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.


 

8 Reasons to Choose Cryosurgery to Cure your Morton’s Neuroma

 


 

1. It Works.

Cryosurgery for Morton's Neuroma has an excellent success rate from just one treatment. 

 


 

2. It’s very safe.

Cryosurgery has better success rates and outcomes than neurectomy surgery.  Unlike neurectomy surgery, cryosurgery poses no risk of stump neuroma because there is no cutting of the nerves in the foot.

 


 

3. Minimal Downtime

You can be back to work and driving after a long weekend.

 


 

4. Cost effective.

Most patients spend thousands on shoes and other less effective treatments. Cryosurgery is also the cheaper option in comparison to private neuroma excision surgery.

 


 

5. Time effective.

Many suffers can spend years suffering with Morton's Neuroma. With Cryosurgery, will see their full results in as little as 12 weeks.

 


 

6. Long Term Results.

For most patients, the results are permanent. Our thorough consultation process is also designed to highlight any common risk factors the patient may be exposed to (such as foot-type, hyper mobility etc), and we work with you to put future preventative measures in place.

 


 

7. Single Treatment.

Cryosurgery is carried out in just 1 short treatment. So you don't have to commit to a course of treatments and multiple trips to the clinic.

 


 

8. Affordable for every budget.

We offer 0% Interest free credit, and a variety of finance options to suit your circumstances and your budget.

 


 

Our Story & Our Ethos

Our Story So Far | 1999 - 2019 | 20 Years of Excellence


Since 1999, Mr Weaver was has taken a keen interest in diagnostic medical ultrasound. This interest was sparked by a realisation that Ultrasound imaging could really remove a lot of the guesswork involved in assessing and treating common podiatric conditions, such as Morton’s neuroma. Mr Weaver realised from the moment he saw ultrasound imaging being used first-hand, that it had the potential to really improve and unlock better treatment outcomes for patients.

At that time in the UK, training in Ultrasound imaging for Podiatrists was pretty much non-existent. Furthermore, organising ultrasound scans to assess and plan treatment for conditions like Morton’s neuroma or bursitis was a painfully slow business, that was sometimes limited by the lack of detailed knowledge of the person performing the scan of what was going on with the patient. Mr Weaver really wanted to overcome these issues by being able to scan his own patients, rather than relying on third parties who don’t know the patient as well as he did.

With a lack of UK based Podiatry specific training, Mr Weaver embarked on Ultrasound training in the U.S.

It was at this time that Mr Weaver completed training in ultrasound-guided injection techniques, including cryosurgery for the treatment of Musculo-skeletal conditions, such as Morton’s neuroma.

Mr Weaver has also successfully completed a UK based Master’s degree in Medical Ultrasound, obtaining the highest possible award of distinction. Since introducing cryosurgery for Morton’s neuroma to the UK, Mr Weaver has continued to strongly advocate its use and has lectured and taught workshops in various settings.

Mr Weaver now regards the information obtained from ultrasound scanning a patient as invaluable. Mr Weaver is better now than ever, able to offer treatment programs that are tailored and individual to each patient’s unique needs and requirements, such complex assessments often involve performing scans immediately after activities like hiking or running that bring the patients symptoms on. This extra layer of attention to detail is often what makes the difference in patients obtaining the outcome they are looking for.

Moving into the future, Mr Weaver has continued to pioneer the treatment of Morton’s neuroma and has become the first Podiatrist in the UK to use a new form of ultrasound imaging called elastography. Elastography is used elsewhere in medicine to map the density of tissue. Morton’s neuroma tissue has been shown to have greater stiffness when compared to surrounding healthy nerves. As such the use of elastography allows Mr Weaver to see a new dimension of the neuroma that has been unavailable, enabling him to address areas of the neuroma that might have previously been missed. This greater appreciation allows for a more tailored cryosurgery treatment.


 

Our Ethos


There is no such thing as an average patient. We don’t do average, only excellent.

