested to know how people differentiate clinically between IM pain on palpation caused by a neuroma from IM pain caused by an ID capsulitis, strained IM ligament, lubricle sprain etc etc. Because it stikes me that if an anti-inflamatory injection works well it suggests an inflamatory pathology. How many Dxs of neuroma are actually something ending in "itis" (including neuritis)

    Kind Regards
  13. Robert, my view: neuroma = space occupying lump caused /made worse by lateral compression, more inflammation = more swelling = bigger lump = more compression= vicious cycle; steroid = reduced inflammation = reduced swelling = reduce size of lump = reduced compression + wider shoes = cycle broken. Just a hypothesis. Also don't inflammatory mediators = nerve sensitisation?

    In addition to looking at history, manual testing of muscles, capsular patterns etc. I usually have diagnostic ultrasound to confirm, but the steroid scatter gun approach will often work.
  14. David Smith

    David Smith Well-Known Member


    Yes my old SAAB had one of those when the oil pump blocked and sent the big ends into complete seizure - Nasty.

    LoL Dave

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