Treatment Options for Neuromas

'Morton's neuroma' (also known as Morton's metatarsalgia, Morton's neuralgia, plantar neuroma and intermetatarsal neuroma') is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the third and fourth intermetatarsal spaces.
This problem is characterised by numbness and pain, relieved by removing footwear and is commonly described by my patients as "feeling like walking on a bunched up sock".




It's not really a neuroma. Adding the Greek suffix "-oma" to a word literally means "tumour". That's why we attach it to words referring to cancerous conditions like lymphomas and benign tumours like fibromas.
A neuroma is not really a tumour at all. It's actually a growth of scar tissue around a nerve, due to chronic irritation. Instead of our using the word "neuroma", the more proper name for the condition would be "perineural fibrosis", which literally translates to "scar tissue around the nerve".

What are my options for treatment at FFLC?

Here at our center we try to avoid any surgical excision by performing various treatments which are minimally invasive, safe, and proven to be effective.

We typically offer several options, one being serial injections of a sclerosing alcohol mixture to dull the painful lesion and ultimately reduce the frequency and severity of the pain experienced. This is a weekly event, which may take up to 10 injections (effectively treating the lesion within 3 months time and avoiding surgery). We have had great success with the injections, and the are very beneficial for patients who are otherwise not great surgical candidates (especially patients with other medical problems which carry higher risk for surgery). Occasionally we use our ultrasound device to pinpoint our injection more accurately, to thereby target the nerve lesion with improved results in more difficult cases.

Another option is cryosurgery. This is illustrated on our Youtube channel. This is a small "stab" incision which is placed between the digits which are on either side of the pain. Then we use the ultrasound machine to visualize the placement of the cryoprobe. Our assistants hold the probe still while it delivers subzero temperature at a pinpoint location which we can see on the small screen. It is done in the office, and with minimal risk. Patients do well with this modality, and leave without a stitch. They follow up with us weekly until the wound is closed, and they are relatively pain free from that time foward.

This is the most common area of symptoms in a neuroma.

We advise patients that no surgery or technique is perfect, and must let you know that a possiblity of recurrence, pain, numbness, and infection are unlikely but known complications. And we reserve open excision for patients with large bulbous neuromas which are either palpated easily in a clinical setting, or visualized well on advanced imaging such as MRI. The large lesions, as well as revisional surgeries may require more invasive surgery but this is not the majority of cases by any means.

When you have finished the treatment course for neuroma ablation/excision, you will feel a numb sensation between the toes which the lesion was found. This is the most common complication, but it is not a true complication. Especially when that area was previously painful and quite problematic while walking.

Arthrosurface and You

Great Toe - Product Overview
The Arthrosurface® HemiCAP® system is a surgical method for the treatment of localized cartilage lesions and defects in the major joints. This system is comprised of three elements; a three-dimensional mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome and titanium implant. The system precisely aligns the surface of the implant to the contours of the patient's articular cartilage surface, thus filling the defect and restoring a smooth and continuous articular surface. The HemiCAP® system has been developed so that it can be utilized via minimally disruptive surgical techniques.

The HemiCAP® Instrument Set enables the surgeon to accurately place the implant and precisely map the curves of the articular surface, in real-time, under direct or arthroscopic visualization, with no angle-induced errors or magnification errors that might exist with MRI, or X-ray imaging techniques.

The HemiCAP® system is intended to provide an effective interim means for managing pain and disability in the middle-aged patient until a total joint replacement treatment option becomes more necessary, and is part of a clinical treatment strategy to help avoid early-age-revision scenarios. The prosthetic may also provide a treatment option for the older patient who may not tolerate the morbidity of a total joint replacement procedure.
The HemiCAP® implants and instruments are designed to remove a minimal amount of bone stock, preserve functional structures and tissues, and allow for an uncomplicated removal in the event of revision. (Taken from the manufacturer's website)

As far as implants go, this utilizes very minimal bone ressection which makes is easier to fuse the joint down the road if the need arises with less need for bone graft and plating techniques. Ultimately this implant in the right patient will do well. If you are too active, young, have Gout, or have bad arterial circulation you are probably not a good candidate for this procedure. Regardless, if you are having joint pain in the first toe joint and other doctors have told you that fusion is your only option, it would not be detrimental to stop here and let us decide if this implant is a good "fit" for you.

LASERS and Nail Fungus

Nail fungus is a chronic condition which manifests as a thickening, yellow or brown discoloration highly associated with concurrent tinea pedis (athlete's foot). This condition has made recent news on account of new NON FDA approved treatments which are beginning to surface here in Naples. I often am asked about the new high tech treatment which is said to be painless and effective. This is LASER fungal ablation. I am highly skeptical about this treatment, as it is only shown to have efficacy in the short term. I am certain it is not covered by insurance, and I doubt it is a first line treatment modality as of yet in terms of standard of care. Regardless, I am glad to enlighten our readers on the topic, and perhaps we can gain a fundimental understanding about this treatment modality.

