What Has COVID-19 taught us?

So, What Has COVID-19 taught us?

For me: ‘To speak up and be confident of my own convictions, to remain positive and finally to prioritize personal health and wellbeing.’

As we enter the end of lockdown in the UK I have been reflecting on what lockdown has taught me. Like many, I have become a little bit fitter, and now more focused on what is important to me as a person.

My Lockdown journey

My Lockdown journey began in March, just as our March blog was published on the 20^th March, a day or so after we had decided to close the clinic and “Flatten the curve”.

Steroid Injections

In the blog, I questioned the wisdom of using steroid injections for the treatment of Morton’s neuroma, especially for those with underlying health problems like diabetes or high blood pressure.  My caution was based on evidence that steroid injections have in the past been associated with an increased risk of death in patients with flu and were again linked to higher death rates, in the 2012 out-beak of the respiratory virus called Mers-Cov.

The blog was widely welcomed by the majority as sensible advice, but not by all.  Six days after our post, the Royal College of physicians and surgeons of Glasgow had formed a similar opinion to us. They published the following advice.

“The College of Podiatry and the Faculty of Podiatric Medicine of the Royal College of Physicians and Surgeons of Glasgow jointly recommend, on the balance of current evidence and risk, that podiatrists should avoid the use of corticosteroid injections and to seek to employ clinical alternatives”. 26/5/2020 (taken from the RCPS website).

The Covid-19 crisis spurred me on to vocalise a growing sense of unease that I have had about steroid injects for some time now. To be clear, I am not against steroid injections, and recognise that they play an important role in helping those with small Morton’s neuroma. Indeed, entering lockdown with a sore foot must have been a grim prospect for many, and steroid injections hopefully will have helped many without underlying health issues get through the lockdown.

However, pre-COVID-19 I was increasingly viewing steroid injections for Morton’s neuroma as a temporary crutch or short-term fix, stopgap, call it what you will.  This view is partly based also on recent evidence that steroid injections rarely provide long-term results, especially when a neuroma has reached a certain size (1).

Cryosurgery

Cryosurgery, on the other hand, offers an alternative to steroid injections and a much nicer and effective alternative to open excision surgery, and it avoids stump neuroma pain, which this lockdown has been one of the main reasons why people have been prompted to contact us.

Stump Neuroma

It is a well-known, but poorly publicised fact, that excision surgery results in the formation a bulbous stump at either end of the nerve, where the nerve was cut, this ‘stump formation’ is a normal part physiological response to nerve transection (were the nerve is cut or divided in cross-section all the way through the nerve) and occurs in 100% of cases.

That’s right, every single person that has a neuroma cut out will develop a stump neuroma. However, only about 30-40% of patients with stump neuromas go on to generate long term pain, the reasons for this phenomenon are poorly understood. The most likely explanation is that, for some, the bulbous nerve endings end up pointing vertically and downwardly towards the ground and not horizontally, making the stump painful when walked on (2).

Cryosurgery for Morton’s

Cryosurgery for Morton’s has now been performed for 20 years, mainly using ultrasound guidance as to the primary souse of imaging. Cryosurgery papers, where ultrasound has been used, have failed to report a single case of stump neuroma formation following cryosurgery for Morton’s neuroma.

A 2016 paper where MRI guidance was used for the first time as the source of imaging, again it showed a zero rate of stump neuroma formation following cryosurgery for Morton’s neuroma and again consistently high patient satisfaction levels (3).

During the lockdown, we carried on offering email advice and telephone support to those suffering from their neuromas, especially those dealing with stump neuroma. The advice to those people was to remain positive, because many who suffer stump pain in the early days after excision surgery, they will often see a substantial improvement or even resolution, simply because time is a great healer.

For those with stump pain 12 months after excision surgery, relief can be obtained from cryosurgery as it can help shrink the size of bulbous stump end making it less likely to become irritated. So even if your lockdown has been blighted by your stump neuroma remain positive!

On a personal level, I have really appreciated the stress relief that daily exercise has given me. My exercise consisted of either running; headphones on, lost in my own world of esoteric music, or as more often was the case (to keep my wife Claire happy) pushing our 3-year-old chunk (real name Monty) uphill and down dale. Being only 3, Monty had not yet fully grasped the fact that children need to stay on the pavement and not scoot or run into the road.

There have been many times this lockdown where I have had run after Monty or even sprint, to get him out of the way of some oncoming boy racer or busy farmer driving his tractor and muck spreader.

The fact that my movement (or chasing after Monty) this lockdown hasn’t been inhibited by pain has been a blessing that hasn’t been lost on me. 

For those this lockdown that have decided to prioritise their quality of life, prioritising being able to walk and run and even chase pain fee, it will be my absolute privilege to see you in this new COVID-19 world (even though the first bit of our interaction will most likely be a telephone consultation, … and be warned Monty is a budding Podiatrist and he likes to help daddy when he’s working from home).

References:

1 Risk factors and the associated cut-off values for the failure of corticosteroid injection in the treatment of Morton’s neuroma. Park YH, Lee JW, Choi GW, Kim HJ. Int Orthop. 2018 Feb;42(2):323-329. doi: 10.1007/s00264-017-3707-8. Epub 2017 Dec 12.PMID: 29230531

2 How to address Stump neuroma. Schroeder S, Podiatry Today October 26, 2009

Volume 22 – Issue 11 – November 2009 Pages:70-77

3 Percutaneous MRI-Guided Cryoablation of Morton’s Neuroma: Rationale and Technical Details After the First 20 Patients

Cazzato RL, Garnon J, Ramamurthy N, Tsoumakidou G, Caudrelier J, Thenint MA, Rao P, Koch G, Gangi A. Cardiovasc Intervent Radiol. 2016 Oct;39(10):1491-8. doi: 10.1007/s00270-016-1365-7. Epub 2016 May 17.PMID: 27189181