Alternatives to neuroma surgery

Today, there is one less neuroma in the world.

Between 7:30 and 8 a.m., I had the privilege of removing Terri's neuroma at the surgery center. I used to remove neuromas every month but, with our newer treatments, surgery is becoming rather uncommon.

Neuromas are swollen nerves that can occur anywhere in the body. The most famous and notorious is the acoustic neuroma found in front of the ear.

The one that most often concerns the podiatrist is usually found in the foot by the third and fourth toes between the metatarsals. It is commonly called a Morton's neuroma after the doctor who first described it in the literature.

When squeezed in shoes, it sends a sharp, stinging and electrical shock up to the tips of the toes. It is totally benign although patients often use the phrase "it kills me." Patients with neuromas often remove their shoes and rub their foot, which I use as a diagnostic sign.

The first step in treating a neuroma is changing or modifying shoes or shoe insoles to give the foot more room. When that fails, neuromas usually find themselves in the podiatry office.

After we examine the foot, often using an X-ray and ultrasound to make sure the problem is only a neuroma, we usually start therapy with a cortisone injection.

Cortisone injections always have two effects: fighting inflammation and tissue destruction. We are using the tissue destruction capability here, as neuromas are a thick bundle of nerve tissue and not really an inflammation. Usually we limit cortisone injections to only three, and they are usually done at least two weeks apart.

In the past, failing three cortisone injections, wider shoes and special insoles left surgical excision as the only option. Now we have a nonsurgical method to kill the pesky neuroma using a series of alcohol injections. The technical name for this is chemical neurolysis but we usually call it sclerosing the nerve.

I have been doing sclerosing for 12 years and have treated more than a thousand neuromas. My impression is that greater than 75 percent of all patients are helped enough by the injections to avoid surgery.

The other 25 percent either live with their pain or, like Terri, choose to have it removed in a 30-minute surgery done under local anesthesia with a little sedation. Recovery is quick with suture removal and normal activities happening in just two weeks.

Our office has been using ultrasound examination of neuromas for eight years. Our findings reflect the national findings: neuromas that are less than 5 mm usually respond to the cortisone injections; those between 5 mm and 10 mm respond to sclerosing, and those greater than 10 mm (Terri's was 11 mm) usually end up with surgery.

If your foot has nerve enough to hurt, consider starting with an ultrasound examination.

Dr. Michael Zapf is a podiatrist in private practice with offices in Old Agoura and on the campus of Los Robles Hospital. For more information on neuromas, see www.conejofeet.com. The office phone is (818) 707-3668.