What is a Neuroma? How do you treat Neuromas? and, Alternatives to Neuroma Surgery when conservative treatment fails. Radiofrequency Ablation for Neuroma.
A neuroma is an inflamed, enlarged nerve. Many problems that end in -oma are tumors but this one is not. Neuromas can occur at any nerve in the body but are very common in the foot, which are the ones I will discuss.
Neuromas are most often found in the common metatarsal nerves of the foot which are the nerves just behind the toes. The job of these nerves is to allow you to feel one side of each of the adjacent toe. For example, the metatarsal nerve between the third and fourth toes allows you to feel the sensation on one side of the third toe and the adjacent side of the fourth toe. These nerves do not connect to any muscles, they are just for sensation.
A neuroma forms when the nerve is pressed upon by the adjacent structures. The four surrounding sides of the nerve are made up of: The two metatarsal bones next to the nerve to the left and right. The top border is a ligament connecting and holding together the two adjacent metatarsals called the ‘deep transverse intermetatarsal ligament’. The bottom structure is the skin and the ground below it.
This space defined above is a small place for the nerve to pass along with tendons. Pressure when walking hurts this inflamed nerve. Most people describe the pain as intermittent and ranges from mild to severe. I often hear it described as pain, numbness and tingling that shoots into two toes. Many people describe an uncomfortable fullness between their toes.
People can have neuroma pain in multiple interspaces and in both feet or just one spot. The most common place is between the third and fourth toes and the second most common place is between the second and third toes. Neuromas are very rare in the the first and fourth interespace.
Neuromas between the third and fourth toes are called “Morton’s Neuromas”. Dr. Morton named this neuroma after himself because they are so predominantly found between the third and fourth toes. The reason for this is that the third interspace nerve is naturally larger than the others and is more likely to become inflamed and painful.
People with arches that collapse (pronate) or flat feet are more likely to get neuromas. When the foot pronates and the arch collapses, the foot moves slightly toward the side, toward the little toe. This puts horizontal forces on the metatarsal bones pushing them together.
Women who wear heels are more likely to get neuromas because the high heels tilt the foot forward putting more direct pressure up on the nerve. People who wear tight shoes in the forefoot also get neuromas as the shoes push the metatarsal bones together.
So now that we have described what neuromas are, why we get neuromas and neuroma symptoms, let’s discuss treatment for neuromas.
The first line of treatment is anti-inflammatory measures in order to decrease pain and make the enlarged, inflamed nerve smaller. This first line of treatment includes prescription and over the counter anti-inflammatory pills, icing, and corticosteroid (‘cortisone-like’) injections.
Often, I will give an injection on the first visit. Injections work very well and very quickly to get rid of neuromas. Unfortunately, there are side effects of steroid injections. Usually one injection will not have adverse effects but I have seen it happen. These adverse side effects of steroid injection include local atrophy (weakening) of soft tissues such as ligaments and tendons. Weakening can lead to injury and rupture of these structures. I do not like to give more than three steroid injections in the same spot within twelve months. Other side effects of steroid injections include fat atrophy where a small indent forms between the bones where the injection takes place because the natural fat below the skin atrophies. This can be permanent or temporary. An additional side effect of steroid injections is loss of pigment in the skin. This can happen just in the area of the injection or it can travel along the lymphatic and vein structures causing a streaking effect. This usually only effects people with darker skin and more pigment.
Again, these are side effects that rarely happen but can occur. I discuss these with patients prior to injecting. Due to these potential problems, I try not to perform injections on the first visit and try alternative treatments first. With that said, I do perform these injections regularly on the first visit. I do them when the patients are in severe pain and want quick relief from the pain they are suffering from as the injection is the quickest and one of the most effective ways of getting rid of painful neuromas.
In my experience a majority of the people that are treated with icing and oral anti-inflammatories return for an injection on the subsequent visits.
The next line of treatment involves a longer approach to eliminating the forces that cause neuroma. This is done with custom or over-the-counter orthotics. Sometimes just a pad alone in the shoe can reduce the pressure by pushing the metatarsal bones apart and off the nerve, but a custom orthotic does this as well as addresses the collapsing arch.
