Don’t mix Coronavirus and a common Morton’s neuroma treatment.

Steroid Injections


Steroid injections are a relatively common treatment for Morton’s neuroma. However, in light of the current Covid-19 crisis we would not recommend anyone having a steroid injection for a Morton’s neuroma, or for that matter, any other musculosketal conditions, such as heel pain or tennis elbow etc. This is because steroid injections, as well as being powerful anti-inflammatory agents are also immunosuppressants, i.e. they reduce the body’s ability to fight off infection. 


One of the most commonly used steroid injections in the UK for the treatment of Morton’s neuroma is a steroid called methylprednisolone. Methylprednisolone is used elsewhere in medicine to help treat certain types of autoimmune disease. Autoimmune diseases are conditions where the body attacks it's own cells. Examples of autoimmune disease include systemic lupus erythematosus and rheumatoid arthritis. Couples undergoing IVF treatment might also be familiar with methylprednisolone too, as it is often used at the time of embryo implantation, because it helps prevent the mother’s body rejecting the implanted embryo. 

From a lung perspective it is used to treat bronchitis because it dampens down acute inflammation. However, French doctors dealing with Covid-19 have raised concerns about the immunosuppressive effects of steroid injections, as they can in some circumstances cause a delayed healing of lung tissue affected by the Covid-19 virus. 


For the time being it might be prudent to give steroid injections for Morton’s neuroma a miss. In any event, there is debate about whether or not steroid injections provide any long-term help for neuromas and when they do help, by what mechanism they are providing the relief. The current research suggests that the diameter of the neuroma is quite important. If the diameter of the neuroma exceeds 5.5 mm then the likelihood of gaining any benefit, or the benefit lasting more than a few months is slim. 


Some experts question the ‘anti-inflammatory effect’ of the steroid injection on the neuroma. Some argue that the benefits of the steroid injection are not directly related to the anti-inflammatory effects but more to the shrinkage of surrounding muscle tissue. Steroid injections are known to cause atrophy or shrinkage of tissue, some think that rather than causing the neuroma to shrink the small lumbrical muscles that surround the neuroma shrink instead, thereby decompressing the neuroma, and giving some relief. However, when the muscles recover to their normal size the neuroma becomes compressed again, generating pain.


The benefits of cryosurgery include:

  • It can be performed without the use of steroid.
  • That the enlarged nerve or neuroma after cryosurgery will return to a normal diameter of 1-2 mm.
  • When the nerve has returned to normal, (typically after 3 months after cryosurgery) there is normally no loss of sensation, and no residual pain.

If you have recently had a steroid injection should you be worried?

Most definitely not, overall the risk is likely to very small and the data on this issue is still very scant and emerging.  It is worth remembering the worst affected people are people whose immune systems go into ‘overdrive’ and generally methylprednisolone is used for dampening down such reactions. Furthermore, the effects of steroid injections are fairly short lived.

So at the moment we are treating steroid injections as an 'unknown' factor and erring on the side of caution.

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Intermetatarsal Bursitis, a condition commonly mistaken for Morton’s neuroma

Morton's Neuroma & Bursitis.


If your 2020 new years’ resolution of, ‘taking up running’ has been thwarted by pain, numbness, and tingling under the forefoot during running, you might be forgiven for consulting Dr. Google and concluding that you have a Morton’s neuroma.

However, don’t throw away your running gear quite just yet, because Dr. Google, like many podiatrists, can’t easily distinguish between Morton’s neuroma and a similar condition called intermetatarsal bursitis; one that can be easily treated, and one that can’t be so easily treated with traditional methods. This inability to separate out bursitis from Morton’s neuroma is because both Morton’s neuroma and bursitis generate very similar sensations in the forefoot, and both can generate a positive ‘Mulder’s click’. 


 

Mulder's Click.


A ‘Mulder’s click’, regarded by many for decades, as the definitive test for the presence of Morton’s neuroma, can be felt by the examiner, and sometimes the patient too. The click occurs when the metatarsal bones are squeezed together whilst simultaneously applying an upward force with the thumb to the underside the forefoot, as seen below.  The clicking sensation is generated by the ‘subluxation’ or upward displacement of the enlarged nerve against surrounding structures.

For many years Morton’s neuroma were, and still are by many, diagnosed purely on the basis of a positive squeeze test. The problem with this way of diagnosing Morton’s neuroma is that the Mulder’s squeeze test also detects bursitis. This is because bursa will frequently click if squeezed. This ‘false positive’ has been known about now for a long time, and discussed in the medical literature since at least 1985 (Bosley and others 1985).

So, as you can see, an examiner can’t really tell the patient “you have a Morton’s neuroma because you have a positive Mulder’s click” at best, all they could say is, “your positive Mulder’s click means you may have bursitis, or a Morton’s neuroma, or even a combination of both”.


 

 


 

Running and Bursitis.


Returning now to your new year’s resolution and running. If you have only felt discomfort, numbness and tingling during running and at no other time, especially if you run a lot uphill, the most likely culprit is not Morton’s neuroma, but intermetatarsal bursitis.

