Morton's neuroma - cryosurgery vs. other treatments

Despite the low risk nature of cryosurgery, non-invasive treatment should always be tried first in cases when a neuroma has been diagnosed. The main treatment options are as follows:

1. Functional Foot Orthoses: these are specialised insoles which rebalance the foot so potentially reduced tension and stress on the neuroma. Our Centre offers very thin computer designed and milled foot orthoses using laser scanning imaging. This is a far cry from the more basic, bulky and often ineffective orthoses sometimes provided to patients. We would advise patients to attend for a full biomechanical assessment and gait analysis at our Centre before proceeding with invasive forms of treatment if this has not been undertaken. If Mr McCulloch agrees that you have received good orthoses and exhausted this treatment then we may be able to proceed with cryosurgery but please, always bring your orthoses with you so that we can assess them.
2. Footwear advice: most patients with a digital neuroma find certain shoes more comfortable than others and we of course advise that high heeled pointed shoes are used sparingly. Completely flat shoes can sometimes trigger symptoms, especially when a patient presents with tight calf muscles. Patient often find Birkenstock sandals and "Fit Flop" shoes comfortable. Stability trainers such as those from Asics can also help. The London Podiatry Centre will assess patients and offer advice on specific shoes following gait analysis.
3. Exercise rehabilitation: Some patients present with increased nerve tension because of conditions such as sciatica which can aggravate or trigger neuroma type symptoms. Tight calf muscles and weakness caused by flat feet can also trigger the condition. Such deficits (and potentially many others) can be detected following in depth biomechanical and gait analysis at our centre in which case rehabilitation programmes are provided.

Steroid injections

A steroid injection can sometimes be effective but the problem often recurs. We believe that the steroid is more effective at dealing with a fluid filled bag more often than not seen around the neuroma called a bursa. By reducing the inflamed bursa with the steroid, the pressure on the nerve reduces and the steroid may also help by breaking down fat around the nerve.

The Centre strongly advises against multiple steroid injections i.e. more than 2 a year. We have seen many patients who have developed extensive "fat atrophy" from multiple injections. This presents as wastage and dimpling within the foot which can give rise to other complications. Furthermore if a steroid has not worked on a couple of occasions, why keep trying?

Alcohol injections

Having reviewed the literature on alcohol injections, the Centre does not recommend or endorse this treatment. It can be effective, but complications including chronic pain appear high and other treatment modalities appear to be associated with reduced risk of complication and higher success rates.

Minimally invasive surgery to release the intermetatarsal ligament

The metatarsals (that cause squeezing of the nerve) are held together by a ligament called the "intermetarsal ligament". This ligament is sometimes surgically cut by means of a small incision (sometimes using a small camera called an endoscope) to release tension on the nerve. The procedure has been shown to be successful in some instances. At the Centre we have reservations about the procedure because the nerve may still become compressed by pressure from shoes which would tend to push the metatarsals together again.

Open procedure to remove the nerve

In cases where cryosurgery has not been effective, the neuroma can be removed through an incision on top of the foot. An incision on the bottom of the foot should be avoided because of possible painful scar formation. A small incision followed by meticulous dissection to remove the nerve is generally effective with success rates between 70 and 90 percent. Mr McCulloch performs this operation when required although very infrequently when compared to cryosurgery which should always be tried first.

Shock wave therapy

The London Podiatry Centre offers shockwave therapy to facilitate healing of various conditions, particularly plantar fasciitis, a form of heel pain. Presently, we remain unconvinced that this treatment is effective for Morton's neuroma.