When all the above treatments fail, my next treatment is physical therapy. Physical therapist perform anti-inflammatory ‘modalities’ to try to reduce the inflammation of the nerve.
When all the above and PT fail to treat neuromas then we discuss a little more invasive procedures. Surgery for neuromas is the last resort. There are some newer procedures that we call minimally invasive procedures for neuromas. Please do not confuse this with minimally invasive bone surgery of the foot which I discussed in detail of the perils of it, in my previous blog.
There are a few minimally invasive procedures for neuromas:
My favorite procedure is called ‘Radiofrequency Ablation for Neuromas’. I have been doing this amazing procedure for a few years and I have close to one hundred percent success with it. This involves inserting a radiofrequency probe into the foot right at the inflamed nerve. Once it is in the perfect spot, I heat up the tip of the probe to ninety degrees Celsius, just below the boiling point of water. I repeat this process at three areas of the neuroma, all through one entry point through the skin. This pin point spot of heat denatures the proteins off the nerve and stops the transmission of the pain fibers.
Occasionally, there is a result of numbness or decreased sensation in the two adjacent toes, but that is rare and when it does happen, people have always told me that a tiny amount of numbness is better than pain.
Radiofrequency ablation for neuromas is a relatively painless procedure that requires just one or two injections that hurt less than a typical steroid neuroma injection.
Recovery after radiofrequency ablation for neuroma is pretty easy as well. Healing time is very short as there are no incisions to heal. Patients do not need to worry about keeping a foot dry for this reason, and can get it wet and shower immediately after the procedure. Additionally, I only recommend patients stay of their foot the night of the procedure and rest only if there is discomfort for one to two days after. Most people report mild soreness or throbbing for one to two days after. Many people have no discomfort at all afterwards.
After radiofrequency procedures I tell patients that they may see immediate relief of the neuroma pain within one to five days. I also inform them that some people require up to three months for the procedure to work. I do not call it a failure until three months have passed and the pain is still the same as prior to the procedure. When people report no relief at two months, I will repeat the radiofrequency procedure at that point. If they have some relief I tell them to wait a full three months. If they still have some or all of the pain at three months, I repeat it then. I have done one, two and three procedures on people so far and have almost a perfect record.
Other minimally invasive procedures for neuroma include a series of seven to ten sclerosing alcohol injections, cryosurgery for neuromas, and a nerve decompression procedure often called a ‘kobygard’ procedure. I’ve done them all in the past and prefer the radiofrequency over them all. The alcohol injections did not work very well with only a handful of patients having any relief. The cryosurgery procedure worked okay but people had significantly more post procedure pain than radiofrequency and no where close to the success rate. Cryosurgery for neuromas is also done in the hospital or surgery center while radiofrequency is done in my office. Lastly, the kobygard procedure had a better success rate than the cryo or alcohol but not as good as the radiofrequency. Kobygard decompression is also done in the hospital or surgery center and is more invasive requiring a small incision between the toes and suturing. This means you need to keep the foot dry for twelve days after surgery. Patients also experience much more post procedure pain than the radiofrequency as well.
The last option is surgical removal of the neuroma. This is a great procedure when it its needed but as you can tell since I’ve started doing the radiofrequency procedure I have not had to do many open surgeries. This surgery involves an incision on the top of the foot and dissection down to the nerve below the ligament. I then remove the enlarged area of nerve and close up the foot.
When I do these surgeries, the nerve is very enlarged. To give you an analogy of what it looks like, a normal nerve looks like a piece of spaghetti’s thickness. A neuroma looks like the size of a jelly bean attached to the nerve. Depending on the severity it ranges from a Jelly Belly small candy to a traditional large jelly bean in size.
Okay, that’s about it for neuromas today. To summarize, neuromas are enlarged nerves caused by mechanical irritation. They can be very painful and annoying. We’ve discussed conservative, non surgical treatment as well as minimally invasive treatment and finally surgical treatment of neuromas.
As always, I hope this help and feel free to comment. I will do my best to reply in a timely manner.
