Experts Share Their Insights On Treating Neuromas

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Samuel Nava, Jr., DPM, says female runners comprise approximately 10 to 15 percent of his patients with neuromas.
Here is a preoperative view of chronic midfoot Charcot neuroarthropathy. A new study shows that the combination of a thorough patient history and simple neurologic testing can help predict the risk of Charcot neuroarthropathy.
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By Brian McCurdy, Associate Editor

Painful foot neuromas are a common dilemma among podiatric patients and the neuromas appear to be increasingly more prevalent among runners. Samuel Nava, Jr., DPM, a Fellow of the American College of Foot and Ankle Surgeons (ACFAS), estimates that approximately 10 to 15 percent of his patients with neuromas are female runners. He notes that female runners who wear more narrow shoes at work and subsequently go running on hard surfaces may be at a higher risk for developing neuromas.
Bruce Werber, DPM, a Fellow and Past President of ACFAS, says the majority of his neuroma patients are female but he believes that non-running footwear is the culprit in the majority of these cases. However, he has found that males with neuromas are more likely to be runners.

Both DPMs emphasize the importance of addressing the patient’s footwear when treating neuromas. In addition to ensuring that patients are wearing proper running and work shoes, Dr. Nava says modifying the shoe with a wider forefoot can be helpful. He also recommends the use of padding via a neuroma pad and strapping/support. Dr. Werber notes that he may modify the shoe liner to facilitate biomechanical control. If this works, he will proceed to cast the patient for a functional orthotic.
In regard to other conservative treatment options, Dr. Nava says using ice or contrast soaks after running can be beneficial. If this proves to be unsuccessful, one may consider NSAIDs, cortisone injections, physical therapy or immobilization.
If footwear modifications fail, Dr. Werber says he will obtain an ultrasound to confirm the presence of a neuroma. If it is positive, he says he may utilize a series of ETOH and Marcaine injections. If the ultrasound is negative, Dr. Werber tries low-dye taping and several other techniques to “change the mechanics of the forefoot.” He adds that he also may consider physical therapy and will evaluate the effect of the gastrocnemius-soleus equinus.

Obtaining High Success Rates With Surgery
When conservative treatment fails, Drs. Nava and Werber have both had a significant rate of success with surgical procedures.
Dr. Werber says he has had an 85 to 90 percent success rate with his primary surgical option, the Isogard™ System (Koby Surgical), which decompresses the interspace. Dr. Werber says approximately 5 percent of his patients who undergo this procedure experience some residual low grade discomfort and less than 1 percent have needed neurectomies.
Dr. Nava has had a “very high” success rate performing neuroma excisions, emphasizing that more than 90 percent of his patients found improvement in their conditions. While he prefers a dorsal surgical approach, Dr. Nava notes certain other approaches, such as plantar incision and endoscopy, can be just as effective.
When neither conservative treatment nor surgical decompression get results, Dr. Werber says he may obtain a MRI in order to obtain a more definitive diagnosis. In these cases, he will also evaluate these patients for the possibility of tarsal tunnel syndrome, sciatic nerve entrapment, a herniated disc or spinal stenosis.

Re-Emphasizing Shoewear And Patient Compliance
When it’s all said and done, both DPMs say ensuring patient compliance with footwear recommendations plays a key role in treating neuroma pain. Dr. Nava suggests providing patients with options for shoes that will help relieve their condition as opposed to exacerbating it.
Like Dr. Nava, Dr. Werber works with his patients, putting the onus of healing on them and telling them if they want relief from pain, they must participate in the process.
“Sometimes participation requires giving up on vanity for awhile and letting their bodies heal,” offers Dr. Werber. “The alternative is lost time from work and the inconveniences of surgery.”

Predicting Charcot Risk:
New Study Says Patient History And Neurologic Tests Are Key
By Brian McCurdy, Associate Editor

Obtaining a thorough patient history and performing simple neurologic tests are the best barometers for determining which patients are at risk for Charcot neuroarthropathy, according to a recent study in The Journal of Foot and Ankle Surgery (JFAS).

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