Treatments for Morton’s Neuroma/Entrapment
Some of the more common treatments for Morton’s neuroma/entrapment include:
Orthotics (Shoe inserts), Pads, Toe spacers
Shoe changes
Cold laser
Injections (Steroid, Dehydrated Alcohol, B12, Toradol, Biologics, Serapin )
– As it pertains to injections, they are usually only temporary and specifically many people get alcohol injections in a series, and unfortunately most physicians administering the injections use less than 6%. Studies have shown that it takes at least 30% in order to cause enough damage to the nerve to create a permanent resolution, however using this much also can have significant negative side effects to the local tissue.
Radiofrequency Ablation– this is a procedure where a probe is inserted directly adjacent to or on top of the neuroma and heated up to about 83°C to cause the nerve to essentially break down and desiccate from the heat. This procedure usually requires multiple treatments and success rate is still dependent upon the person performing the procedure and is not covered by insurance in most cases.
Cryotherapy is another option similar to Radiofrequency Ablation however it is also highly user dependent and there really is no go data to show it is a viable consistent procedure.
Imaging of MNE: Xrays, MRI, Ultrasound.
First of all, I would say that imaging is NOT needed to make the diagnosis. It is more likely that it may find something else such as a stress fracture or plantar plate tear. Often an MRI or Ultrasound will state that a Morton’s neuroma is present when the patient has not symptoms of it. A very skilled ultrasound tech needs to be doing the exam to actually see a proper MNE.
Medications for pain relief:
No medications can help with curing but can provide temporary pain relief, but should not be used long term. Common ones used are: Gabapentin, amitriptyline, nortriptyline, desipramine, Cymbalta, Topamax. NSAIDS.
Surgical procedures: The most common procedure performed around the world is a neurectomy. The other surgical procedure is decompression which can be done open or endoscopically. This is really the only choice for a first time surgery.
Neurectomy – This is where an incision is made on the top of the foot or the bottom of the foot more commonly on the top and the surgeon will dissect to the nerve and essentially cut it and in most cases just let it retract back into the foot sometimes surgeons will try other methods to avoid the stump neuroma such as tagging it into bone or muscle or putting some type of implant on top of it to prevent regrowth. This should be avoided as a first time surgery whenever possible.
Decompression – this procedure is essentially the same as a neurectomy with the significant difference that the nerve is not cut but released or decompressed. The procedure can be performed endoscopically but when performed in this manner there can be no direct visualization of the neuroma or entrapment or removal of scar tissue. When performed openly, the deep transverse intermetatarsal ligament which is the anatomic part responsible for compressing/entrapping the nerve is cut very carefully and any other tissues that are compressing the nerve are cut using microsurgical enhanced techniques. Approximately 40% of the cases require dissection of scar tissue off of the nerve as it goes into the toes. Very often surgeons will use some sort of biologic implant to place on top of the nerve once it has been decompressed to prevent scar tissue from invading the nerve. I have decompressed over 1000 MNE with a success rate of 92%.
Stump Neuroma – this is a condition whereby after cutting the nerve in a neurectomy procedure the nerve will try to send out new nerve fibers to find the other end of the nerve that was cut. In a more than comfortable percentage the nerve fascicles will get scrambled up or find scar tissue instead of retracting and essentially dying and cause significant pain which again is usually much worse than what you started with. Many times after having a neurectomy and the patient is experiencing significant pain weeks or months after the procedure the surgeon will incorrectly state that this is a scar tissue problem and it will eventually go away. This is a situation where a stump neuroma is probably present, and an appropriate referral should be made to someone who can treat this very serious complication appropriately. Very often patients are referred to pain management specialist which unfortunately do not have a resolution for this problem in most cases and more than likely there will not be a resolution to the symptoms. They are not the best option for you the patient.
Treatment options for stump neuroma– once you have a stump neuroma the goal is to reduce the pain by more than 50% to help restore function and provide pain relief. It is rare to get 100% pain relief but achieving something the patient can live with and function with is certainly possible. It is important that you are being treated by a peripheral nerve specialist, in order to achieve maximum results.
There are different opinions on the best way to treat stump neuromas and there are several that are more successful when performed by appropriately trained individuals. Dr. Bregman has evolved his technique to provide consistent and successful outcomes.
Revision old dorsal incision-approaching the stump neuroma through a dorsal incision again making sure you resect as much nerve as possible has some positive limited studies.
Plantar revisional incision-approaching the stump neuroma from the plantar surface gives better direct access to the nerve and ability to cut farther back, also can manipulate the nerve as the surgeon sees fit. This procedure seems to have a somewhat increased success rate over revisional dorsal incision based on the literature.
Plantar traditional approach with nerve transposition into muscle or bone-this has been the main approach by specialists for many years. The idea being placing the end of the cut nerve into an area where the nerve will eventually die out and not be painful anymore. It is important to note that any of these procedures will replace pain with numbness.
Plantar approach with nerve cap placed over the nerve, in order to prevent regrowth. This can enhance the success rate by not allowing the recurrence of a stump neuroma.
Plantar approach linear incision-this is commonly used. The incision is placed significantly more proximal, towards the arch to allow access to the nerves involved. The goal is to cut normal nerve so that the damaged nerve is not remaining and then it is usually buried into muscle.
Plantar approach with open flap and nerve transposition into muscle or neuroplasty or Neuromyodesis– this is where nerves can be brought together and often placed in a tube made of collagen or porcine so that the nerve endings from each separate branch will join together and eventually become quiet after they combine. Alternatively, the nerves can be place into muscle by the TMR or RPNI technique. Nerve caps can be used to cover the nerves before burying in muscle. These are the preferred procedures of Dr. Bregman.
Peripheral nerve stimulator-this is a device which is a small wire/transmitter that is placed in the ankle area (by the Tibial nerve) where the nerves that go to the stump neuroma originate to create an electrical field in order to reduce the pain signals going to the brain. This can be done with a trial ( in office ) before putting the permanent implant in and it is minimally invasive. Unfortunately, many insurances will not cover it although Medicare usually will. This procedure can be done as a standalone procedure, or in conjunction with any of the above nerve procedures. This is something that can be discussed with you are peripheral nerve specialist.
If one is being treated for a stump neuroma they have to be prepared for a longer recovery process. This usually requires weeks of non-weightbearing possibly longer, and usually takes about a minimum of 3 months all the way up to a year to be able to return to normal activities. Dr. Bregman has treated dozens of these with a successful outcome in over 85%.