Dr. Sergi
reading your article was very informative. But I still cannot find a surgeon for me. I have a neuroma, but in a rare place.. My left knee. I seen so many different doctors, and had 2 injections and nothing worked. I was told to get surgery. I Think Now there is 2 neuromas and i’m in much more pain than before.Please help !
Hi Haman.
I only treat the foot and ankle and I reall do not know anything about knee neuromas. However, I Can’t I imagine the treatment is much different except for the weight bearing part. speak to a neurologist or orthopedist about treatment with more invasive procures once the other treatments have failed.
This includes radiofrequency ablation, sclerosing alcohol injections and surgical excision.
Get a MRI to confirm the size and location of the neuromas.
i had a neuroma between my second and third and was a very successful surgery which it was done on march 2011. but due to it. my small toe suffered severely and i dislocated it. im in the Navy and wear boots hours on end and get at least 5 to 6 hours of rest. Another surgery was performed about a little over 2 months ago with a cast on my left leg and im back on my boots. my Doc. told me to take it easy. i am a sailor and go up and down the ladders all day onboard ship. turns out i also have RA and both my feet were swollen after work. what else do i need to do to get better and do my job a little bit fast. i drag my feet all day. i can barely walk. thank you.
Hi Jenny.
See a rheumatologist for your RA and see if the recommend any medications to prevent of slow progressive arthritis from getting worse. See a podiatrist to get some custom molded orthotics to make walking, climbing and working more comfortable.
Dear Dr. Silverman,
I developed a neuroma between my left toe and the second toe. I have tried rest, mortrin, anti-inflammatory medication (both topical and oral) called voltaran, had 1 corrizone injection and am on anti-inflammatory medication, hoping for the best. I am an Amerixan living in Sourh east Asia for an extended time period. Do you have any recommendations on either what to do at this point or can you recommend a competent podiatrist abroad? I am in Bali and should be in Thailand on a few weeks. Do you know if anyone in This part of the world performs the radiofrequency procedure?
Thanks in advance for your help. It is sincerely needed and appreciated.
George
Thanks in advance
Hi George.
From your comment, it sounds like you are describing pain between you left great toe and second toe.
It is very, VERY rare, to have a neuroma there. 99% of inter metatarsal neuromas are between the second-third and third-fourth toes, inter metatarsal spaces.
If your pain really is between first and second toes it is probably not s neuroma and radio frequency ablation procedure will not work.
More likely diagnoses are: bursitis, sesamoid injury, capsulitis, avulsion fracture, tendinitis, sprained ligaments or strained muscle / tendon.
Good luck. Dr. S.
Thank you for your response. I appreciate your help and advise as the problem has been frustrating to say the least. I looked up the other potential diagnoses that you mentioned and two of them seem plausible, similar in characteristics to a neuroma. At any rate, I am very happy to report that the nerve problem and the lamp cord feeling under the center of my foot have been remediated after rest, a cortisone injection, and two weeks of anti-inflammatory oral and topical medication. However, I now have some pins and needles feelings and slight numbness in my big left toe. Is this likely a residual characteristic after having maybe a neuroma or a nerve related problem or is it a serious concern that I should have looked at? We are leaving Bali (amazingly not one podiatrist here) to Thailand where they should have a specialist (I hope). Do you suggest that I follow up as soon as possible or should I wait to see if the tingling goes away with time?
Thank you so much for you time and advise.
George
Dr. Silver,
I have two neuromas, one between 2nd and 3rd and one between 3rd and 4th. I have ultrasound and x rays available from HSS where I got injections that didn’t work. Can you do RF on both of these at the same time? Do you do this guided by ultrasound? I am cancelling surgery since my spine doctor talked about RF that he is doing successfully on nerves. He suggested I look into this before open surgery.
Hi Karen,
Thanks for the comment / question.
Yes, I often do both second and third interspace neuromas at the same time with the radio frequency ablation procedure. I do use ultrasound guidance to fine-tune and confirm the placement of the probe.
Since I started doing RFA procedures I have been doing significantly less open neuroma removal surgeries.
