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Neuroma treatments??

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

  1. bartypb

    bartypb Active Member

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    Hi everyone Just wondering what treatment modalities people use generally for mortons neuroma's I seem to have poor outcomes with met domes, shaft pads etc and nearly always end up injecting (below 6mm diameter) or referring for surgery, I hear people talking about addressing the biomechanics but does this really work? After all if there is a fibrous mass in a small area no matter what you do with mechanics its still going to cause pain right? I'd appreciate other clinicians ideas/comments???


  2. Admin2

    Admin2 Administrator Staff Member

  3. clairoo

    clairoo Member

    I have good outcomes with FFO +/- metatarsal pad. Also I find acupuncture a really effective way of pain relief. In house audit is 87% patients gain significant improvemnt. Sorry I have no reseach to back up.
  4. Are you saying acupuncture gives 87% of your patients positive results ?

    If so, care to explain how acupuncture reduces compression of the interdigital nerve ?
  5. drsarbes

    drsarbes Well-Known Member


    I have found over the years that it's very important to take an xray when evaluating neuromas. If there is very little intermetatarsal space (regardless of the cause, and there are several) I have not found conservative treatment very rewarding, especially long term.

  6. clairoo

    clairoo Member

    I'm not saying or suggesting that acupuncture reduces interdigital compression.My own very informal finding were that 87% of my patients have found acupuncture gave them significant pain relief, that's all. I usually use the acupuncture while my patients are waiting for our NHS lab to make the insoles ( if you are lucky 6 weeks is the return time :wacko:) I just think that it can and for me has offered a really useful tool while i am waiting for imaging results or insoles. I found this wee quote on the NICE guidelines:

    Research by the University of Regensburg has shown that acupuncture is one of the most effective therapies for back pain. The research published by Archives of Internal Medicine, showed that acupuncture can provide significantly more relief from lower back pain than conventional therapies. The Chinese needle treatment was 74% more likely to lead to a sustained reduction in pain or improved ability to function normally than physiotherapy, medication and advice on exercise.

    If it can offer pain relief in back pain, placebo or otherwise, why can't it help with
  7. drsarbes

    drsarbes Well-Known Member

    73% of all statistics are made up on the spot.

    Can I ask how many patients you treated and what scale you used for outcome measurements?
    What were the pretreatment diagnosis criteria?

    I think 87% is quite high, probably higher than my success for cortisone injections (just guesstimating from the million injections I've given for neuromas).

    What is your technique?
    I'd like to learn more.


  8. Stanley

    Stanley Well-Known Member

    Hi Colleagues,

    For Morton's neuroma, I used to make an orthotic that had a met dome plus an extension under the fifth metatarsal head. I had pretty good success with that.

    I now manipulate the 4th met-cuboid joint, and follow with friction of the plantar 4th met-cuboid ligament as my primary treatment. I will occasionally have to use the orthoses and even less often have to inject 4% ethanol.

    For the second interspace, I perform either strain-counterstrain or reverse strain counterstrain to the planter interossei

    A month ago I excised a neuroma in the second metatarsal which was 6mm in diameter. It was my first excision in about 15 years.


  9. We are disc ussing neuromas not back pain one is not linked to the other.

    You made a statement. I am calling you on it. Acupuncture may or may not work this is a topic for another thread.

    You make claims of an 87% success rate for neuromas using orthotics and acupuncture.

    Very high I so once again how does acupuncture reduce compression of the nerve ?
  10. Y'all Know how I feel about acupuncture. But c'mon, give the girl a break.

    She didn't say acupuncture reduced compression of the nerve and she didn't claim an 87% success rate. She said
    Which is not the same as an 87% success rate, nor is it to claim that it reduced IM compression. She specified good results for pain relief.

    And with respect mike, treatment of back pain with acupuncture IS linked to treatement of neuromas with acupuncture. By reason of the acupuncture. Neither condition is especially well understood and the mechanism of acupuncture is understood still less.

