Conservative care of Morton's neuroma
Conservative care of Morton's neuroma begins with understanding how weight bearing, walking and shoes contribute to the symptoms of Morton's neuroma. Wider shoes with a lower heel will help to decrease the symptoms of Morton's neuroma. Narrow shoes have a tendency to compress the forefoot which in turn compresses the interdigital nerve, contributing to the onset of a neuroma. The higher the heel, the greater force the forefoot will carry and subsequently increase the symptoms of Morton's neuroma. It's interesting how some shoes seem perfectly designed to bring about the onset of Morton's neuroma. When you look at the function of a high heel pump, there's really only one part of the shoe that grabs onto the foot and that's at the forefoot. By doing so, a pump will compress the forefoot and initiate a new neuroma or irritate an existing Morton's neuroma. Add a bit of a heel to that and you've got a great potential for problems. I've treated many patients who have found that by simply changing the style of their shoes they correct all problems with a Morton's neuroma. They just keep their pumps for special occasions.
But it's not only high heels that are the trouble makers. There are a lot of specialty sports shoes that contribute to the onset of Morton's neuroma. Biking shoes are a big one as are bowling shoes. In both cases, you wear a shoe designed for the activity and then once you're actually in the activity you focus load bearing on the forefoot. In biking you focus load on the peddle and in bowling, load is focused with the delivery of the ball.
What is the Jane Russell effect?
Once you've determined that you shoes are wide enough, it's time to start working with different types of pads to treat Morton's neuroma. My favorite pad is the felt metatarsal pad. In practice, I tell my patients that the felt metatarsal pad offers the Jane Russell effect. Jane Russell was the spokesperson for Playtex Cross Your Heart Bras. Jane was a big girl and needed the support offered by the Cross Your Heart Bra. Their motto was that the Cross Your Heart Bra 'lifts and separates'. Well that's exactly what the felt metatarsal pad does when used to treat Morton's neuroma. When properly placed, the felt metatarsal pad will lift and separate the metatarsal heads. By doing so, the felt met pad will off-load the Morton's neuroma and decrease pain. I really think the use of a felt met pad is under utilized in foot care. In my practice, I tend to find that up to 7 out of ten folks who use a felt met pad to treat Morton's neuroma respond favorably if not completely to this simple treatment. Metatarsal pads come in a variety of sizes, shapes and materials. Sizes and material often become a personal preference. But in terms of durability and success of treatment, my go to is the felt met pad.
Orthotics with a metatarsal pad are one further step that can be used to treat Morton's neuroma. Orthotics will tend to offer a bit more mechanical stability for the foot. When combined with a met pad, orthotics can be an awesome tool in the tool box for treating Morton's neuroma. I think the issue with orthotics though is fit. From an academic standpoint, orthotics make good sense. But sometimes, from a practical standpoint, orthotics just won't work. Orthotics are great for work boots and running shoes but will never work in dress loafers. It's important to speak with your doctor prior to being casted for orthotics to have a thorough discussion regarding your intended use of the inserts. If you are an office worker wearing dress shoes, you may be better off with a met pad in the shoe or with the use of an Arch Binder with Met Pad. But if your daily activities allow for an orthotic, that might be the better way to go.
One additional shoe modification that's often overlooked in the treatment of Morton's neuroma is the anterior rocker sole. To describe an anterior rocker sole, think clog. Clogs will rocker off the forefoot with each step. The forefoot rocker will decrease ground reactive force to the forefoot and decrease load bearing to the Morton's neuroma. Clogs are in fact a great tool used in treating Morton's neuroma due to their wide, open forefoot and anterior rocker sole. Anterior rocker soles can also be added to your shoe by a shoe repair shop.
When should you use cortisone to treat Morton's neuroma?
So if shoe modifications, met pads and orthotics don't do the trick, how then do we treat Morton's neuroma? At this stage we'd consider using one of several choices of injectable medications. The mainstay of injectable medications for years has been cortisone. Cortisone is used to decrease inflammation of the nerve and nerve sheath. Other injectables include dilute absolute alcohol. Injection of alcohol adjacent to the neuroma is used to intentionally destroy (ablate) the contents of the nerve. Bear in mind though that you really shouldn't use both at the same time. Cortisone will decrease the ability of alcohol to ablate the nerve. Think cortisone for nerve healing and alcohol for nerve destruction. Let's talk about each in a little more detail.
Cortisone for injection is a man made chemical analog of a hormone that is secreted by your body each and every day. The cortisone secreted from your adrenal gland is used to regulate both emotional and physical stress. When you doctor recommends the use of injectable cortisone to treat your Morton's neuroma, he or she is recommending a concentrated does of cortisone to be placed immediately adjacent to the neuroma. An injection of cortisone can be very successful in reducing the inflammation in the neuroma which subsequently reduces pain. How many cortisone injections is too many? There's no definitive answer for this question due to the fact that each patient and each injection may vary. Some patients will respond to cortisone injections very favorably and tolerate several injections with no ill effects. Also, the type of cortisone and the dosage of cortisone used by your doctor may vary. As a rule of thumb, I don't use more that two injections of cortisone for the treatment of Morton's neuroma. These two injections are usually going to be spaced at 3-4 weeks apart. My fear with multiple injections of cortisone is fat pad atrophy of the ball of the foot. When used judiciously, cortisone is a great drug. But when overused, cortisone can weaken tendons and destroy the plantar fat pad of the forefoot. Cortisone also needs to be used sparingly in diabetic patients. An injection of cortisone can make a Type 1 or Type 2 diabetic's blood sugars go on a roller coaster ride. Easy does it with the cortisone.
Injectable alcohol is one of those medications that comes into vogue every 30 years or so. This technique goes by a number of different names including chemical ablation, chemical neuro-ablation and chemical neuroma injection. Injectable absolute (pure) alcohol has been used for years to treat trigeminal neuralgia (facial pain). In the past 6 years or so, alcohol injections for the treatment of Morton's neuroma have become very popular. The advantage of alcohol injections is that the injection spares the nerve sheath. The intent of the alcohol injection is to destroy the contents of the nerve (like surgery) but spare the sheath of the nerve (unlike surgery). Peripheral nerves have a tendency to try to grow back. In surgery where the nerve is removed (neurectomy) there are many instances of an attempt to regenerate the nerve which results in a regrowth of poorly differentiated nerve tissue often called a stump neuroma. The beauty of the alcohol injections is that your essentially performing a neurectomy without the surgery. Alcohol injections for ablation are performed on a serial basis and repeated each week for 5-7 weeks. That means if you're interested in this method of care you need to be ready for up to 7 injections. The success rate of alcohol injections is quite good. Occasionally we do see regrowth of the nerve following ablation that require additional injection one to two years following the initial series of injections.
What else might be tried to treat Morton's neuroma? Additional physical therapy measures such as ultrasound or electric stimulation have not really proven to help in cases of Morton's neuroma. I'm not familiar with chiropractic methods of care, but I have heard from patients that their chiropractor has helped with manipulation of the foot. Massage, acupuncture and orthobiometrics may also be tried. Personally, I don't have experience with these methods of treatment and cannot cite success rates with their use.
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