Noveon Laser
Nomir Medical Technologies in Waltham, MA is developing a laser called Noveon for treatment of nail fungus. Noveon is a type of laser already commonly used by doctors for treatments like cataract surgery, dental work and hair removal. Noveon beams two different wavelengths of near-infrared light at toenails to selectively take aim at and kill fungi.In the latest study, after four Neovon laser treatments, about half of the 39 toenails tested no longer had active nail infections. Six months after the initial treatment, about 76 percent of the patients had clear nail growth,.

Patholase Laser
Another company, Patholase, is already marketing the Patholase PinPointe FootLaser for treatment of fungal nails. Clinical trials released by the company report 88% cure of the fungal infection with one laser treatment. However, according to a March 19, 2009 article in the New York /Times, the company’s claim of FDA approval for this procedure is being questioned. We will keep track of how this progresses and update this page when we have new information.

Will this Treatment be covered by Insurance?

Laser treatment of nail and skin conditions is not covered by insurance plans as it is considered aesthetic. You can expect the cost to run between $600 and $1200.

Recommendations
If this modality seems applicable to you, by all means feel free to explore it. I am certain that more cost effective measures should be taken first, and if traditional treatment fail, perhaps the pursuit of more advanced treatment should then be entertained. This is an off label use of LASER modality, and only time will tell if it is advantagious longterm or at all to utilize this costly treatment protocol.

Pesky Warts

What exactly are they?? How did I come to get them? What can I do to rid my skin of them??


These are the main questions that patients frequently ask me when I initially see them for these lesions. I plan to answer each one and give you some insight as to what sorts of treatment strategies are available at our center.


Verruca vulgaris, or verruca plantaris is an epidermal manifestation of a viral infection from particles of the human papilloma virus. This sounds rather deleterious, but truthfully this is a mild variation of viral substances which are in a family of pathogens that cause various wart like lesions in other areas of the body. To simplify, it is a virus that causes wart tissue proliferation. The virus produces it's own blood supply, and the tissue gets thick very quickly causing the characteristic black spots within. When we "scrape" the wart off, we can see pinpoint bleeding from the vessels created by the viral tissue.












The skin has lines which we see as "Fingerprints" and the skin on the bottom of our feet have them too. When viral particles integrate with the skin tissue, these lines disappear. This is another clue towards the diagnosis of verruca.

The reason some people are susceptible to contracting plantar warts is a controversial topic. Some researchers believe it is stress. Others believe a juvenile immune system, or immune compromised individual are more prone. I believe there are a multitude of reasons, but don't fret if you think you will spread them to everyone in your family, because chances are you will not. They are contagious, but only to those who have the inherent susceptibility to getting them.

Treatment is varied, and little scientific research has shown one method of wart removal to be superior to another. In my practice, I have seen warts spontaneously resolve, and I have seen multiple attempts of their removal including surgery fail. They are resilient at times, and at other times they are simple to cure. Some believe with younger patients, you can actually coax the wart to resolve by simply drawing a picture of the wart and crumbling the artwork into the trash.

At the Family Foot and Leg Center, we have an excellent track record in their eradication. We use a multitude of treatment modalities, including PlantarStat application, Cryofreeze technology which using subzero temperatures to remove the lesions, and simple surgical excision as major options. Duct tape has also been utilized as an occlusion material with our medications, to soften the tissue and some believe even elicit further immune response against the viral particles. Come in to see us and we will be happy to assist you in your need to remove those pesky warts.

Adult Acquired Flatfoot (AAF)

Why do some adults get flat feet when they weren't born with flat feet ?

Occassionally I will get questions which are profound, as they give me insight into what people want to know as a whole. So whenever I get a good question I will try and answer it on this blog. This information may answer many of your questions that you did not know you had at the time, and may make for some intelligent reading as well.

The adult acquired flatfoot (AAF) is a progressive, symptomatic (painful) deformity resulting from gradual stretch of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.

Most flat feet are not painful, particularly those flat feet seen in children. In the adult acquired flatfoot, pain occurs because soft tissues (tendons and ligaments) have been torn. The deformity progresses or worsens because once the vital ligaments and posterior tibial tendon are lost, nothing can take their place to hold up the arch of the foot.

The painful, progressive adult acquired flatfoot affects women four times as frequently as men. It occurs in middle to older age people with a mean age of 60 years. Most people who develop the condition already have flat feet. A change occurs in one foot where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Why this event occurs in some people (female more than male) and only in one foot remains poorly understood. Contributing factors increasing the risk of adult acquired flatfoot are diabetes, hypertension, and obesity.

