04/15/2021    Robert D Teitelbaum, DPM

Reducing the Need for Neuroma Surgery

When I started in private practice some decades
ago, neuroma was a surgical condition. For every 10
patients I saw with it, four were going to be
surgerized. I used steroid injections/metatarsal
pads, and counseling to reduce barefoot walking on
hard floors which complicates many podiatric
ailments. I also counseled against shoes that were
tight in the forefoot, which causes metatarsals
heads to come too close to each other, pinching the
nerves. Some years later, I found myself needing
to do far fewer surgeries. The condition hadn't
changed but I became more adept at treating them--
the following are what I do to heal more neuromas
without surgery.

1. I massage the anesthetic steroid mixture in
after I inject it. This does two things-- it brings
the therapeutic mixture away from the skin and
deeper where it will do its work. Many of the
complications of steroid injection have to do with
dermatologic effects like atrophy, telangectasia
formation, streaking, de-pigmentation. Since I have
been doing that, I have had no local steroid
reactions. Also, if I do not massage in local
anesthetic it becomes encysted in the tissues and
onset of and depth of anesthesia is negatively
affected. I first noticed this very early in my
career when in my initial digital surgeries
teaching residents ("see one, do one, teach one"),
it looked like there was a cyst in the tissues that
was a surprise finding. It was not a cyst, it was
simply what local anesthetic looks like when
injected into, but not spread around the target
tissues.

2. I manipulate the individual toes of the neuroma
duet and manipulate them together in all
directions. If there is an associated
synovitis/capsulitis near the neuroma, a positive
therapeutic effect will occur with this range of
motion manipulation. It also facilitates the
complete spreading of the steroid around the
neuroma and the transverse intermetatarsal
ligament. I have always felt that if that ligament
can be chemically stretched, so to speak, even 1
millimeter, pressure on the interdigital nerve can
be effectively reduced.

3. A prior observation by a surgeon noted the
transverse fibrous bands that can be found
digitally after the nerve is resected. I use a
Metzenbaum scissors to lyse them. Possibly the
decompression procedure that concentrates on
severing the intermetatarsal ligament can also
include lysing these fibrous bands, which I feel
are a major cause for neuroma pain. Doing this may
also reduce post-operative stump neuromas.

Robert D Teitelbaum, DPM, Naples, FL

There are no more messages in this thread.