Excerpt for Morton Neuroma, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions by , available in its entirety at Smashwords

Morton Neuroma,


A


Simple


Guide


To


The Condition,

Diagnosis,

Treatment


And


Related Conditions


By


Dr Kenneth Kee


M.B.,B.S. (Singapore)

Ph.D (Healthcare Administration)


Copyright Kenneth Kee 2016 Smashwords Edition


Published by Kenneth Kee at Smashwords.com





Dedication



This book is dedicated

To my wife Dorothy

And my children

Carolyn, Grace

And Kelvin




This book describes the Morton Neuroma, Diagnosis and Treatment and Related Diseases which is seen in some of my patients in my Family Clinic.


(What You Need to Treat Morton Neuroma)


This eBook is licensed for the personal enjoyment only. This eBook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each reader.


If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy.


Thank you for respecting the hard work of this author.




Introduction


I have been writing medical articles for my blog http://kennethkee.blogspot.com (A Simple Guide to Medical Condition) for the benefit of my patients since 2007.


My purpose in writing these simple guides was for the health education of my patients.


Health Education was also my dissertation for my Ph.D (Healthcare Administration).


I then wrote an autobiolographical account of his journey as a medical student to family doctor on his other blog http://afamilydoctorstale.blogspot.com.


This autobiolographical account “A Family Doctor’s Tale” was combined with my early “A Simple Guide to Medical Conditions” into a new Wordpress Blog “A Family Doctor’s Tale” on http://kenkee481.wordpress.com.


From which many free articles from the blog was taken and put together into 700 amazon kindle books and some into Smashwords.com eBooks.


Some people have complained that the simple guides are too simple.


For their information they are made simple in order to educate the patients.


The later books go into more details of medical conditions.


The first chapter is always from my earlier blogs which unfortunately tends to have typos and spelling mistakes.


Since 2013, I have tried to improve my spelling and writing.


As I tried to bring you the latest information about a condition or illness by reading the latest journals both online and offline, I find that I am learning more and improving on my own medical knowledge in diagnosis and treatment for my patients.


Just by writing all these simple guides I find that I have learned a lot from your reviews (good or bad), criticism and advice.


I am sorry for the repetitions in these simple guides as the second chapters onwards have new information as compared to my first chapter taken from my blog.


I also find repetition definitely help me and maybe some readers to remember the facts in the books more easily.


I apologize if these repetitions are irritating to some readers.



Chapter 1


Morton’s Neuroma


What is Morton’s Neuroma?


Morton’s Neuroma (inter-digital neuralgia) is a medical disorder which causes pain in the forefoot especially in between the digits.


A neuroma is a benign tumor of a nerve.


Morton's neuroma is not exactly a tumor, but a thickening of the tissue that covers the digital nerve leading to the toes.


Morton neuroma is damage to the nerve between the toes, which induces thickening and pain.


It often involves the nerve that travels between the third and fourth toes.


It is a disorder that involves one of the common plantar digital nerves that run between the long bones (metatarsals) in the foot.


It most often involves the nerve between the third and fourth metatarsal bones, producing pain and numbness in the third and fourth toes.


It can also involve the nerve between the second and third metatarsal bones, producing symptoms in the second and third toes.


Morton's neuroma seldom involves the nerve between the first and second, or between the fourth and fifth, metatarsal bones.


It is likely to involve only one foot.


It is rare to get two neuromas at the same time in the same foot.


What is the cause of Morton’s Neuroma?


The cause is due to perineural fibrosis of the planter nerve where the medial and lateral planter branches of the nerve join.


The fibrosis is probably due to repeated injury of the nerve resulting in a painful fusiform swelling of the nerve.


Morton's neuroma happens as the nerve passes under the ligament joining the toe bones (metatarsals) in the forefoot.


Morton's neuroma most often forms between the third and fourth toes, normally in reaction to irritation, trauma or excessive pressure.


The incidence of Morton's neuroma is 8 to 10 times higher in women than in men.


Females are normally involved because of the shoe wear. (High heel tight shoes)


Causes:


The exact cause is not known.


Doctors think the following may play a part in the formation of this disorder:


1. Wearing tight shoes and high heels

2. Abnormal positioning of toes

3. Flat feet

4. Forefoot problems, including bunions and hammer toes

4. High foot arches


Morton neuroma is more frequent in women than in men.


Some say that this disorder should not be called Morton's neuroma as, in fact, it is not exactly a neuroma.