The RFA procedure has been used in the spine much longer than the foot as spine doctors originated the procedure. I have had incredible success with the RFA procedure for neuromas. I estimate the success rate to be 8-9 out 10, or 80-90% success.
Dr. S.
Thank you so much for your article. It was very informative, and explained things in a very easy to understand way. I had decompression surgery more than 2 months ago for a neuroma between the 3-4 metatarsals. During surgery, he contemplated removing the neuroma, but opted to continue with the plans of decompression. It, however, has not relieved the pain and my surgeon is now suggesting either radiofrequency ablasion or neuroma excision. He wants to do the ablasion, but is concerned because the neuroma is very large, and wonders if he should just excise the neuroma. Should ablasion be avoided with larger neruomas? Thanks for your thoughts.
Hi Amy.
There is really no downside to delaying neuroma excision to try radiofrequency ablation surgery prior.
I actually will recommend three RFA procedures prior to neuroma excision surgery. I do them 2-3 months apart as it can take that long for the RFA to be effective.
When all three fail, then I excise the neuroma.
RFA works on all sizes of neuroma. Often when there is a very large neuroma the pain will go away but that clicking still occurs when the neuroma moves up and down between the bones.
Hope this helps.
Dr. S.
Thanks! I’m keeping my fingers crossed that my scheduled ablation will eliminate my pain. Thanks again for your thoughts and advice.
Hi doctor! I’m nurse, work with pain and live in São Paulo, Brazil. You can help the brazilians doctors with coagulations of morton’s neuroma? My adress is saudemfoco@bol.com.br.
Thank you very much.
Alexandra Bizerra
Hi Alexandra,
Perhaps someone will want to sponsor me to come to Brasil and bring my radiofrequency ablation equipment with me to train a bunch of doctors on its use. I’ve never been to Brasil but would love to.
All I would require is paid airfare and lodging and I’d lecture for free.
Dr. S.
That you so much for this information. I have a neuroma between my second and third toe. I only recently found out what it was after having the pain since May. It took a long time to get into the doctor. I had an MRI and the doctor said even though the tech said it was normal, he looked at it and said I have a neuroma. He said it’s not reversible and I’m scheduled for surgery next month. Earlier he had mentioned injections and orthotics, but now he must think this is beyond that. He never said anything about the other procedure you mentioned. Do you think there is ever a time to skip those things and go right to the surgery? The foot is bothering me a lot and it seems like this taking forever. Thank you.
Hi Cindy,
I always do conservative treatment for neuroma prior to surgery. A majority of patients with neuromas (est. 90+ %) do not need surgery.
My first line of treatment is Kenalog injection, Ice 20 min twice daily, oral anti-inflammatories for 1-2 weeks and often custom orthotics.
When these fail, I will give a second injection one month later. I often prescribe physical therapy at this time too. When another 6 weeks go by and there is still pain, then I recommend more invasive treatments.
My first choice is the radiofrequency ablation procedure. More than 90% of the time this gets rid of the pain with one radiofrequency ablation treatment.
If the patient still has pain after 8 weeks, I will repeat the radiofrequency ablation surgery. I do up to 3 radiofrequency ablation treatments. If these fail, then I schedule the patient for removal of the nerve.
In the past I had done decompression surgery to release the nerve by cutting the ligament above it. (This procedure is often called a KobyGard procedure, named after the brand name of the cutting instrument, KobyGard.) I do these procedures less lately as the nerve excision is much more often successful.
With all that said, I will sometimes jump to the Radiofrequency ablation procedure sooner if the patient is in severe pain or if they have zero improvement after the first injection.
Hope this helps.
Dr. Silverberg
Thank you, Dr. Silverberg, for this information. I’m going to call my doctor’s office tomorrow and inquire.
One more question. Is radio frequency ablation normally covered by insurance?
Hi again Cindy,
Yes, radiofrequency ablation surgery is covered by insurance.
Dr. S.
