A neuroma is a common malady that usually occurs between the third and fourth metatarsophalangeal joints in the fore foot. Commonly, patients complain of the sensation of a wad of sock or a lump of some sort felt in the sulcus area (under the base of the toes). Some complaints also involve numbness and burning sensations at the sulcus and toes. Treatments for this condition vary, but are usually successful in eradicating the disorder.

The anatomy involved in a neuroma condition include the common plantar digital nerve(s). These nerves are common to two adjacent toes, lie in the plantar surface (bottom) of the foot, and provide sensory sensations to the digits (toes). The deep transverse metatarsal log, located above and below the metatarsal phalangeal joint (ball of the foot), irritates these nerves. Commonly, shoe gear can also irritate this disorder by causing compression at the forefoot level. The nerve reacts to this irritation with swelling and scarring, thus increasing its size. As the size of the nerve increases locally, the nerve tissue degenerates, thus leading to numbness.

The diagnosis of a neuroma is based on the symptoms the patient presents and the examination the surgeon performs. A diagnostic maneuver used to exclude other possibilities by eliciting a palpable "click" when the patient’s nerve is re-excited is a positive Mulder’s sign. An intermetatarsal bursal sac, however, can also mimic this condition. The surgeon will be able to recognize this distinction during surgery. Prior to such surgical involvement, conservative therapy should be explored and utilized.

The conservative approach to a neuroma includes padding the transverse metatarsal arch, administration of non-steroidal anti inflammatory drugs, and reduction of activity. Functional orthotics are recommended as part of the conservative route, but usually a change in shoe gear leads to more relief, as orthotics may also cause irritation to the neuroma. Often, a steroidal injection into the neuroma proves effective. This treatment may be repeated. However, the surgeon and patient must recognize that if the injection fails to provide relief after two or three attempts, other options must be explored. Oral steroids can help, but only limitedly. Another possibility to render relief is Sclerotherapy. Literature regarding this technique notes great success. The goal of this approach is to inject a chemical that causes further scarring and eventual disconnection of the pain stimuli from the nerve. But if all of the above treatments fail to render relief of pain, then surgical intervention may be considered.

The standard surgical approach is the excision of the neuroma (neurectomy) of the common plantar digital nerve. This procedure has been reported to have an approximate success rate of 85%. Endoscopic neurological decompression is a recently advanced approach of transecting the deep transverse metatarsal ligament, thus decompressing the nerve and salvaging the nerve from excision. This, likewise, is successful in treating a neuroma.

Many options exist in the treatment of neuromas. Wether surgical or non-surgical options are utilized, it is important to note that one needs not to live in pain from a neuroma.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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