We place a large amount of emphasis treating you as an individual and making your Morton’s recovery journey as quick and as smooth possible. To us, you are foremost, a person and not just another number.


 

A little bit more about Robin

When not treating patients in clinic, Robin enjoys spending time with his wife, Claire, a former dance and fitness teacher and his young son, Monty. He is a keen skier, plays club level tennis and enjoys hiking & mountain biking in the Peak District. He also likes a wide range of music, particularly house music.

 


 

Can Morton’s Neuroma ever be cured?

The short answer is yes, with Cryosurgery. And here's why...

Broadly speaking, there are two routes that you can take when it comes to treating a Morton's Neuroma. Those 2 routes are:

Management of the Morton's Neuroma


 

  • Orthotics - Most orthotics issue is that they work best in enclosed winter footwear and unless you have very specialist low profile dress orthotic they don’t work in open summer footwear. This means that every summer the neuroma tends to enlarge little by little, to the point that orthotics will eventually stop working. 
  • Footwear Modification - Choosing 'Zero-Degree Heel' Footwear, such as the Altra Zero-Drop range of footwear, Hocker, or Birkenstocks can be beneficial for Morton's neuroma sufferers due to the reduction of the forces on forefoot caused by the heel of the foot being higher than the toes. You can read about our footwear advice here
  • Lifestyle Modification - includes a reduction of your normal day-to-day activities, such as driving to the shops rather than walking or avoiding events or parties at which you will likely be stood for a long length of time
  • Reducing or Ceasing Sport of Activity - Reducing or omitting your favourite sport or activity can reduce irritation of the Morton's Neuroma by limiting the activity you are carrying out, and reducing time spent on your feet. For so many patients, this simply isn't an option, due to the enjoyment they feel when engaging in their chosen sport or exercise. 
  • Wearing metatarsal domes or pads.

All of these options generally help to alleviate the symptoms of the neuroma, but the neuroma is always there in the background. Your neuroma will soon start to throb if you even look at high-heeled shoe, let alone wear one! And then, there are lot of practical problems with management options.

Interventional Treatment for Morton's Neuroma


 

  • Steroid injections are anti-inflammatories and cause atrophy (shrinkage of tissue). Many experts think it is the atrophy, both of the swollen nerve tissue and the tissue surrounding the nerve that helps relieve the neuroma pain. The ‘atrophy effect’ causes shrinkage of the tiny lumbrical muscles (that allow you to curl your toes) that surround the nerve. As the lumbrical muscles shrink due to the steroid, the neuroma is temporarily decompressed giving relief. However, after 3-4 months the lumbrical muscles recover and regain their bulk and the nerve is again compressed. Leaving you back where you began. In our experience steroid injections don’t seem to offer a long-term solution or cure for Morton’s neuroma.
  • Alcohol injections generally provide terrible outcomes, and can often make matters a lot worse.
  • Decompression surgery doesn’t cure a neuroma, it is simply an attempt to make room for the nerve, by cutting the transverse ligament (an important structure that stabilises the forefoot). The main issues with decompression are the risk of accidental injury to the nerve during the decompression surgery, and the amount of scar tissue that can form in the ligament and around the nerve after the decompression. Even when the symptoms are alleviated by decompression, the enlarged nerve (often measuring around a centimetre in diameter - normal diameter 2-3mm) will still be present in the forefoot and will often require a degree of ‘management’.
  • Excision surgery  - There is a little-known fact that every single person who has a neurectomy will develop a stump neuroma, because fusiform stump formation is the body’s normal physiological response of the body after a nerve has been cut.  Only a relatively small number of patients (around 35%) ever report being totally pain free after excision surgery and many are made a lot worse. Can excision surgery be a cure for Morton’s suffers? If a cure is based on having no symptoms then possibly, for some patients. If a cure is based on having a normal nerve in the foot, then no.

