Morton's Neuroma

Is a painful benign fibrotic enlargement of one of there common digital nerves. It is caused by a shearing force of the adjacent metatarsal bone. It most commonly affects the third common digital nerve. Morton's Neuroma is found to be more common in females. This may be related to the type of shoe gear often worn by females. It is most common in the 4th - 6th decade.


History

Obtaining an accurate history is important to making the diagnosis of Morton's neuroma.

Common Findings

• Pain in the forefoot and corresponding toes adjacent to the neuroma
• Pain is usually described as sharp and burning
• Pain may radiate proximal
• Numbness and tingling often is observed in the toes adjacent to the neuroma
• Intermittent pain
• Massage of the affected area may give some relief
• Narrow tight high-heeled shoes aggravate the symptoms
• Patients may feel as though they are walking on a wrinkle in there sock

Exam

• Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating pain.
• Mulder Sign - A silent palpable click produced by the lateral squeeze test. The neuroma moves between the metatarsals.
• Passive and active bending of the toe in an upward direction may aggravate symptoms.
• Sullivan's Sign - Toes adjacent to the affected interspace splay apart on weight bearing.

Imaging

• Ultrasonography
• MRI

Differential Diagnosis

• Stress fracture of the metatarsal
• Rheumatoid arthritis
• Hammertoe
• Metatarsalgia- plantar tenderness over the metatarsal head
• Neoplasms
• Metatarsal head osteonecrosis
• Freiburg osteochondrosis- characterized by interruption of the blood supply of a bone followed by localized bony necrosis.
• Ganglion cysts
• Intermetatarsal bursal fluid collections

Treatment

Treatment strategies for Morton's neuroma range from conservative to surgical management.


Conservative

Bio mechanical

• Orthotics

Medications

• Injections- Corticosteroid- Anti inflammatory agent
• Alcohol sclerosing- Causes a chemical neurolysis of the nerve and used as an alternative to surgery for Morton's neuroma
• NSAID's- Non Steroidal Anti Inflammatory such as Ibuprofen or Naprosyn
• Tricyclic Antidepressants- Amitriptyline(Elavil)
• Anticonvulsants- Neurontin (Gabapentin)
• Pregabalin (Lyrica)
• Duloxetine (Cymbalta)

Rehabilitation Program
Physical Therapy

• Cryotherapy-Cold Therapy- Cold may be applied using an ice bag or a cold pack
• Ultrasonography- Sound waves that are transferred to a specific body area via a round-headed probe. The sound waves travel deep into tissue, creating gentle heat. The heat helps relieve pain and inflammation
• Deep tissue massage
• Stretching exercises
• Phonophoresis- Has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound

Surgical Intervention

• Neurectomy- When conservative measures for Morton's neuroma are unsuccessful surgical excision may be beneficial

Diabetic Peripheral Neuropathy

Diabetic Peripheral Neuropathy is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes.
Neuropathies are characterized by a progressive loss of nerve fibers

Noninvasive Testing

• Nerve conduction studies and Electromyography- A test commonly used to evaluate the function and the ability of electrical conduction of the motor and sensory nerves.
• Quantitative sensory testing
• Autonomic Function Tests
• Monofilament testing - If the patient does not feel the wire at 4 or more at 10 testing sites- the test is positive for neuropathy

Pathophysiology of Diabetic Peripheral Neuropathy

Result from vascular disease:

• Endothelial dysfunction
• Deficiency of myoinositol-altering myelin synthesis
• Chronic hyperosmolarity-causing edema of nerve trunks
• Increased sorbitol and fructose

Diabetic Neuropathy can contribute to Structural foot deformities

Hammertoes

Bunions

Metatarsal deformities

Charcot foot

Eventual tissue breakdown

The symptoms of peripheral neuropathy include the following

• Hyperesthesia-Is a condition that involves an abnormal increase in sensitivity to stimuli of the senses.
• Paresthesia- Is a sensation of tingling, pricking, or numbness of a person's skin. It is more generally known as the feeling of "pins and needles".
• Dysesthesia-It is defined as an unpleasant, abnormal sense of touch, and it may or may not be, considered as a kind of pain.
• Radicular pain-Is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation
• Anhydrosis-Means lack of sweating.

