Surgical Overview
The nerves going into the foot send interdigital branches (nerves between the metatarsal bones) that end in the toes. At the end of the metatarsal bones the nerve splits and continues out to the end of the toe. Each nerve ending supplies feeling to two different toes. The interdigital neuroma occurs in the nerve just before it divides into the two branches under the ball of the foot. A neuroma is formed by swelling or thickening/scarring in this part of the nerve.
A neuroma is a painful, inflamed nerve in the forefoot. It is usually brought on by chronic trauma, such as prolonged, repetitive sports or poor shoe wear. When it occurs between the third and fourth toes it is called Morton's Neuroma. However, it is also common between the second and third toes, but is rare anywhere else.
A common symptom of a neuroma is pain in the ball of the foot when walking. Some patients experience sharp pains or electric shooting pains that extend into the distribution of the two toes the nerve supplies. Another common symptom is feeling like the ball of the foot is swollen and that you have a “rock in your shoe”.
The diagnosis of a neuroma is often through a good history and physical examination. X-rays are used to rule out any other possible causes for the pain. Other imaging studies may help in confirming a neuroma but are often not conclusive. These studies include an MRI with contrast or an ultrasound evaluation. Lidocaine injections in that specific interdigital space should give some relief if there is a neuroma which can help with the diagnosis.
Neuroma’s are usually treated conservatively with foot orthotics and a metatarsal head pad (small pad placed just under the metatarsal heads to open up the intermetatarsal space), shoe modification with a wide toe box and corticosteroid or PRP injections. If the interdigital neuroma returns or does not respond to conservative treatment then surgical excision is the next step.
Excision of an interdigital neuroma requires removing the common nerve that provides sensation to the inner half of two toes. For all intent and purposes, the resulting numbness will remain for life, but it rarely bothers patients and is an acceptable trade-off for the chronic pain.
Neuroma
The vast majority of patients can go back to their activities, including sports and running.
While relatively minor, neuroma surgery requires a period of recovery. Alternatives to surgery include activity modification, shoe pads and adjustments, orthotics, anti-inflammatories, and cortisone/PRP injections.
The neuroma is easily removed through a small incision on the top of the foot, near the web space.
Your surgery generally takes place in a surgical outpatient setting.
The procedure generally takes about an hour and you will go home the same day.
Either a foot anesthetic block with sedation, or general anesthesia, will be offered.
Yes. You will get a dose of antibiotic before surgery. Also, patients are started on one 325 mg aspirin once a day for 4 weeks.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read carefully the “What to expect and how to prepare for surgery” handout.
After surgery, you will be placed in a bulky bandage with a stiff surgical shoe and will recover in the outpatient post-anesthesia area. When you have adequately recovered and have passed the criteria, including weight-bearing in the surgical shoe with crutches, you will be discharged home.
For the first two weeks you must rest, sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. You may weight-bear on the heel of the surgical shoe, using crutches as needed. You may remove your shoe for sleep. Keep the bandage clean and dry. Drink plenty of clear fluids, keep your foot elevated to the level of your heart, and take pain medicine as prescribed.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (e.g. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
This is an important question because it impacts home and work situations. A typical recovery is about six weeks. After your sutures are removed, you may increase your day-to-day activities, using the surgical shoe and a clean sock. If your incision is well healed, you may wash the surgery site after sutures are removed. Most patients transition into a roomy, comfortable shoe between three and four weeks after surgery. Use crutches as you feel necessary for balance and comfort. Try to keep your foot elevated when sitting for the first couple months after surgery. In most patients, dress shoes can be worn around six weeks after surgery.
Download the Neuroma Post-Operative Guidelines for full details.
Most patients drive by two weeks when they are off the pain medications, even if the surgery is on your right foot.
That depends on what you do. Sedentary desk workers may return as soon as one to two weeks. On the other end of the spectrum, construction laborers are typically out of work for 1-2 months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, recurrent neuroma or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopaedic Foot and Ankle Society website. Also, FootcareMD.com is very helpful.