Intermetatarsal bursa (singular) or bursae (plural) are sac-like structures that normally contain a small amount of ‘lubricating’ synovial fluid. Sometimes but not always, they are connected to nearby joints. Their function is to reduce friction between structures that might otherwise become inflamed (in this case the interdigital nerve), if you like, they are a kind of internal buffering mechanism. There are 160 bursae found all over the body (Lohr, KM. 2016).

These bursae can become problematic when inflamed, because they fill up dramatically with synovial fluid, the walls of the sac can thicken and harden and sometimes calcify, overall, a process called bursitis. Over time, the bursa press-on, and ultimately compress the nerves in the forefoot, causing pain and sometimes Morton’s neuroma. It is also worth remembering that bursae occur quite normally and harmlessly between 1st - 2nd metatarsals and the 4th - 5th metatarsals. In those locations they are described ‘anatomical’ because they are a normal anatomic feature, a feature that we are all born with. Bursa can also develop over time in places where we weren’t born with them. These are known as ‘adventitious’. Adventitious bursa, develop at mechanical irritation ‘hot spots’ and are particularly prone to inflammation in the 2nd - 3th and 3rd - 4th interspaces, especially if someone is running in shoes too tight in the toe box, that squeeze the contents of the forefoot together, or if the soles of the shoes are too thin, causing irritation from tree roots and stones and pavement potholes from below. 


In runners, as the bursa become inflamed they press on the interdigital nerves causing a sensation of fullness in the forefoot, accompanied by numbness and tingling. Usually these sensations typically wear off shortly after the run stops.

For many runners, myself included, the symptoms from bursitis can often be addressed by changing running shoes. Simply changing from a shoe with a tapered toe box (seen below on the left, with my foot resting on a traditional Ascis shoe with a tapered toe box) to a shoe with a more ‘squared off’ toe box, will resolve the bursitis (seen on the right, with my own Altra paradigm 4.5s).

Tapered Toe Box


Tapered shoe boxes can constrict the foot and lead to the development of bursa and Morton's neuroma.

 

Squared-Off Toe Box


Choosing a shoe with a 'squared-off' toe box offers runners less side-ways compression on the forefoot.

 


The diagram above shows the side-ways constriction of the toes and forefoot in shoes with a narrow toe box. 


 

My recommendation to patients with wider feet and bursitis, is to try Altra shoes. Not only are they wider in the toe box, they also don’t load up the forefoot in the same way as other running shoes, due to the heel and toes sitting at the same level; which is unlike most running shoes, that place the heel higher than the forefoot. Failing Altra, Brooks are often a good bet, with a broader last, but for those with a slightly narrower forefoot, should look at the Hoka range. You can read at little more about Altra Zero Drop Shoes in one of our previous blog posts here.

If you find that the numbness, pain, and tingling continue well into your non-running day-to-day life, it generally means you have either developed a very inflamed nasty bursa, that will require rest and expert management or worse still, your bursa may be evolving into a Morton’s neuroma.


 

How are Bursa best diagnosed?


With high-quality ultrasound imaging equipment. With such equipment, an expert in forefoot problems can easily distinguish between a bursa and a neuroma within a matter of minutes. Why is it important to distinguish between bursa and Morton’s Neuroma? Because, otherwise without imaging there is no way of knowing if the pain is coming from a neuroma or a bursa. From a surgical perspective, bursae when ‘excised’ or cut out are removed with the nerve as one combined unit, this is because the nerve and bursa are closely entwined. So, to answer the last question in other way, why would you have a healthy nerve removed if the issue is a bursa?

For at least half of those with bursa pain, the pain can generally be addressed with simple changes, with running for instance, simply avoiding running up hill will often calm them down. Failing that, injections of steroid or newer non-steroid treatments can encourage the bursa to calm down and empty, and ultimately become pain free.


 

What happens if conservative treatments for bursitis fail?


Cryosurgery has long represented an effective and superior treatment for bursitis over conservative treatments. This is illustrated by a study involving 170 patients, dating back to 1988 study entitled “…treatment of chronic bursitis by a local cryogenic procedure.” It showed at followed-up, (between 12 and 24 months) that just under half of those treated with usual conservative measures were free of bursitis, compared to 100% of patients who remained bursitis-free following cryosurgery (Goriachev An, and others.1988). 

At ‘The Barn Clinic’ treatment centres in London and Sheffield, we routinely perform cryosurgery for forefoot pain that stems from bursitis or Morton’s neuroma or even for those with a combination of both Morton’s neuroma and bursitis.

Similar to cryosurgery for Morton’s neuroma, Cryosurgery treatment of bursae, usually results in a small patch of numbness at the base of the toes and of the two toes of the affected metatarsal interspace. The numbness typically wears off after 3-4 months. We usually recommend waiting until total pain relief has been achieved before returning to running. Even when total pain relief is obtained within the first couple of weeks post cryosurgery, we still recommend not running for 6 weeks to allow the tissues time to recover. The minimum rest time after cryosurgery before returning to running is 6 weeks, however cycling and cross training can be undertaken with guidance after 2 weeks.

For more information about cryosurgery for bursitis or Morton’s neuroma, diagnostic ultrasound scans, injection therapy and other conservative treatment options please contact the clinic for more information.