    It might just be that acupuncture is a **** hot placebo. But if your **** hot placebo gives significant pain relief in 87% of your clients, then the best of British luck to you! There is no shame in placebos provided they are not misrepresented.

    I'd be interested in the following:-

    • Where were the needles inserted?
    • Was the sample group treated with acupuncture alone or with combination therapy?
    • How were the neuromas diagnosed?

    Rip into acupuncture all you like! But lets not resort to straw men. There's no need!
  11. :drinks

    Well played sir!

    I would love to see people be a bit less knife happy with neuromas. I know people who diagnose them in almost everybody and whip them out at the drop of a consent form. And all too often, the patients end up worse off than they started!
  12. Significant reduction in pain is a success in my book

    alright Rob how do you reduce pain without reducing compression ?

    And not by using local either.

    My point was what is the mode of treatment that acupuncture has specific to neuromas, so back pain is not significant here unless the mode of treatment is the same.

    I leave it now
  13. drsarbes

    drsarbes Well-Known Member

    Hi Robert:

    "......And all too often, the patients end up worse off than they started!"

    I agree and don't agree (schizophrenic I guess). I agree that "perhaps" excision is suggested too quickly but I do not agree that the patients are frequently worse off. It's a fairly straight forward procedure and quick healing. The only additional factor that I see at times is the decreased intermetatarsal space, which should be corrected.

    I think patient's age, activity level, duration of symptoms, severity of symptoms, unilateral vs bilateral - these all come into play in deciding what Tx plan may be best.

    For instance: if I get a 20 something active patient with 1 year+ Hx of pain; with a collection of orthotics and Primary Care has given several cortisone injections - I'll suggest surgery. This patient does not want another orthotic or another injection.

    As far as non surgical Tx in patients with a palpable neuroma who seem to respond to acupuncture or manipulation, etc... I would be interested to know what the follow up is on these patients and why we are assuming that relief is long term, or even permanent. Just because a patient does not return to your clinic one cannot assume it's because they are "cured" -

  14. And in mine too. But it might not be in hers. World of difference between claiming pain reduction and claiming success. Paracetamol might give you pain reduction but thats not neccessarily the same.

    Well there's the rub! I have NO idea. But since pain is an entirely subjective measurement and a reduction in pain was reported, there obviously is a mechanism. Might be placebo. Might be something else. But I'm not going to assume that reduction in IM compression is the ONLY way to reduce pain.
    Which it could easily be! Especially if it is placebo. I don't know enough about acupuncture to say. Thats why I want to know where she stuck her needles.
  15. Stanley

    Stanley Well-Known Member

    Hi Steve,

    I agree, it is difficult to know if your therapy worked or you scare away a patient.
    I really can't tell you more than the patient leaves pain free and they tell me the foot feels right. Some of these patients I have seen for other problems later, and then I have a patient that I treated for 10 years with orthoses. He would come back when the materials compressed and I would bulk it up. The last time I saw him I manipulted his 4th met-cuboid joint and he hasn't been back . I would imagine he would have come back if there was a problem, as he had a 10 year track record of returning as needed.
    As far as the mechanism of neuromas, I think the cause is compression of the nerve from the metatarsals (the tight shoe history supports this). Lis Francs joint allows for dorsiflexion and abduction of the metatarsals. So if the 4th met is prevented from dorsiflexing, there is more compression on the nerve in the 3rd interspace. Plantar interossei muscles flex the proximal phanx in open kinetic chain, but in closed kinetic chain they lift the head of the metatarsal. This would also increase the size of the interspace. Also a met dome would have the same effect if the 4th met cuboid joint had enough compliance. I am not sure why an extension under the fifth met head would work, but it may have to do with the amount of pressure on the 4th ray and reflexive inhibition. I hpe this helps.

