We're gonna talk about neuromas today
second most common problem we see in the practice are neuromas
patient usually complains about burning on the bottom of foot
feeling like they're walking on a rock
typically it -- or even tingling in the toes
in the front of the toes
neuromas can happen in the third interspace or the second interspace
and being one, two, three, four
that's how we count interspaces, so this is interspace 2, interspace number 3
the most common are these 2 spaces
now sometimes people can feel a click when they do this or squeeze their toes
that's a very good indication of a neuroma
now, a patient can have a bigger neuroma in this space than over here
anatomically the reason why is because the bones between the number two and three
are very snug together
the bone between three and four have a little bit of wiggle room to play with
so this is what a neuroma looks like
I'm drawing on the outside of my assistants foot right here
just inflamed nerves right about here
inflamed nerves right about here
and then each nerve gives off a branch to each end of the toe
actually go up all the way up to the tip
so that's where the people usually feel sensation with neuromas
either here, here -- a lot of times happens in both
so the way that tests for that
is when they come in with that complaint I feel like a rock or it hurts on the bottom
typically you press right here, typically it's painful
or squeeze right here where you feel a pop
it's called Mulder's click, M-U-L-D-E-R click, when you do this and it clicks
Typically seen in some females wearing high-heeled shoes or
wearing shoes are too narrow
so if you wear shoes that are too narrow
if your foot -- if your shoes are like this already when you're not standing
when you stand your foot is supposed to spread out
if you don't allow your foot a chance to spread out
it's gonna be really tight here
causing that nerve to be irritated
so again these are neuromas, 2nd interspace, 3rd interspace they have this
now what are the treatments for this?
Number one, patients usually come in with that complaint, give them a corticosteroid injection
such as this right here, you put it into the space
there's the corticosteroid injection right here
mix it up, it's a mixture of a local anaesthetic with two kinds of steroid in here
typically we put it in there
another way of treating it is alcohol injection or Sarapin injection
both are targeted to destroy these nerves
helps to irritate the nerve where it doesn't give any kind of response
higher end to that we can go ahead and do a little radiofrequency ablation
where we go in and burn the nerves out
now typically of course beyond that there's also surgical intervention
I typically try not to cut these out because complication rates are about 50%
I always discourage that for my patients
a lot of times I get 2nd opinions, 3rd opinions from people who've already had it taken out
and really hard to treat those type of patients
when they've already had the neuroma taken out
and there's something called stump neuroma
it's really difficult to treat but we do have modalities such as platelet-rich plasma
shockwave therapy as well radiofrequency
to try on whatever stump we have left inside there
a repeat surgery in there is not very successful
because you really can't find that stump neuroma
it's really hard to find it so we end up doing something called a spacectomy
we just go in, just cut out any soft tissue that we think it looks like a nerve
we cut it out and a chance of that being successful is very minimal also
so you end up with two surgeries with minimal improvement or even worse
you can even get RSD or complex regional pain syndrome from that
so the goal of neuroma is to not cut that is the main point of trying to say but we have many modalities that other doctors may I have for you we have the radiofrequency to play the rich plasma even stem cell injection into a nerve main goal is to decrease the inflammation of that nerve that nerve is not not cancerous so we can treat that nerve and get inflammation go down once we get it down typically the patient or not symptomatic does it fully go away no but it's agent thematic we don't touch it so it's only exercise after the injection some of the exercise I tell my patients do go ahead put ice on it you can go ahead some of the exercise that tell my patient do get some marbles or crunch your toes quite your toes for me grip grip grip up grip get the marble or a towel learn letting a grip with your toes like your fingers grip release grip release give good release do that many time about 10 sets three sets of 10 what that does it actually moves these these toe joints right here get to get the fluid moving get these swelling down on the nerve and then get some ice on the bottom okay that's where the neuroma is it's on the bottom okay most of time people feel pain on the bottom now something like a mimic neuromas our stress fracture stress factors can mimic