 


 

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References

  • Bosley CJ, Cairney PC. The inter metatarsal phalangeal bursa - its significance in Morton’s Metatarsalgia. J Bone Joint Surg. 1980;62(2):184–7
  • Goriachev AN, Ivashchenko NM, Potapov IuA. Treatment of chronic bursitis by a local cryogenic procedure.Vestn Khir Im I I Grek. 1988 Jan;140(1):128-31.
  • Lohr KM: Bursitis. Medscape Drugs and Diseases. New York, NY 2016. Available from: http://emedicine.medscape.com/article/2145588-overview

 

What will your 2020 New Year’s Resolution be?


It’s that time of year again, when we all vow to become a new and improved version of ourselves. But according to Forbes, statistics show that only less than 25% people stay committed to their new years resolutions after just 30 days, and just 8% actually accomplish them.

So, what is it that’s keeping us from achieving our new year goals? Well, we can’t vouch for everyone, but for many of our patients, Morton’s Neuroma is often the culprit.
The most commonly made (and subsequently broken) New Years resolutions are:
  • To lose weight & get fit
  • Learn something new
  • Spend more time with family
  • Travel to new places
  • Be less stressed.
It’s easy to see why these goals are so difficult to achieve when so much focus and energy is spent on managing the painful symptoms of Morton’s Neuroma. At The Barn Clinic, we understand the limitations Morton's Neuroma can place on your life and well-being, and as a team, we look forward to getting you back on your feet, and ticking off your 2020 goals. 
Cryosurgery for Morton’s Neuroma is a great choice for sufferers wanting to achieve the goals they have set for the year. With minimal downtime of just 3 days, the majority of patients are able to return to work just 3 days post treatment, and resume exercise and activity from as early as 2 weeks post treatment.

Consider Cryosurgery for your Morton’s Neuroma this new year, take the first steps to becoming pain free and hit the ground running in 2020.
0% Finance options are also available.

 

 

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Get on your dancing shoes.

Get on your dancing shoes.


One of my favourite expressions is ‘Happy wife, happy life’. With that in said, and with my wife being a professional dancer teacher and dance costume designer, it will come of little surprise that the Autumnal TV viewing in the Weaver household is dominated by one TV program, and one alone, woe betide anyone (me) with alternative viewing ideas!

Over the years in pursuit of a happy life, I have endured or should I say enjoyed more than my fair share of ‘Strictly’. 


So, I can genuinely say I have watched every moment of this season’s show and have been extremely impressed by the progress of Kelvin. Kelvin’s victory is even more impressive as he was drafted in at the last minute to replace Jamie Laing, who sadly suffered a foot injury in training. 

Jamie’s very public dance related foot injury served to highlight the struggles and ‘foot sacrifice’ that dancers have to suffer for their art. 

During my career as a Podiatrist I have been very privileged to have worked with many elite athletes and dancers. I have seen first-hand the toll that sport and dance can take on the feet of such athletes and dancers. Broken metatarsal bones, arthritic big toe joints, sprained and torn ankle ligaments, Morton’s neuroma. The list goes on and on.

The very pinnacle of such ‘foot sacrifice’ is that that made by ballet dancers. This is because the ballet dancer has to be able to completely extend the feet and support all of their body weight as they move over the extended feet, a process known as going ‘on pointe’. To be able to go ‘on pointe’ requires years of training.

For most girls in the UK the transition from this training and actually going onto ‘pointe’ takes place between the ages of 11-13, and yet the bones in female developing feet don’t properly harden until somewhere between the ages of 8 and 14. 

All of the above take a toll on the dancer’s feet long after they have hung up their ballet shoes, one common condition being Morton’s neuroma. The treatment choice of Morton’s neuroma is especially important for dancers. This is illustrated by the following extract 


 

‘Struck numb’ published online via The Independent. 

The operation was apparently a common one, and was a success, but the after-effects are a total disaster. I am a trained dancer and, before the operation, still did class every day with great pleasure, as I was generally fit and supple. Since the operation, I cannot feel anything in my feet. I have lost my balance, and my ability to jump, move quickly across the floor, or do anything gracefully or easily. The numbness was supposed to go away but it has not. This has robbed me not only of one of the great pleasures of my life, but also of a professional skill (I am an actress). What can I do about this? Is it a hopeless situation? Is there a remedy or an alternative treatment? Why was I not informed of the possible after-effects and given some kind of choice? It has all been a great shock and has seriously diminished my quality of life. I have a high pain threshold and it is possible that if I had known what I now know, I might have preferred the pain.” 

Ref: https://www.independent.co.uk/life-style/health-and-families/health-news/a-question-of-health-will-i-ever-be-able-to-dance-again-and-how-many-calories-are-there-in-a-bottle-5353539.html


Cryosurgery is now the choice of dancers due to the fact that Cryosurgery does not result in permanent numbness. Quite the opposite, after cryosurgery normal sensation is typically restored by 3-4 months. Dancers are also able to resume training as quickly as 6 weeks post treatment.”

If you are lucky enough to dance like Oti and Kelvin, or you just enjoy dancing round your handbag at the Christmas office party, keep on dancing and choose cryosurgery.

 


 

 

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November is CRPS Awareness month

Morton’s Neuroma, CRPS, and the role of Vitamin C and Mirror Therapy.