  16. I guess it depends on how and more to the point when the surgery is done! I'm convinced that a lot of the patients I see who get double neurectomies (2-3 and 3-4) actually have nothing more than 3rd met head capsulitis. And I see more double than single scars. I'm pretty sure the success rate for treating capsulitis with a neurectomy kinda sucks ;).

    I had a patient once who had a diagnosed neuroma, confirmed with ultrasound. They also had a large VP in the area which the surgeon wanted cleared before they operated. We got rid of the VP and the patient cancelled their surgery because the pain was gone. Could be a co-incidence but I rather suspect that it was a misdiagnosis. Just because there is an enlarged nerve does not mean that its causing the pain.

    I suspect that the neurectomy can be an excellant proceedure. But where I am, its normal for the "healing" (time to get back below pre operative levels) to take 6 months or more and the exception for it to take less.
  17. Unless he's dead of course.

    Stanley, can you explain how you isolate the plantar interossei, the difference between "strain-counterstrain and reverse strain-counterstrain" and how you perform these, please?
  18. Have a similar tale, in my case it was a corn which was causing the pain. There's nothing like ignoring whats in front of your eyes.

    "Specialised subject?
    The bleeding obvious

    You have two minutes on the bleeding obvious, starting now..

    Morontons Neuroma is believed to be caused by nerve compression due to the wearing of shoes which are too narrow and compress the forefoot; how do you reduce the compression forces?

    Wear wider shoes.


  19. clairoo

    clairoo Member

    Wow I didn',t expect such a strong reaction. Thanks Robert for the support. I shall explain a little further, I have been doing acupuncture for several years although I promise to finish my masters at some stage my 'research methods' for my acupuncture stats are extremely basic. Once clinical diagnosis of neuroma made the patient was asked for VAS pain on the day acupuncture was started and after a six week course( weekly intervals) was completed. I considered a significant improvement in pain relief 50% reduction in pain. The total number of treatments on my spread sheet at work is 174. Now I started this note keeping as such as I too was sceptical about success of acupuncture and I have totally been surprised by the outcomes, placebo or otherwise I find that pain reduces. In all cases acupuncture was carried out pre orthotics and whilst imaging was being processed. At the end of the day I now offer acupuncture prior to steroid injection. Anyway as long as my patients are happy and pain free I'm happy. Actually maybe I've finally came up with a masters research. Ultrasound neuroma pre acupuncture and post 6 weeks and see if any reduction in size?? Anyway for those that care I bilateral liver 3 and direct needle the neuroma as if giving steroid injection don't ask me why it works but it does :drinks
  20. musmed

    musmed Active Member

    Dear Claroo
    Acupuncture does work. Been using it since the late 70's.
    I use the same point as well as direct into the 'ah shi' ='oh yes' point. that is the most tender point, in this case the neuroma.
    I presume you rupture the neuroma, pain gone.
    Paul Conneely
  21. bob

    bob Active Member

    But what you haven't considered here Robert is that the VP patient could have had neuroma surgery and not felt any pain from the VP - success either way! Everyone's a winner! I operate on fewer double neuromas as the years pass by. No matter what your sonographer says, I think clinical examination/ patient history is the most important factor in making the right diagnosis.
  22. bob

    bob Active Member

    Ruptured neuroma? Eh? It's not a zit.
  23. musmed

    musmed Active Member

    Dear Bob
    Smart talk will not contribute anything to the site.
    Indeed you can Zit them with a acupuncture needle under ultrasound.
    Try it it works.
    Nothing like experience
    Paul Conneely
  24. Well that is possibl...

    Wait, what?!
    That makes no sense! Thats like saying "I cast the broken leg and it stopped hurting"" ah, but if you'd treapanned the patient, their leg could have stopped hurting! success either way!";)

    I'm a simple man Bob. foot + big ass VP + neuroma = pain. Foot + big ass VP + neuroma - big ass VP = no pain. Leads me to strongly suspect that since the neuroma was still there but the pain wasn't, the neuroma was sub clinical all along.

