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By Dr. Pedram A. Hendizadeh
April 28, 2017
Category: Foot Tips
Tags: foot   Feet   Injections   Neuroma  
      
 
Sclerotherapy Injections for Morton's Neuroma:  The latest treatment with a high success rate
    
When it comes to the health of our feet, women are much more vulnerable to ailments than men. One such problem that targets women more than men is Morton's Neuroma (perineural fibroma), which is 10 times more likely to affect woman than men.  This painful condition is caused by an enlarged nerve, usually one that runs between the metatarsal heads of the ball of the foot.  Morton's neuroma involves a thickening of the tissue around one of the nerves leading to your toes. It is sometimes referred to as an inter-metatarsal neuroma because of its location, which is usually at the ball of the foot between the third and fourth toes. Problems often develop in this area because of two nerves that intersect and become inflamed.   These nerves are typically larger in diameter than those going to the other toes, causing the nerve to become enlarged.  The thickening, or enlargement, of the nerve that defines a neuroma is the result of compression and irritation of the nerve. This compression creates swelling which eventually leads to a radiating, burning or a shooting type of pain.
Who is at Risk?

There are many factors that contribute to Morton's neuroma, though the condition can arise spontaneously for reasons yet unknown. Flat feet can cause the nerve to be pulled towards the middle of the foot, which can cause irritation and enlargement of the nerve. However, the primary reason  women are more often affected by this condition than men, is the same reason for a host of other foot problems that occur mostly in women – poorly fitted shoes. Statistics show that this condition most often afflicts women in their 30s and 40s. Sorry ladies, but wearing the latest 5-inch heels from Jimmy Choo will contribute greatly to this condition. High-heeled shoes cause weight to be transferred towards the front of the foot, increasing pressure on the ball of the foot. Narrow, pointy, and tight-toe boxes create lateral compression, which squeezes bones, ligaments, muscles, and nerves in the forefoot, causing pain and swelling. 
 
Morton's neuroma can also result from physical activity that over-pronates the foot. Running, racket sports, and certain dances such as ballet, often cause trauma to the foot. This trauma can lead to a build-up of pressure on the ball of the foot. Additionally, an injury or structural defect of the foot can also cause Morton's neuroma. 

Signs and Symptoms: 
 
The pain caused by Morton's neuroma typically develops as an ache in the ball of the foot and progresses to a burning pain. This pain is often described as an intense feeling of pins and needles and a feeling like a pebble stuck inside the ball of the foot. The burning sensation leads to numbness in the second, third and fourth toes. These symptoms begin gradually, with the discomfort occurring when walking, but easing when resting or upon removal of shoes. Some symptoms that indicate Morton's neuroma include: radiating pain from the ball of the foot to the toes, intensifying pain during activity and when wearing shoes, and occasional numbness, discomfort, and tingling. These symptoms may be relieved temporarily by simply massaging the foot or by avoiding extravagant shoes or activities. However, if these instigators are not avoided, symptoms  can become progressively worse and may persist for several days to several weeks. 
 
Morton's neuroma is usually diagnosed by podiatrists.  They perform an exam called Mulder's Sign, where the foot is first squeezed from the sides while pressing down on the ball of your foot, mostly between the third and fourth metatarsal bones. If this squeezing results in extensive pain, as well as a clicking sound, the results are considered positive for Morton's neuroma. Sometimes further testing is needed, such as Diagnostic Ultrasound or MRI Studies.
 
Treatment:

The podiatrist will devise a treatment plan based on the severity and duration of the symptoms. Treatment approaches vary depending on the severity of the problem. Usually, conservative measures are suggested before considering surgery. Some of these treatments include padding, icing, orthotic devices, activity modifications, changes in shoe styles, oral anti-inflammatory medications, and injection therapy. 

Better footwear is probably the first and most important step you can take to alleviate this condition. Wearing a shoe with a wide-toe box and a low heel can reduce pain tremendously. Your doctor may also recommend some sort of padding to provide support to the metatarsal arch, thereby reducing the pressure on the nerve when walking. Custom orthotic devices provide the support needed to reduce pressure and compression on the nerve. 

Modifying physical activities will also go a long way in reducing the severity of Morton's neuroma. Activities that put repetitive pressure on the neuroma should be avoided until the condition improves. In the meantime, to ease the pain, application of an icepack to the affected area can help reduce swelling. Alternatively, non-steroidal anti-inflammatory drugs, such as ibuprofen, can also help alleviate pain and swelling. 
 
If after the initial treatment no significant improvement is seen, sclerosing injection therapy is now the treatment of choice with a 94% success rate. In the past, the treatment plan would have been steroid injections followed by surgical excision of the neuroma.  Sclerosing injections were developed several years ago to help alleviate the pain of neuromas.  This conservative treatment option has significantly decreased the need for surgical excision.  The treatment is performed in an office setting. Sclerosing injections consist of a cocktail of 0.5% Marcaine and 4% dehydrated alcohol.   Studies have shown that this small concentration of alcohol can shrink the neuroma and, with the use of ultrasound guidance, sclerosing injections have had an excellent success rate. The majority of patients require a series of five to seven small injections given over the course of three months.  Most patients begin to see improvement after the third or fourth injection.   This novel treatment is effective and is covered by most insurance companies.

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