Complex Regional Pain Syndrome (CRPS, also known as RSD) is a rare, but not uncommon condition that can cause significant, sometimes life changing pain and loss of function in either, the lower leg and foot, or the lower arm and hand. It can also affect those that have had excision surgery for Moron’s neuroma.

CRPS is generally caused by trauma such as ankle or wrist fracture, or by a period of immobilisation such as having the foot or arm in a plaster cast or brace. Sometimes, even a seemingly very minor injury such as a sprained ankle can trigger CRPS.


CRPS

Approximately 80% of people affected by CRPS are European, or have European ancestry. CRPS associated with trauma affects approximately 26 people per 100,000 every year (1). Much like Morton’s neuroma it affects 4 times more women than men, and like Morton’s neuroma the typical age of onset is mid-forties. The female bias however, could simply be explained by the fact that women suffer more fractures especially of the wrist than men, making them more likely to develop CRPS.

Most cases of CRPS are associated with fracture and the upper limb seems to be more commonly affected than the lower limb.

CRPS also occurs at a surprisingly high rate of just under 4.5% for those having elective or planned foot and ankle surgery (1), though some UK podiatric surgeons suggest that the risks of CRPS from Morton’s neuroma excision surgery alone is as low as 0.46% (2).

Excision of Morton’s neuroma is the biggest cause of surgically induced CRPS in the foot (3,4). The exact rate of CRPS is hard to know for sure, because estimates are based on retrospective studies that look back on patient’s treatment records, meaning they rely on clinicians being able to recognise and document or report a complex condition that can easily be mistaken for other conditions. The true rate of CRPS could be either higher or lower that the figures quoted (3).


What are the features of CRPS?

Constant or fluctuating pain is the most prominent feature of CRPS. The pain is often out of proportion to the injury or stimuli. CRPS can cause a variety of symptoms including, swelling, movement disorders such as tremor or involuntary muscle contraction, and pain is often felt from even the lightest touch or pressure.

Other features include altered skin temperature and altered nail and hair growth, and overall increased sensitivity to pain. Body perception disturbances are not uncommon, such as the hand or foot feeling like it doesn’t belong to the owner.

CRPS is hard to diagnose, for patients developing CRPS following Morton’s neuroma excision surgery, the average length of time from onset to diagnosis is just over 9 and a half months (3). In extreme cases the effects can drive sufferers to seek amputation of the affected limb, however around 16 % of those who proceed with amputation continue to experience the same level of pain.

The outlook for most is good, with many experiencing substantial improvement or remission of symptoms within 12 months, though for some, full recovery may never be attained or can take some years.

Studies have helped develop a profile of those most susceptible to developing CRPS. Just about 50% of CRPS sufferers have a previous history of anxiety and depression. CRPS sufferers are 3.5 times more likely to experience migraine especially migraine with aura than the general population. Smokers and those having repeat forefoot surgery also have increased risk.

The image below illustrates how the foot can look in the early stages of CRPS. The foot is often moderately swollen and slightly discoloured and warmer due to increased blood. In later stages the appearance can reverse, with the foot becoming cooler and darker and slightly bluish-purple discolouration.

 


What can be done to reduce the risk of developing CRPS in the first place?

Avoidance of trauma and surgery are the two obvious things that spring to mind. However, as we all know, avoidance of such things, especially slips and trips is easier said than done.

If you are unlucky enough to suffer a fracture or if you are waiting for elective foot and ankle surgery you should give serious consideration to taking Vitamin C.

The reason why is clearly illustrated by a 2007 study of men and women who had fractured their wrists. Following their fractures, 317 patients were given Vitamin C daily for 50 days, and 99 were given a placebo tablet.

Only 2.4% of the Vitamin C group went on to develop CRPS, compared with 10.1% of the control placebo group. This research has since been repeated many times nearly all studies showing Vitamin C can reduce (but not entirely prevent) rates of CRPS in those suffering fracture or undergoing elective surgery (5).

 

 


Treatment of CRPS

Like most things in medicine, better outcomes are achieved with early diagnosis and treatment. Treatment typically involves the use of differing drugs that include antidepressants, anticonvulsants and anti-bone loss drugs.

Other treatments includes repeat local anaesthetic injections, epidurals similar to those given during childbirth and spinal cord stimulators.

An emerging treatment that shows some promise that does not involve drugs involves the use of mirrors. The affected side is hidden and the other foot is then observed by the patient performing movement or activities that would normally be painful. Tricking the brain to process information differently does seem to significantly help reduce pain both during and after mirror therapy especially if performed regularly over a 3 month period (6).

 


Cryosurgery and CRPS.

Cryosurgery to sensory nerves (the nerves that contain Morton’s neuroma) triggers a localised breakdown of the nerve however the nerve is able to regenerate and return to normal function. Critically, Cryosurgery avoids cutting the nerve. Cryosurgery has been applied to nerves for pain relief since 1961 to approximately 30 nerves throughout the body (7). Thankfully, while CRPS does not seem to be a prominent risk for those having cryosurgery to a nerve or a neuroma, we would still advise anyone having any treatment for a neuroma, be it an injection of steroid, Cryosurgery or excision surgery to consider Vitamin C.

Most studies dealing with Vitamin C and CRPS suggest either taking either a full, or half a gram (1000mg / 500mg) of Vitamin C approximately 1 week before and up to 30-40 days post treatment. Always discuss with your doctor or clinician first.