Peripheral Neuropathy Signs

• Loss of sensation in the foot- Results in repetitive stress
• Injuries and fractures
• Loss of vibratory and position sense
• Loss of deep tendon reflexes
• Trophic ulceration
• Foot drop

Treatment


Diet

• Patients with diabetic neuropathy should develop a realistic diet for lowering blood glucose. This should be guided by a nutritionist or doctor

Medicines widely used to help with painful symptoms

• Selective serotonin and norepinephrine reuptake inhibitors- example:Duloxetine (Cymbalta)
• Tricyclic antidepressants- example: Amitriptyline (Elavil)
• Anticonvulsants- example:Gabapentin (Neurontin)
• Pregabalin (Lyrica)- FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia.
• Capsaicin cream (Capsacin)- A natural chemical derived from plants of Solanaceae. This is a topical medicine and is the active component of chili peppers.
• Neuremedy (Benfotiamine)- For the nutritional management of peripheral neuropathy.

Obese children are more prone to leg, ankle, and foot injury.

A new pediatric study reveals that obese children are more prone to leg, ankle, and foot injury than other children their age. Dr. Wendy J. Pomerantz of Cincinnati Children’s Hospital in Ohio and several of her colleagues studied the patient records from the emergency room in their hospital from January 2005 to March 2008. They noticed some very interesting trends. About 30% of obese children in their study had suffered from lower extremity injuries verses the 18% of normal weight children. On the other side of the spectrum the study showed that 15% of the normal weight children suffered from head injuries compared to 10% of the obese children. The study showed that over weight children often had a longer recovery time than other children. They also found that ankle sprains where twice as common among obese children as other children their age. Although the researchers didn’t have the information explaining how these children became injured the group hypothesized that obese children are more vulnerable during walking or running while normal weight children have an easier time playing sports that carry the risk of head injury.

Of course parents want to protect their children so these numbers might scare some parents into not letting their children be active. But this is not what the study was meant to do. We want children to be active but we want them to be safe about it. Obese children (just like adults) should ease into exercise and sports instead of jumping right in.

Pomerantz’s steps following this study are to figure out why these numbers are slated this way and try to find some protective measures to help keep children safe.

5 warning signs of foot problems in children

Foot pain in children is not something to be taken lightly or ignore. Sometimes it is hard for children to tell their parents when they are having foot troubles. Perhaps the child was born with a foot abnormality so their gait, though abnormal, seems normal to them. Or, a child may feel embarrassed about how their feet appear so they don’t want to bring it up. So, it is very important for parents to keep an eye on children's feet to keep them just as healthy as the rest of their body. Remember these feet have lots of miles ahead of them!!

Here are five things to look out for that might indicate your child is having foot pain or problems.

1. If your child is having trouble keeping up with other children~ If your child frequently lags behind other children in sports or other physical activities this could be due to flat feet causing the leg muscles to tire more easily. The muscles and feet become tired easier because the feet are not functioning as efficiently as they could be.

2. If your child suddenly stops wanting to participate in activities they enjoy~ If your child is suddenly not participating in their favorite activities this could be due to heel pain that is common in children ages 8-14. Heel pain can be caused by repetitive stress that occurs while playing sports. Too much strain can lead to pain and inflammation in the growth plate at the back of your child’s heel.

3. If your child is reluctant to show you their feet~ If a child notices a change in their feet they might be embarrassed or nervous that the change could lead to a trip to the doctors office. Start making it a habit early to check your children's feet for discoloration of the skin or nails, growths, calluses, redness, swelling or ingrown nails. Seek podiatric help for any of these signs of a problem.

4. If your child trips or falls often~ Although children are often clumsy while they are getting used to their body, repeated clumsiness can be a sign of in-toeing, balance problems or neuromuscular conditions.

5. If your child tells you they have foot pain~ Sometimes we get lucky and our children will tell us that their feet hurt. If this happens be thankful and take them to see a podiatrist right away. It is never normal for children to have foot pain and since they are growing all the time foot pain should not go overlooked. If injuries cause pain or swelling for more than a few days see a podiatrist asap.

Even if no symptoms are present and your children don’t complain of foot pain it is a good idea to get a yearly check up to make sure that the feet are growing properly.

Let's Go Fly A Kite

What a beautiful weekend for the 12th Annual Blue Ridge Kite Festival! The sky at Green Hill Park in Salem was filled with kites of all sizes and colors. And while I spent most of my time looking up at the sky, it is inevitable that I will look down at what people are wearing on their feet. With the warm weather that day, many were sporting flip-flops. I want to tell those people - BEWARE :) Sprained ankles, heel pain and blisters are just a few of the problems I see in my office as a result of wearing flip-flops. To learn more about better summer foot wear choices - watch my interview with Jean Jadhon.

Dedicated To Your Healthy Feet,

Dr. Jennifer Feeny

For more information visit our website www.roanokefoot.com