Neuroma Information

A neuroma is an enlarged fibrous nerve in the front of the foot in-between the metatarsal bones (inter-metatarsal space). The deep transverse ligament runs across the metatarsal heads. The nerves run in the inter-metatarsal space underneath the deep transverse ligament and divides into two digital nerves. The neuromas are most commonly found in the 3/4 intermetatarsal space and subsequently in the 2/3 with some patients experiencing the problem in both.

The cause of neuromas remains unclear with potential causes including traction, compression, inflammation or alterations in the blood supply to the nerve.

Symptoms

Most patients complain of a sharp shooting pain affecting the front of their foot that radiates towards their toes. Some patients experience numbness, tingling and often describe a sensation of “walking on a stone”. Symptoms can be initiated or made worse by wearing footwear with a narrow toe box or increased heel height, walking or driving for extended periods of time and high impact activities. Resting and removing aggravating footwear can often alleviate symptoms.

Diagnosis

A clinical diagnosis can be made via an examination and taking a through medical history, with confirmation by an ultrasound scan or MRI.

The MRI scan shows a neuroma with the classic dumbbell appearance, outlined by the arrows lying in the 2/3 intermetatarsal region

Treatment options

The treatment normally follows a sequential approach conservative care tried in the first instances, although the effectiveness of these measures can be compromised if the neuroma bursa complex is large

Surgical Management

When conservative treatment fails or is unsuitable the neuroma can be treated surgically by either decompressing the nerve or removing it, normally via an incision on the dorsum (top).

Dorsal approach

An incision will be made on the dorsum (top) of your foot over the inter-metatarsal space that the neuroma or neuromas are situated in. The incision is approximately 4cm long and can either be made in a straight line or a curved line if there are two neuromas.

Dorsal incision over the 3-4 intermetatarsal space

A cut is made through the deep transverse ligament to access the neuroma. The neuroma is released from the surrounding soft tissue structures and removed.

Decompression

An incision will be made on the top of your foot over the inter-metatarsal space that the neuroma or neuromas are situated, as with the dorsal approach. The deep transverse ligament is cut and the neuroma is released from the so ft tissue and debrided if required. The nerve remains with the aim being to alleviate the pain whilst maintaining sensation.

Discharge

Before you leave the hospital, you will be given a post-operative shoe and shown how to walk with crutches. Crutches provide support for the first twenty-four hours whilst your foot is numb. The nurses will dispense post-operative pain medication. You should arrange to go home via car or taxi with an escort. You will need to have someone with you for the first 24 hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48 hours (essential walking only). It is important that you do not interfere with the dressings and keep them dry. You can buy a purpose made waterproof cover to keep the leg dry, (Limbo M100 above the knee) at the hospital.

Outcome

Professor Tagoe’s published results following an audit of neuroma surgery outcomes (dorsal approach) was a 94% satisfaction rate.

Possible complications

Most patients have an uneventful recovery. Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit, we have used published results from the podiatric literature. These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation site.
• Thick and or sensitive scar.
• Adverse reaction to the post-operative pain killers. 1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue. The incidence is 1 in every 83 operations*
• Delayed healing of soft tissue
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition. Deep vein thrombosis requiring treatment, within the published literature, is 0.3% *
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident. This normally requires management by specialists in this condition and does not always resolve. This is a rare complication with no audit data available.

Specific complications following neuroma surgery

• Reoccurrence of symptoms.

• Localised scar tissue, this normally resolves with post-operative massage or physiotherapy

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre-operative screening of your health allows us to determine whether you are fit for surgery. It is important that you disclose your full medical history.  If there is a question mark against your health then further investigations or the advice of other surgical and medical specialties will be sought. Professor Tagoe and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post-operative instructions which include resting and elevating the operated leg. Keeping the wound clean and dry until advised otherwise is essential. Please ask the nurse or a member of the podiatric team if you are not sure what to do.
• Having a healthy diet is important; this provides the nutrition required for healing.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
• Post-operative mobilisation will be advised, this helps improve the flexibility, strength and stability of your foot.