Dear Doctor, thank you for your gentle and kind reply, I admire your work and now also admire your attention and kindness. There is the possibility of coming to Brazil, yes, it would be wonderful to welcome you to train and empower our physicians in this technique, we have equipment schwa-medico RF (German) we used for other treatments for pain. Some of our customers will go to Las Vegas this year, you would be able to receive it for a while agilizamos their training trip to Brazil? I would be happy to offer our caipirinha!
Dr Silverberg:
I am a 54 year old female that is 10 weeks post op from Bunion, neuroma and 3 hammertoe surgery to my right foot.
I had virtually no pain after the surgery due to being completely numb because of what I had to have done. The neuroma was huge with 5 neuromas around it. I have most of the feeling back in three of my toes. My big toe and the one next to it are numb. I have followed my Doctor’s orders to the T. She says I am getting along great, but I am no where near fully recovered.
How can I further reduce the swelling? She offered to send me for physical therapy but who has time for that?
I am doing exercises but my toes are like sausages, I can barely move them let alone think of bending them. I am back walking 2 miles a day in # 18 compession socks.
I am so ready to be over this, any advice you have would be appreciated.
THANKS,
K.M. CARBAUGH
I have done the injections — don’t work, in fact, sometimes make it worse. I have had surgery to remove a neuroma which has partially grown back — just a nub. I have had an MRI and a sonogram of my foot that confirmed that there is definitely something there, but it’s not clear what it is, but probably a neuroma. I have also used orthotics on and off for years — before 2012 mostly on. They do not help either and sometimes make it worse. It feels as though there is a stone in my foot. I am having trouble walking and it is also causing knee problems. I was scheduled for surgery, but it was cancelled because my surgeon wasn’t sure they would be able to get at it. I cannot take anti-inflammatories for more than a couple of days before my stomach is a mess. Ice works temporarilty. It is getting much worse. Do you think the radiofrequency ablation would work for me? I would also consider the cryosurgery (which I had done for plantar fasciitis). I’m getting desperate and am in a lot of pain. Please help!
I had a lapidus bunionectomy in Sept. 2012. Was in a cast for 6 weeks and a CAM boot for another 6 weeks. Within two weeks of transitioning to shoes I developed severe burning pain on bottom of foot. My doctor diagnosised a neuroma. I had two cortisone shots 3 weeks apart. Severe pain is gone but I have developed pinching pain on the medial side of my third toe. This occurs with every step. Can neuroma develop after a bunionectomy? My doctor states it formed by my biometrics of walking after the surgery. I don’t want another cortisone shot since atrophy is present and I experienced lower back and hip pain in addition to both legs feeling as if ice water was running through my veins after the second shots. Any suggestions to relieve my constant pain?
I had a Neuroma and after many alternate procedures (not RF Abalation) I had it surgically removed. The shooting pain has simply become dibilitating. Painful recovery from surgery but succesful, problem is now I have a dull pain back farther in the foot (towards the arch) that has been diagnosed as a stub neuroma. So question is, have you used RF in a stub neuroma, is it effective? Is the probe inserted from th etop or bottom of the foot? Thanks
I have been diagnosed with a neuroma in the middle of my foot i guess you would say third toe. I have had an xray, orthotics, new shoes, anti inflammatory regimin, cortisone shot, acupuncture, nothing helps! I’m frustrated. I want to look for a good doctor who can maybe do the new treatment you speak of along with new recommendations such as maybe a mri or something. All this doctor did was squeeze my foot together which caused pain. It doesn’t tingle but feels like a bruise internally and hurts to walk when I rest it. I don’t know what it is but it’s been going on for like a year now. Do you know of any good central fl. Doctors you can recommend? Thanks so much.
Dear Dr. Silverberg,
I have a neuroma btwn the 3rd and 4th toes. I have had the Kenalog injection w/anti-inflammatory meds. Didn’t help. Next, the series of alcohol injections. STILL have excruciating pain when walking. I am very interested in trying the RF treatment. Are there any side effects or possible complications with this treatment? My prior treatments were with my doctor in Florida. I am now living in Boston and would greatly appreciate any recommendations of doctors in the Boston area. Thank you in advance for your help!!!
Kindest regards,
Jennifer