Is Injection Therapy The Best Solution for Foot Neuromas?

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Be sure to inject the dilute solution of alcohol proximal to the point of maximum tenderness.
Small glass vials of pure ethanol for injection come in 1 ml doses and are available from several different manufacturers and distributors.
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Author(s): 
Gary Dockery, DPM

At the next visit, the patient reported the pain in the ball and toes of the left foot had returned. I recommended the series of alcohol sclerosing injections and gave the first injection of 1/2 ml of 4 percent alcohol proximal to the maximum point of tenderness. I then instructed the patient to make six consecutive weekly appointments for additional alcohol injections.
After five weeks, the patient was totally pain free. She completed all seven of the injections and, during a six-month follow-up visit, reported no recurrence of symptoms. Later the next year, the patient returned and I corrected her bunion deformity.
Case Study 2: When The Patient Has
Burning And Numbness
A 56-year-old overweight female came into the clinic complaining of burning pain in the ball of the right foot and a feeling of numbness in the middle toes. The insulin-dependent diabetic patient had previously been treated with two cortisone injections and orthotic devices. When the foot problem grew worse over the last several months, the patient came in to our clinic.
After doing the physical examination, it was apparent the patient had a clinical neuroma of the third intermetatarsal space of the right foot with burning and numbness both reported. The exam revealed evidence of thinning and discoloration of the skin over the area of the previous cortisone injections. I discussed the options of a series of 4 percent alcohol sclerosing injections and surgery to remove the neuroma.
The patient elected to proceed with the injection series and I performed the first injection on the initial visit. I then saw her for four additional weekly injections of 1/2 ml of 4 percent alcohol and provided no other treatment. The patient had almost total resolution of her foot symptoms and discontinued treatment because she was pleased with the results as they were. This patient continued to be a great source of referrals, as we saw her friends and acquaintances for several years.
Final Notes
Injecting a dilute solution (4%) of ethyl alcohol for chemical neurolysis is a good alternative to other conservative treatments (such as cortisone injections) and surgical options for foot neuromas. There are very few reported complications with this technique and the success rate is relatively high.
During the early stages of treatment, you may find that some patients have an increase in the nerve symptoms of burning or pain, which is a direct result of nerve irritation from the chemical solution. However, be aware that this early post-injection increase in pain is believed to be a good sign and usually indicates that you’ll have favorable results.
In those patients that have some improvement but have not achieved complete resolution of their symptoms at the completion of the injection series, it is advisable to allow additional time to occur since many of these cases continue to improve. After about three months, if the patients still have pain, you can offer them the following options: a) discontinue all treatments; b) proceed with an additional series of 4% sclerosing injections; c) consider a cortisone injection; or d) undergo surgery.

Dr. Dockery is the Founder and Director of Scientific Affairs of the Northwest Podiatric Foundation for Education and Research, USA in Seattle. He is a Fellow of the American Society of Podiatric Dermatology and a Diplomate of the American Board of Podiatric Surgery.




References:

1. Dockery GL: The treatment of intermetatarsal neuromas with 4% alcohol Sclerosing injections. JFAS, 38(6):403-408, 1999.

2. Miller SJ: Morton’s neuroma: a syndrome. In, McGlamry ED, Banks AS, Downey MS (eds): Comprehensive Textbook of Foot Surgery, 2nd ed. Ch. 11, Williams & Wilkins, Baltimore, 1992;304-320.

3. Mendicino, SS, Rockett MA: Morton’s neuroma: update on diagnosis and imaging. Clin Pod Med Surg. 14:303-311, 1997.

4. Gaynor R, Hake D, Spinner SM, Tomczak RL: A comprehensive analysis of conservative versus surgical treatment of Morton’s neuroma. J Am Podiatr Assoc. 79:27-30, 1989.

5. Steinberg MD: The use of vitamin B-12 in Morton’s neuralgia. J Am Podiatr Assoc. 45:41-42, 1955.

6. Weisfeld M: Understanding porokeratosis plantaris discreta. J Am Podiatr Assoc. 63:138-144, 1973.

7. Dockery GL, Nilson RZ: Intralesional injections. Clin Podiatr Med Surg. 3:473-485, 1986.

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