Cryosurgery for Morton's Neuroma

Cryosurgery does not kill or permanently destroy the nerve. The freezing of the nerve triggers a breakdown of the scar tissue that caused the nerve to be enlarged. Typically, after 16 weeks the nerve has totally recovered and reduced from 1cm in diameter to measuring a healthy 2-3mm again. Cryosurgery is the only intervention at this moment in time that leaves no trace behind. If you scan the foot of a patient that has had cryosurgery all that will be seen is a normal forefoot. On the other hand, if you scan patients that have had the other interventions listed above you can generally see varying degrees of scar tissue and damage.

Cryosurgery has been performed since 1960's on nerves, and it is regularly carried out on various part of the body to provide pain relief. It's been proven that freezing nerves causes no damage at all, and if anything, it actually has a rejuvenating effect. One of the features of Morton's neuroma, is the development of abnormal blood vessels around the nerve sheath. This is a process called angiogenesis. Angiogenesis helps drive the inflammation process. Cryosurgery has been shown to reverse angiogenesis. 

Being the first person in the UK to offer cryosurgery and having performed well over 3000 cases over the last 12 years, I now regard cryosurgery as the ‘Gold Standard’ for the treatment and cure of Morton’s neuroma.

If you are fed up of managing your neuroma and you are ready to choose an intervention, choose the right one, choose cryosurgery.

Get your foot and your life back. And let us help you.

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Morton's neuroma advice for cyclists

Morton’s Neuroma Shoes – The Good, The Bad & The Terrible

 

 

 

 

 

Altra Zero-Drop Trainers can improve Morton's neuroma symptoms.

 

 

 

 

 

 

 

 

Avoid wearing thin soles flip-flops with Morton's neuroma

 

 

 

High Heels Morton's Neuroma

The Good

Zero degree shoes, such as the footwear brand 'Altra' are an excellent choice of shoe, especially if you are a runner suffering with a Morton’s neuroma.  Most running shoes lift the heel of the foot around 1-2 cm higher than the forefoot. The lift of the heel increases the forces on the forefoot that cause Morton’s neuroma by 3-4 times.

Running shoes such as Altra and Hocka have a ‘Zero drop’ or 'Zero-Degree Heel'. This means that the heel of the foot and the toes are literally on the same level. Zero-Drop shoes are beneficial for Morton's neuroma sufferers due to the reduction of the forces on forefoot caused by the heel of the foot being higher than the toes.

Shoes with a positive heel raise the heel above the forefoot and push the pad of fat tissue that protects the metatarsal heads and inter-metatarsal nerves forwards. This exposes the nerves to increased compressional forces making Morton’s neuroma more likely.

 

 

The Bad

If you are on a rocky beach this summer think twice about wearing flip flops.

Thin flip flops are often 'Zero-Drop', which as we know is beneficial for Morton's neuroma. However, the toe-post that slots between your toes can compress the 2nd and 3rd metatarsal together, making developing Morton’s neuroma in this region more likely.  Thin-soled flip flops also offer little protection from protruding objects underfoot, such as rocks and stones.

Try to remember, the nerves in the forefoot are actually very close to the ground. Sometimes the nerves in the forefoot can be injured by walking on sharp rocks or stones, and such injuries can progress in to Morton’s neuroma.

 

 

The Terrible!

Studies that measure peak pressures in the feet (plantar pressures) show that, in a flat shoe only 28% of the body’s weight runs through mid-foot region (where Morton’s neuroma form). However, this increases to a staggering 66% of body weight in a high heel.

Not only do the high heels increase plantar pressures they also are tight in the toe box, crushing the contents of your midfoot together, this crushing action is also responsible for Morton’s neuroma formation.

High heels can cause changes to the feet that can trigger Morton’s neuroma even when you aren’t wearing them. This is because regular use of high heels causes a shortening of your Achilles tendon and overtime time can alter the position of your lumbar spine (lumbar lordosis). Unfortunately, both of these issues also increase forefoot plantar pressures and can aggravate Morton’s neuroma.