 


Patient Resources

CRPS charity: https://www.burningnightscrps.org

References:

  1. De Mos M, De Bruijn AG, Huygen FJ, Dieleman JP, Stricker BH, Sturkenboom MC. The incidence ofcomplex regional pain syndrome: a population-based study. PAIN 2007;129:12–20.
  2. Tollafield D. Morton’s Neuroma Podiatrist turned patient: My own journey 2018 ISBN-13: 9781981779284 page 95.
  3. Incidence of Complex Regional Pain Syndrome after Foot and Ankle Surgery 2014
  4. Anderson DJ, Fallet LM. Regional pain syndrome of the lower extremity: a retrospective study of 33 patients. J Foot Ankle Surg 38:381–387, 1999.
  5. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin c prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89:1424-1431. Mirror therapy for Complex Regional Pain Syndrome (CRPS)-A literature review and an illustrative case report.
  6. Sayegh Scand J Pain.2013 Oct 1;4(4):200-207. doi: 10.1016/j.sjpain.2013.06.002.
  7. Trescot AM. Cryoanalgesia in interventional pain management. Pain Physician. 2003; 6(3):345–360

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Autumn’s here, so what does that mean for your Morton’s Neuroma?


Well, the summer seems to be well and truly over, so what does that mean for your Morton's Neuroma?


In a nutshell, it is probably be going to become more noticeable, simply due to the fact winter shoes are more compressive and often have more of a heel which throws weight forward onto the forefoot.

By and large, we often advise our patients to try and adopt flatter ‘zero degree’ heel shoes. Zero-degree, as the name implies, are shoes where the heel doesn’t sit higher than the forefoot, this in turn reduces pressure in the region of the foot where Morton's Neuroma form, which for many will give some degree of symptomatic relief.

 

However, there is a big exception to this footwear rule that every Morton’s Neuroma sufferer should be aware of. A pair of zero-degree heel shoes that will help you for walking, will also make your neuroma worse if you run with them. This is because zero-degree heel running shoes offer little to no cushioning under the heel during running. This lack of cushioning forces the user to land more on the forefoot rather than the heel.

Add to this, the fact that during running, when the foot lands and comes into contact with the ground all of the body’s weight is going through one leg.  A 2014 study of female runners using shoes with minimal heel cushioning found peak forefoot pressures increased by almost 40% when compared to female runners who used shoes with heel cushioning.

So, the take home message is flat zero-degree shoes are good for day-to-day leisure wear, but for running, a positive-degree heel shoe with heel cushioning should be used to allow the heel region to take pressure.


If you don’t want to be ruled by your shoes for the rest of your life there is no better time to book your cryosurgery treatment.
Patients treated at this time of year are often totally recovered in time for the new year and the winter ski season.

 


 

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Is there a link between Plantar Fasciitis and Morton’s Neuroma?

Plantar Fasciitis


At some point in their life, most people will either suffer from, or know someone who is suffering from a type of heel pain called plantar fasciitis or plantar fasciopathy. The source of the pain is initially caused by inflammation, followed by a prolonged degeneration of the heel bone ligament, called the plantar fascia.

Plantar fasciitis is the most common foot ailment that will prompt patients to see a GP or Podiatrist.

The symptoms include sharp, stabbing pains in the heel and is most noticeable when getting out of bed in the morning or when standing after a period of rest or inactivity. Plantar fasciitis typically grumbles on for at least 6 months, and in some cases many years. Over time, many people with plantar fasciitis gradually alter their walking patterns, taking more weight along the outside of the foot and commonly avoiding placing too much weight directly through the heel itself.


 

Morton's Neuroma


Morton’s neuroma on the other hand is a far less common condition, which causes a burning pain in the ball of the foot and toes. Sufferers experience numbness, pins & needles and sharp, stabbing pains in the forefoot, most commonly between the 3rd and 4th toes, and sometimes between the 2nd and 3rd toes. The cause of the pain is degeneration and thickening of the small nerves that sit between the long bones of the forefoot; the metatarsals. When the thickened nerves reach a certain diameter in thickness they run out of space, leading to the nerve becoming squeezed and irritable. Like plantar fasciitis, Morton’s neuroma sufferers gradually alter how they walk, choosing to slightly rotate the foot outwardly "pushing off" less forcefully through the ball of the foot.


 

 


Very little is known about the rates of cross-over, ie. how many people with plantar fasciitis will go on to develop Morton’s neuroma or vice versa.
However, we do know that there are a number of patients who are unlucky enough to have both conditions simultaneously.


 

What's the link?


A common factor that can predispose a person to both conditions is a reduced ability to point the foot toward the shin bone, a movement known as dorsiflexion. Normal ankle dorsiflexion values range between 0 - 20 degrees. Broadly speaking, the more ankle dorsiflexion you have the better, but as we age, we start to experience reduced ankle dorsiflexion. This reduced ability often stems from tight calf muscles behind the lower leg. Such tightness impinges the ‘up-down’ hinge movement of the foot, causing the foot to adapt and compensate by performing the next best movement which is a ‘rolling in’ or ‘flattening’ movement of the longitudinal and transverse arches of the foot. The rolling in movement (known as eversion) has long been associated with increased rates of Morton’s neuroma and plantar fasciitis.