A neuroma is a non-cancerous (benign) tumor that grows from the fibrous coverings of a nerve.


There is no tumor development in Morton's neuroma.


The exact cause of Morton's neuroma is not known.


However, it is thought to form as a result of long-standing (chronic) stress and irritation of a plantar digital nerve.


There are a few factors that are thought to contribute to this.


1. Some thickening (fibrosis) and swelling may then develop around a part of the nerve.


2. This can look like a neuroma and can lead to compression of the nerve.


Sometimes, other problems can contribute to the compression of the nerve.


These are:

1. The growth of a fatty lump (called a lipoma) and

2. The formation of a fluid-filled sac that can form around a joint (a bursa).


3. Inflammation in the joints in the foot next to one of the digital nerves can occasionally produce irritation of the nerve and result in the symptoms of Morton's neuroma.


Incidence


About 75% who have Morton's neuroma are women.


It often involves people between the ages of 40 and 50 but can happen at any age.


Poorly fitting or constricting shoes can be a contributing factor to Morton's neuroma.


It is more frequent in women who habitually wear high-heeled shoes or in men who need to wear tight (constrictive) footwear.


It may also be more frequent in ballet dancers.


What are the symptoms of Morton’s Neuroma?


If the patient sometimes senses that he or she is "walking on a marble," and there is a continuous pain in the ball of the foot, the patient may have a disorder called Morton's neuroma


Symptoms:


1. Severe burning pain in the region of the third web


2. Pain may spread to the third and fourth toes


3. Pain is exacerbated by tight shoes


4. Pain is frequent alleviated by removing the shoes and massaging the foot.


5. Numbness is present in the involved toes.


Normally, there are no outward features, such as a lump, because this is not exactly a tumor.


6. There is a burning pain in the ball of the foot that may radiate into the toes.


7. The pain normally worsens with activity or wearing shoes.


8. Night pain is infrequent.


9. There may also be numbness in the toes, or an uncomfortable sensation in the toes.


10. Runners may sense pain as they push off from the starting block.


11. High-heeled shoes put the foot in a same position to the push-off and aggravate the disorder.


12. Tight, narrow shoes also exacerbate this disorder by compressing the toe bones, pinching the nerve


13. Tingling occurs in the space between the third and fourth toes


14. Toe cramping


15. Sharp, shooting, or burning pain in the ball of the foot and sometimes toes


16. Pain that worsens when wearing shoes or pressing on the area


17. Pain that gets worse over time


18. In infrequent cases, nerve pain occurs in the space between the second and third toes.


19. This is not a frequent form of Morton neuroma, but treatment is similar.


20. People with Morton's neuroma normally complain of pain that can begin in the ball of the foot and radiate into the affected toes.


21. Some patients just have toe pain.


22. There may also be burning and tingling of the toes.


The symptoms are normally felt up the sides of the space between two toes.


If the nerve between the third and fourth long bones (metatarsals) of the right foot is involved, the symptoms will normally be felt up the right-hand side of the fourth toe and up the left-hand side of the third toe.


Some people define the pain that they sense as being like walking on a stone or a marble


Symptoms can be made worse if the person wears high-heeled shoes.


The pain is relieved by taking the shoe off, resting the foot and massaging the area.


The patient may also experience some numbness between the affected toes.


The affected toes may also seem to be spread apart, which doctors describe as the 'V sign'.

The symptoms can vary and may come and go over a number of years.


Some people may feel two attacks of pain in a week and then nothing for a year.


Others may have regular and consistent (chronic) pain.


How is the diagnosis of Morton’s Neuroma made?


Diagnosis:


1. During the examination, the doctor will feel for a palpable mass or a "click" sound between the bones.


2. He or she will put pressure on the spaces between the toe bones to try to induce the pain and look for calluses or proof of stress fractures in the bones that might be the source of the pain.

There is tenderness on digital pressure between the third and fourth metatarsal heads

Compression of the forefoot transversely also produce the same pain


3. The range of motion tests will exclude arthritis or joint inflammations.


4. X-rays may be needed to exclude a stress fracture or joint arthritis that joins the toes to foot

X-rays do not show any abnormality.


A foot x-ray may be done to exclude bone problems.


5. MRI or ultrasound can successfully detect the condition.


6. Nerve testing (electromyography) cannot detect Morton neuroma.

But it may be used to exclude disorders that produce similar symptoms.


7. Blood tests may be done to examine for inflammation-related disorders, such as certain arthritis.


Morton's neuroma is normally diagnosed by the doctor listening to the symptoms and examining the foot.