    I rather doubt that's the mode of action. As Bob says, its not really a "ruptureable" type of a growth. I'm not disputing your results, just the mechanism. I can think of a few more likely than rupture. Some form of prolotherapy type effect would be high on the list. Some sort of trigger point effect on one of the intermetatarsal muscles. Pokin' a hole in a bursiitis. The patient being willing to tell you anything to stop you sticking them again. All sorts.

    But rupture? Nah.
  25. musmed

    musmed Active Member

    Hi all
    Maybe a quicktrip to the surgical text book by Hamilton and Bayley:
    What is the commonest cystic swelling on the dorsum of the hand of a young lady?
    Ans: a Neuroma
    Treatment: Hit it with the family bible.
    Saw it hit with the phone book in out patients one very hot friday afternoon in 1967.
    Guess what it worked after the patient returned to their nornal colour. He was a Figian. No Pain. Never forgot the experience.

    Yep, been there done that.
    More to life than just what they told you at university.
    Paul Conneely
  26. I think if someone could record a neuroma being popped by a needle under ultrasound and post it up on face tube that would make a good educational resource. A quick question though, if we do pop a "cyst" how do we know it was a neuroma and not some other kind of cyst? Anyone have experience of dissecting the neuroma once removed?
  27. musmed

    musmed Active Member

    Dear Mr Spooner
    I would have thought that a neuroma would produce pain in the distal toes.
    I highly doubt a cyst could do that in the vast majority of cases I have seen.
    But there again I am always willing to learn.
    Paul Conneely
  28. For the record, my title is Dr. As you already know. I think if a cyst / bursa were pressing against the nerve it could produce a pain and or tingling / numbness into the toes. How many biopsy reports for excised neuromas come back stating the excised mass was something other than a neuroma? This despite the patient having been diagnosed as having a neuroma based upon symptomology and objective assessment. I ve seen a few.
  29. Furthermore: there is something wrong with the logic here- the most common cyst on the hand is a neuroma- I've seen "ganglions" hit with a book and they disappeared- therefore you can burst neuromas.

    I'm sure someone clever can put a name to the type of logical fallacy being committed here.
  30. Peter

    Peter Well-Known Member

    I might be missing something here, but i stick a 25g needle (thicker than an acupuncture needle), into the intermet lesion under US guidance and have no evidence of "bursting" the neuroma/intermet bursitis/cyst
  31. drsarbes

    drsarbes Well-Known Member

    Just to clarify:
    A neuroma is NOT a cyst, it's a mass.
    You cannot "burst" it.
    I have held hundreds if not thousands in my fingers and can assure you they are solid.
    So lets move on and not confuse our definitions (mass vs cyst).
    In addition, I don't ever recall Dx a neuroma, having a positive mulder's sign, palpate a mass, schedule surgery, open up the foot and NOT find a mass. So let's not state that frequently surgery is done on these and there is no neuroma. It doesn't happen.

    Re: acupuncture: if I am understanding this procedure correctly, you are merely inserting a needle into the area of the neuroma as if you were injecting cortisone, but you do not inject cortisone. And this helps. And we are calling this acupuncture.

  32. Association fallacy. Occasioned by a combination of representativeness heuristic and the availability heuristic. But dave would know better than me.
  33. And here, with respect, is another rather huge fallacy for several reasons.

    1. You said that YOU had never opened a foot and not found a mass (fair play) then extrapolated from that the surgery is never done when there is no neuroma. You can't get from A to B. Just because YOU have never done it does not mean that nobody ever does it!

    2. You said, and I believe you, that you'd done thousands of these proceedures and never failed to find a mass. That could be viewed one of several ways. One is that the clinical diagnosis is 100% accurate in your hands, which is possible. However I tend to the view that given the wonderful and terrible complexity of the human body, no clinical diagnosis is 100% accurate. Take into account patients giving vague or misleading information, I think it more likely that sub clinical masses exist in many / most people. A little error makes a test more believeable to me.