Studies looking at both Morton’s neuroma and plantar fasciitis have shown reduced ankle dorsiflexion to be a big villain of the piece.

The single factor that chronic plantar fasciitis sufferers share is not age or weight but reduced ankle dorsiflexion. Reduced ankle joint dorsiflexion is found in a staggering 80-85% of heel pain sufferers. It’s a similar picture for Morton’s neuroma; a 2016 study compared 68 patients with Morton’s neuroma to non-neuroma control subjects of similar age, weight, sex and foot type. They found that factors like foot type, foot shape and body weight didn’t really seem to be significant in the formation of neuromas. The big factor that stood out like a sore thumb was reduced ankle dorsiflexion.

They calculated that the odds of developing a Morton’s neuroma increased by a staggering 61% in the right foot and 43% in the left, for every 1 degree loss of ankle dorsiflexion (why there was such a difference between the right and left feet is the subject of another blog entirely).

Treating a combination of conditions


At The Barn Clinic treatment centres in London and Sheffield, we have performed cryosurgery for long term sufferers of both plantar fasciitis and Morton’s neuroma for over 12 years. As such we have built up a vast amount of knowledge about causes and links between the conditions. Accordingly, we now regard reduced ankle dorsiflexion to be at least equal to, the risks of being overweight or wearing poor footwear. In our experience virtually, every patient with either plantar fasciitis or Morton’s neuroma will experience an improvement in their symptoms if they regain a few degrees of ankle dorsiflexion with the appropriate exercises.

So, if you are doubly afflicted with both plantar fasciitis and Morton’s neuroma it is statistically highly likely you will have reduced ankle dorsiflexion, so you definitely should perform calf stretching.  However, Morton’s neuroma pain will only be eased but never disappear with calf stretching alone.  Cryosurgery offers such patients a more permanent solution.  For patients who developed plantar fasciitis after chronic neuroma pain we often find that after cryosurgery for Morton’s neuroma the heel pain will quickly resolve once the person starts walking more normally again.

For those patients who develop Morton’s neuroma pain soon after, or sometimes, a long time after experiencing plantar fasciitis, care must be taken separate out the two conditions from each other. This is because many people have small neuromas in their feet and luckily get no pain from them. Some studies estimate that just over half the population will have a neuroma, however only a tiny percentage of people with a neuroma actually experience pain from them.

Sometimes we see patients that have been diagnosed elsewhere with both plantar fasciitis and Morton’s neuroma based on clinical examination, patient history and sometimes, imaging reports. The difficulty is that sometimes plantar fasciitis can sometime mimic the pain of Morton’s neuroma. This is because the thickened heel ligament can compress the nerves in the heel area that supply the forefoot. When nerves become compressed they radiate pain forwards, and in this case into the ball of the foot. Unless the nerves around the heel ligament are carefully assessed for signs of entrapment a clinician could mistakenly attribute forefoot pain to neuromas (that are actually silent and causing no pain) and not the plantar fasciitis. Accordingly, when we see patients with both plantar fasciitis and small Morton’s neuroma we have found that by treating and curing the plantar fasciitis only with cryosurgery that the forefoot pain previously thought to stemming from Morton’s neuroma disappears when the plantar fasciitis clears up often as early as 3 weeks post cryosurgery.


 

To summarise


If you have both plantar fasciitis and Morton’s neuroma the take home message from this blog is:

  • Ankle dorsiflexion exercises will help (email us for free advice exercise sheet).
  • Plantar fasciitis that developed after a long history of walking awkwardly due Morton’s neuroma can clear following cryosurgery to the Morton’s neuroma only.
  • Plantar fasciitis can sometimes mimic Morton’s neuroma pain. If you have been diagnosed with both conditions simultaneously you need careful assessment.

For more information please visit our sister website


www.plantarfasciitis.co.uk


 

Orthotics for Morton’s Neuroma


Do Orthotics help reduce Morton's Neuroma pain?


Our understanding of the answer to this question is based on two things.

  1. The findings of a 1994 Study
  2. Our own day to day clinical experiences of treating 1000s of Morton’s neuroma sufferers with modern orthotics.

1994, as well as being the year the Spice Girls got together and Oasis released their first album ‘Definitely maybe', was the year that the first and more or less only study into the benefit of orthotics for Morton's neuroma was published. It evaluated the effect of using foot orthotics, and particularly their effects on Morton’s neuroma sufferers pain levels.

It showed that depending on foot type, orthotics offered a 45% reduction for pronated (flatter) feet, and 50% reduction for supinated (high arch feet).

The study had a few weaknesses by modern standards. One, being participants had no prior ultrasound imaging to exclude the presence of co-existing problems that sometimes go hand in hand Morton’s neuroma such as arthritis, bursitis, capsulitis etc. Overall, the author did an excellent job with the limited resources available to a UK NHS Podiatry department in 1994. This research has not been significantly updated since 1994.


 


Why hasn't this work been updated?

One of the reasons that this research has not been updated is that it is difficult to find a group of Morton’s Neuroma sufferers who are happy to agree to have no treatment other than orthotics for their neuroma pain for a period of months. This agreement, to have no other treatment, is a requirement of modern study methodology. This is because the scientific validity of a study is undermined if participants use orthotics as well as other treatments, such as physio, stretching icing, anti-inflammatory medications etc. If patients simultaneously use other treatment options, the researchers find it very hard to determine the single effect of using orthotics.