The doctor can palpate the 'neuroma', or an area of thickening in the foot, which may be tender.


Occasionally, the doctor may indicate an ultrasound scan or MRI scan to determine the diagnosis but this is not always required.


Some doctors inject a local anesthetic into the region where the patient is experiencing pain.


If this produces temporary relief of pain, burning and tingling, it can occasionally help to determine the diagnosis and show where the problem is.


What is the treatment of Morton’s Neuroma?


Treatment:


1. Surgical removal of neuroma is often essential.

2. Local injection of lignocaine and steroid may relieve the pain.

3. Tight fitting shoes should be avoided


Non-surgical treatment is used first.


The doctor may advise any of:


1. Padding and taping the toe area

2. Shoe inserts

3. Changes to footwear, such as wearing shoes with wider toe boxes or flat heels

4. Anti-inflammatory medicines taken by mouth or injected into the toe area

5. Nerve blocking medicines injected into the toe area

6. Other painkillers

7. Physical therapy

8. Anti-inflammatories and painkillers are not advised for long-term treatment.

9. In some patients, surgery is needed to remove the thickened tissue and inflamed nerve.

This helps alleviate pain and improve foot function.

10. Numbness after surgery is permanent.

Initial treatments are non-surgical and relatively simple.


Non-surgical treatments


Simple treatments may be all that are needed for some people with a Morton's neuroma:


1. Changes in footwear


Footwear adjustments such as avoidance of high-heeled and narrow shoes and having special orthotic pads and devices fitted into the shoes.


Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole.


This allows the bones to spread out and may decrease pressure on the nerve, giving it time to heal.


2. Orthoses


Custom shoe inserts and pads also help alleviate irritation by lifting and separating the bones, decreasing the pressure on the nerve.


3. Injection


One or more injections of a corticosteroid medicine can decrease the swelling and inflammation of the nerve, causing some relief.


Steroid or local anesthetic injections (or a combination of both) into the affected area of the foot may be needed if the simple footwear changes do not fully alleviate symptoms.


The footwear modification measures should still be continued.


Sclerosant injections require the injection of alcohol and local anesthetic into the affected nerve under the guidance of an ultrasound scan.


Some studies have shown this to be as effective as surgery.


4. Physical treatment


Calf-stretching exercises may also be taught to help alleviate the pressure on the foot.


5. Cryotherapy


Cryotherapy, or freezing, is sometimes used but is not widely available.


Several studies have observed that a combination of roomier, more comfortable shoes, non-steroidal anti-inflammatory medicine, custom foot orthoses and cortisone injections give relief in over 80 % of people with Morton's Neuroma.


If conservative treatment does not alleviate the symptoms, the orthopedic surgeon may discuss surgical treatment methods with you.


Surgery can excise a small portion of the nerve or release the tissue around the nerve, and normally affects a short recovery period.


Surgical treatments


If these non-surgical measures do not work, surgery is sometimes required.


Surgery normally requires a small incision being made on either the top, or the sole, of the foot between the affected toes.


Normally, the surgeon will then either create more space around the affected nerve (or nerve decompression) or will excise the involved nerve.


If the nerve is resected, there will be permanent numbness of the skin between the affected toes.


This does not normally produce any disorders


The patient will usually have to wear a special shoe for a short time after surgery until the wound has recovered and normal footwear can be worn again


Surgery is normally successful.


With any surgical operation, there is a risk of complications.


Following this surgery a small number of people can form a wound infection.


A complication may be long-term thickening of the skin (callus formation) on the sole of the foot (known as plantar keratosis).


This may need treatment by a specialist in care of the feet (chiropody).


What is the prognosis for Morton's neuroma?


Prognosis


Non-surgical treatment does not always help the symptoms to be better.


Surgery to remove the thickened tissue has success in most patients.


About 25% will not need any surgery for Morton's neuroma and their symptoms can be controlled with footwear alteration and steroid and local anesthetic injections.


Of those who choose to have surgery, about 75% will have good results with relief of their symptoms.


Recurrent or persisting (chronic) symptoms can happen after surgery.


The decompression of the nerve may have been incomplete or the nerve may just stay 'irritable'.


In those who have had resection of the nerve (neurectomy), a recurrent or 'stump' neuroma may form in any nerve tissue that was left behind.


This can occasionally be more painful than the original disorder.


What are the complications of Morton’s neuroma?


Complications


Morton neuroma can make walking difficult.



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