The following scheme of events is thought to cause the adult acquired flatfoot:

1) A person with flat feet has greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot.

2) Throughout life, aging leads to decreased strength of muscles, tendons and ligaments. The blood supply diminishes to tendons with aging as arteries narrow.

3) Heavier, obese patients have more weight on the arch and have greater narrowing of arteries due to atherosclerosis. In some people, the posterior tibial tendon finally gives out or tears. This is not a sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation and degeneration of the tendon.

4) Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down from above. The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot literally dislocates outward from under the ankle joint.

Treatment varies based on the stage of the disease, and each patient is treated differently based on findings. Arthritis, age, comorbidities, and whether it's flexible or rigid greatly influence the the foot and ankle surgeon's modalities. Surgery and bracing are key elements to reconstruction and palliative symptom control.

In this section, I encourage readers to submit questions/comments/personal stories/etc and I will definetly respond on this forum. I enjoy informing people about their conditions and the reasons why we do what we do for them. I do not have all the answers, as nobody can say they do, but I will strive to report the latest information available and keep you up to date as I go through these many topics.

Smoking and Bone Healing

After joining the Family Foot and Leg Center here in Naples, Florida, I have met quite a number of younger adult patients who have no idea of the deletarious effects that smoking can have on overall healing. Although this is a circumstantial finding backed by significant amounts of statistical evidence, many younger patients still are not aware of this. I thought it would be beneficial to enlighten everyone about this common topic.

Why are bones affected by smoking?


Bones are nourished by blood much like the other organs and tissues in your body. Nutrients, minerals, and oxygen are all supplied to the bones via the blood stream. Smoking elevates the levels of nicotine in your blood and this causes the blood vessels to constrict. Nicotine constricts blood vessels approximately 25% of their normal diameter. Because of the constriction of the vessels, decreased levels of nutrients are supplied to the bones. It is thought that this is the reason for the effect on bone healing, as the impending need for more oxygen and nutrients during fracture and osteotomy healing are not met, causing prolonged union time.

Evidence Based Medicine Review

"Cigarette smoking is detrimental to bony healing," said Dr. Franklin Chen, an orthopaedics instructor at Northwestern University Medical School in Chicago, Illinois, and lead author of a report presented at the recent annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held in New Orleans, Louisiana.
He and his colleagues focused on the 13-month healing rates of 54 patients who underwent surgery to help correct a specific type of (often work-related) wrist injury called symptomatic ulnar impaction syndrome. Chen says "95% of nonsmokers healed compared to 68% of smokers; this difference is statistically significant. The mean time to healing was 5 months for nonsmokers and 7.2 months for smokers." Previous studies have shown similar slower healing rates among smokers who have undergone spine or ankle fusion surgeries.

So that being said, it is important to note that when I or any of the physicians at our office "lecture" to you about the cessation of smoking and it's direct impact on your healing potential, we are not just being mean. It's based on clinical evidence that is monumental for your optimal outcome. This can impact healing time in stress fractures and wound healing as well, so cessation is your best bet!!!

Here is a link to a recent news article discussing this topic as well:

http://www.msnbc.msn.com/id/9730345/

Heel Pain and Life

So many people suffer from this day ruining clinical entity loosely labeled "heel pain". I often wonder what the staggering statistics would reveal about how many people encounter this at some point in their lives, especially since many people who deal with this will not enter the doctor's office at all, or wait until it has been bothersome and worsening for a number of months. Some will find out they will get better on their own. The rest will limp into the chair and tell us that they feel their life is in shambles because they are constantly in pain.

Many patients who deal with heel pain are most likely going to be under the common diagnosis of "plantar fasciitis". There are many other conditions that reveal themselves by heel pain as well, and these can be diagnosed by exclusion most times in a clinical setting. On it's own, plantar fasciitis is a relatively easy condition to treat, and there are many options to treat this nonsurgically. I will describe some simple stretch routines as well as ways to relieve this prior to any physician intervention.















Foot/Toe Stretch:
 Sit on a chair and place your ankle over the opposite knee.
 Grip toes and gently pull them back towards the knee, while holding the ankle to prevent it from moving.
 Feel the stretch in the sole of the foot all the way to the heel.
 Hold the stretch for 30 seconds.
 Repeat three times for each foot

Sometimes you can simply ice the foot with a frozen water bottle and roll this along the bottom of the foot at the end of the day for 3 to 10 minutes. Some people found that even having their significant others give a simple foot massage can alleviate these symptoms significantly. Also over the counter ibuprofen or other medicine (NSAID) can be useful. If this persists for more than a four week period of time without any relief, one should come see us at the Family Foot and Leg Center, PA so that we can get you over this hurdle and let you live without pain in the foot.