So, to recap, according to the study, orthotics in the distant days of the Spice Girls had a pretty good success rates, a 45% reduction for pronated (flatter) feet, and 50 % reduction for supinated (high arch feet).


 


What about today?

Our understanding of biomechanics and orthotics have moved on a long way since 1994.

These days we are able help a lot more than 50% of patients. The figure in 2019 based on my own experience and based on discussions with colleagues, is a lot closer to the region of between 70-80%.

Approximately 70-80% of patients with established neuromas will see a reduction in their pain levels. It is also our experience that with smaller neuromas, the pain can often totally resolve (whilst the orthotics are being used).


 

What is responsible for the improvement?


There is no doubt that modern orthotic manufacturing, helped by computer aided design and 3D printing, has come on a long way since 1994. Such improvements have allowed Podiatrists to design and prescribe ever more complex devices, which have probably helped raise overall success rates.

However, it’s not just orthotic manufacturing that has evolved. Our understanding of biomechanics has altered significantly since 1994.

When I was a Podiatry undergraduate in the 1990’s a lot of emphasis was placed on ‘kinematics’ or the visual ‘alignment’ or appearance of joints and foot position. Subsequent studies have shown that Kinematics are far less important than we first thought.

In 2019 most podiatrists subscribe more to the tissue stress model, and attempt to alter and manipulate the 3 key variables that are involved in damaged overloaded tissues.

The 3 variables are:

  1. Magnitude of reaction forces.
  2. Vector of reaction forces.
  3. The temporal pattern of reaction forces.

Normally at this point in a blog, I generally attempt to simply and summarise scientific data. But when it comes to the 3 variables above, on this occasion you will simply have either complete a degree in biomechanics or take my word for the fact those 3 variables are not easily broken down into understandable bite sized pieces. Especially how they are applied to orthotics, it is complicated... very complicated!


 

So, is the improvement simply down to better quality orthotics and an improved understanding of biomechanics?


Possibly, but I doubt it is just down to those factors alone.

Our treatment planning involves a very detailed biomechanical assessment that involves ultrasound imaging and elastography imaging of the forefoot. This type of extra imaging data provides a wealth of knowledge.

For instance, a scan will alert us to the presence of co-existing issues that often go hand in hand with Morton’s neuroma, conditions such as arthritis, bursitis capsulitis plantar plate degeneration etc. When we see such issues, we can now alter the design of the orthotic accordingly, making a better outcome for the patient more likely.


 

So, how do orthotics reduce pain?


Orthotics are constructed using corrected 3d models of your own feet. The process of taking the casts of your feet is a highly skilled process that enables your clinician to realign your joints as they take the impressions. When the impressions are poured, orthotists generally make angular corrections to the models of your feet. After this process has been completed, the orthotics are then moulded over the corrected models of your feet.

We know from modern studies that orthotics can reduce abnormal overloading mechanical forces responsible for Morton’s neuroma formation. Some orthotics also have domes that lift and separate the metatarsal bones creating room for the neuroma to sit in.

Orthotics also help reduce the hammering or retraction of the lesser toes. This is very helpful because hammered toes contribute to elevated pressures in the forefoot region.


 

Orthotics - Myth Buster


 

        1. Orthotics act as a brace and orthotics weaken the muscles of the feet.

          Electromyography (EMG) is a branch of medicine that for evaluates and records the electrical activity produced by skeletal muscles, it can be used to assess the muscles in the feet and legs during walking and running.
          A ground breaking 2009 paper entitled “Effect of foot posture (foot type), foot orthotics and footwear on lower limb muscle activity during walking and running: a systematic review, found the evidence does not support the idea that orthotics act as a foot brace or using orthotics causes muscle weakness. This paper was a quality study that collated the findings of 38 published studies.  It actually found the opposite.  It showed that the muscles of people who had certain foot types that included flat pronated feet only started working normally when the subject used orthotics. There is no evidence that using orthotics is detrimental, quite the opposite.

        2. Orthotics are uncomfortable.

          Custom made orthotics are orthotics made over models of your own feet. As such the vast majority of our patients find their orthotics comfortable to wear from day one.

        3. Orthotics are expensive

          High quality carbon fibre orthotics are very durable often lasting many years, and cost as little as £350. Which is approximately £29.17 a month through our 12 Month Interest free Credit Plan.

        4. All orthotics are the same.

          Orthotics purchased from a pharmacy or a trade fair are in no way comparable to quality prescription devices that are prescribed and fabricated to a prescription unique to your feet.  At The Barn Clinic treatment centres we have over 20 years of experience dispensing Morton’s neuroma.


 

The take home message


  • Custom made and even pre-made orthotics can be very helpful in managing Morton’s neuroma pain 
  • Modern manufacturing methods allow for smaller more user-friendly orthotics 
  • Ultrasound imaging when combined with a detailed biomechanical assessment can provide better outcomes for patients 
  • Orthotics are highly individual and totally dependent of the skill and experience of the clinician providing them

Will my Morton's Neuroma benefit from orthotics?