    3. Whilst your statement that surgery is frequently done when there is no neuroma there may be true, I think that is a statement which only you have made. What I said was that I believe Neuroma surgery is done when the neuroma is not the cause of the pain.

    4. I seem to remember a study carried out in which IM nerves were excised from asymptomatic and symptomatic people and sent to a lab, all of which were reported as Neuromas (I'll have a dig). My point is that just because a neuroma mass is there, does not mean that it is the cause of the pain, or even symptomatic.

    I stand by my Slur. Finding masses in every single one of the patients you look for them does not prove that neuroma surgery is never done unnecessarily.
  34. Viewed a number of biopsy reports for a certain podiatric surgeon for his neurectomies which read: "normal fatty tissue". Steve, I don't pretend to be knowledgeable in these areas but if I sent a "mass" for biopsy which I suspected was a neuroma, should I expect it to come back saying "normal fatty tissue"? When is a "mass" a neuroma and how is this distinct from a "mass" of "normal fatty tissue"?

    I'm no surgeon, but I did teach dissection and I reckon I could open up any foot and remove a "mass" of something or other from between the metatarsals within it, but that doesn't mean I've excised a neuroma. Right?
  35. bob

    bob Active Member


    I pretty much agree with you. If a patient presents with neuroma like symptoms and clinical signs, ultrasound, etc.. I would generally think horses and not zebras. However, in my experience of taking out intermetatarsal perineural fibromas (neuromas), I have yet to receive a histopathology report back that does not state that I have excised anything that macroscopically does not represent a 'neuroma'. Microscopically they usually say myelinated nerve tissue showing fibrous perineurium, etc...

    Having said that, if I went around cutting healthy nerves out of patients, I wonder how many reports would come back with a similar report. I doubt my local ethics committee will let me do a study.

    My point about taking the neuroma out and the VP becoming painless is that much neuroma surgery could be successful as it may deinnervate pathologic areas and the neuromas that we believe are the problem might not be the full story.

    Apologies for the cheap shot Paul. If you let me cut a healthy nerve out of your foot and send it off to see what it says on the histo report, I'll let you pop one of my nerves with an acupuncture needle - deal? :drinks
  36. So why do you think a number of the post neurectomy pathology reports I observed stated: "normal fatty tissue" or "adipose tissue"? Give me a verbatim of your last two pathology reports for neurectomy.
  37. drsarbes

    drsarbes Well-Known Member

    Robert and Simon:

    When I discussed the fact that after my work up and decision that a surgery is indicated, neuromas are found at the time of surgery. I have NEVER scheduled a neuroma surgery if I had not palpated it, and or have seen it on US or MRI...I'm always sure that one is in there before I schedule the surgery. I was merely responding to a statement made that ALLL TOO OFTEN surgery is done on for a MN and in actuality there is another pathology.

    There is no way a surgeon will confuse normal adipose with a perineurofibrosis. There are surgeons that will do a "space-ectomy" and of course some fat will be excised along with everything else in the interspace. Neuromas are VERY easy to indentify, as are the distal branches and the proximal truck. All are identified and dissected.

    I realize in this day and age BAD news travels fast, you may hear about poor outcomes of surgery, misdiagnoses, etc...but I can assure you that given the training and expertise of surgeons (yes, even lowly foot and ankle surgeons) the VAST majority of surgeries are done correctly for the right purpose with the correct indications.

    Here is a photo - pretty classic MN, even prior to dissection you can see how obvious they are.

    Attached Files:

  38. bob

    bob Active Member

    Yes Sir!

    I think Steve has already answered this. If you perform a neuroma excision you may also remove part of the surrounding adipose tissue as well - the pathologist will tell you what you put in the pot. I do not keep all my pathology reports on me at this time of night, sorry.
  39. Again Steve, with respect, thats not an assurance you're in a position to give!
  40. Found it.


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