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.