Well to quote my favourite album of 1994 in the words of Oasis…Definitely Maybe.

They don’t work for everyone but they certainly help the vast majority.


 

Elastography Imaging for Morton’s Neuroma


Elastography imaging of Morton’s neuroma represents possibly one of the greatest breakthroughs in the imaging of Morton’s neuroma in the last 30 years.

It provides a whole new level of detail, a level that until recently, we could have only dreamt of.


Elastography is a specialised form of Ultrasound imaging that can assesses the stiffness of certain tissues. It is commonly used to assess tumours in other areas of the body, such as the liver and breast. This is because tumours are known to be much stiffer than surrounding healthy tissue. A Morton’s neuroma is not cancerous, but like breast and liver tumours, they are known to be a lot stiffer than healthy nerves. The fact they are stiffer means they are perfectly suited to this new form of detection.

Elastography is the ultrasound equivalent of being able to feel a lump between your finger and thumb and instantly know how hard or soft the lump is. Standard black and white ultrasound only gives the user clues as to how hard or soft a tissue is, but no solid facts or data. Elastography Ultrasound on the other hand, utilises a range of measurements and colours that show the user instantly how hard or soft a tissue is. Different colour codes are superimposed over the 2-Dimensional images.

Stiff areas are marked with blue and soft/elastic tissues with various shades red or green.


 

Elastography for Morton's Neuroma


During Elastography imaging, a healthy nerve appears as a shade of green. However, a diseased Morton’s neuroma nerve will change colour and typically show as blue during the scan.

A 2016 study of 24 Morton’s neuroma evaluated the percentage of change in Elastography values between Morton’s neuroma and healthy nerves. The Elastography values of the Morton’s neuromas was 220% greater than healthy nerves in the same or opposite foot. 

Elastography now allows for increased accuracy in the mapping of the Morton’s neuroma. Small, but painful neuromas that could have previously been missed by Ultrasound and MRI can now be detected with Elastography. Elastography also allows us to more accurately assess and treat patients that have had failed alcohol injections, failed neuroma excision surgery and those suffering from a related condition called bursitis.


 

What Elastography means for our Patients


Using elastography will give us an additional level of knowledge and understanding of your condition. This means patients could benefit from a more specific diagnosis, improved insight with regards to recovery and treatment expectations & outcomes, and an even higher level of precision and accuracy in the treatment you receive.

Both conventional Ultrasound and Elastography scanning is provided to all of our patients as standard, and is included in the cost of the assessment consultation.


 

Our Commitment to Investment in new Treatments & Technology


We are proud to announce that as well as being the first to introduce cryosurgery for the treatment of Morton’s neuroma in to the UK over 12 years ago, we are the first and only clinic in the UK offering elastography as standard to all of our patients. We have been so impressed with the extra information that Elastography has provided in our Sheffield clinic we over the last 12 months, that we are pleased to announce we have recently taken delivery of a second brand-new Elastography scanner for our busy London clinic.


 

Why does Morton’s Neuroma seem better during the Summer?

Why do so many people report that their neuroma feels so much better in the summer?


Could it be the sunshine and sangria effect? Where we are either, on holiday or have a holiday to look forward to, or we are super relaxed after a holiday. The sun is shining and psychologically we all feel so much better and our day-to-day problems seem just that little bit less bothersome, including our neuroma. Why should this be, is it all down to the sunshine? Well the sunshine could definitely help.

There is a lot of evidence now, that the sunshine vitamin, vitamin D has an important role to play in the body’s tissue repair and anti-inflammatory mechanisms and we know neuromas do have an inflammatory component to them. Maybe a boost of vitamin D levels, combined with a week or two of the famous Mediterranean diet, high in anti-inflammatory omega 3s, and low in inflammatory omega 6s could be just what the food doctor ordered, however, there is probably something much more simple and down to earth at play.  

For most, once a Morton’s neuroma has reared its ugly head there is a period of time where the symptoms can be managed with lifestyle changes, especially choice of footwear. For most, year by year the symptoms ebb and flow, they feel better in the summer and worse in the winter. This seasonal change is really down to the fact that summer footwear is so much flatter and wider and forgiving.  In a flat shoe, the forefoot region where neuromas form, takes approximately 30% of body weight, this is far more manageable than the 66% of body weight going through the forefoot in a shoe with a higher heel. Secondly sandals benefit from being wider in the toe-box making more room for you and your little foot fiend to get along with each other. 

For the record we don’t sell footwear or have shares in Birkenstocks, and with that said, this year the Birkenstocks Arizona 2019 is a really good choice if you suffer from neuroma, it ticks all the neuroma friendly boxes. It has an adjustable forefoot strap, a supportive cork foot-bed that will support your feet In all the right places. The cork foot-beds also mould around any lumps and bumps your feet might have, meaning the shoe adapts around you and not the other way around (for the friendly people at Birkenstocks reading this I take a size UK 10.5).

October and November are our busiest months, with a large influx of new patients. This is simply because a lot of people can no longer put up with the pain once the neuroma has been compressed again by their winter shoes. Our advice would be, choose your winter footwear very carefully and try and transition into a shoe that is as wide and as flat as possible.

Be kind to your neuroma, don’t go from one footwear extreme to another.