Morton’s Neuroma Injections
People that come into our office will often complain about foot pain accompanied by tingling or numbness or a sensation that they have a pebble in their shoe. Sometimes they will describe a snapping or cracking sensation and a shooting burning kind of nerve pain. Often times that patient has a Morton’s neuroma. This means that the nerves that travel in between the bones of the foot have become impinged or squeezed.
How did this happen?
The bones in the foot are unstable forces, meaning that the connective tissues that are holding them together have been weakened. When the bones collide, they squeeze everything between them including the nerves. If those bones are moving so much that they are putting pressure on the nerves, the nerve will swell.
Before visiting our office, people will typically try everything that their insurance will cover. This includes cortisone, physical therapy, massage and chiropractors. They will also go for wider shoes, arch supports and assorted orthotics. As a final resort they will avoid activity that aggravates their foot pain as the best symptom control.
Prolotherapy is an injection technique that stimulates the repair of the tissue that has become weak and this allows the hypermobility of the foot bones, causing them to squeeze the nerves.
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The research into treatments
Morton’s neuroma, occurs in a digital nerve in the foot, often between the third and fourth toes. It involves a thickening of tissue around a digital nerve, which may be a result of ligament or tendon weakness.
Morton’s neuroma is typically diagnosed from the symptom of burning pain in a toe or toes. Although this burning pain and numbness may be due to nerve entrapment, it may also be due to problems of the ligament and tendon.
It is quite common for people with the diagnosis of a neuroma, or nerve entrapment, to undergo multiple surgeries attempting to alleviate the entrapment. One individual came to us with a history of 15 surgeries. Multiple surgeries occur primarily because most physicians incorrectly believe numbness is equated with a pinched nerve. Ligament and tendon weakness in the limb also cause chronic numbness in an extremity.
Despite years of experimental research and clinical investigation, the painful neuroma has remained difficult to prevent or to treat successfully when it occurs. More than 150 physical and chemical methods for treating neuromas have been utilized including suturing, covering with silicone caps, injecting muscle or bone with chemicals such as alcohol, and many others.
Cortisone and beyond
Doctors in the United Kingdom assessed patients who received a cortisone injection for their Morton’s neuroma problem. They were looking for factors in the treatments that would allow them to predict who would need more treatments within 2 years of a the single ultrasound-guided corticosteroid injection the patients received.
Of the treated feet:
54 patients (57 feet) were reviewed:
- 51% required further treatment within 2 years (11 repeat injections, 18 surgical excisions).
- Larger neuromas and younger patients were more likely to need further treatments.(1)
In June 2017, hospital and university researchers in Barcelona published their findings on cortisone in the medical journal Foot and Ankle International.
Here they write that the effectiveness of corticosteroid injection for the treatment of Morton’s neuroma is unclear and to see if they could make it clearer that reviewed 41 patient with a diagnosis of Morton’s neuroma.
- The 41 patients were randomized to receive 3 injections of either a corticosteroid plus a local anesthetic or a local anesthetic alone.
- The results they found was that there were no significant between-group differences in terms of pain and function improvement at 3 and 6 months after treatment completion in comparison with baseline values.
- At the end of the study, 17 (48.5%) patients requested surgical excision of the neuroma: 7 (44%) in the experimental group and 10 (53%) in the control group.
- The injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and function improvement in patients with Morton’s neuroma.(2)
Surgical treatment for Morton’s Neuroma has been problematic with poor results and complications
Doctors at the Royal Infirmary of Edinburgh wrote in the Bone and Joint Journal of examined patients who had excision of a Morton’s neuroma. (The removal of the Neuroma and the nerve it was attached to).
- 49.5% of patients reported their overall satisfaction as excellent
- 29.3% of patients reported their overall satisfaction as good
- 8.1% of patients reported their overall satisfaction as poor
- 2% of patients reported their overall satisfaction as very poor
- Only 63 patients (63%) were pain-free at follow-up:
- in eight patients (8.1%), the score worsened.
There was no statistically significant difference in outcome between surgery on single or multiple sites. However, pain scores were significantly worse after repair or revision surgery
“The patient-reported outcomes after resection of a symptomatic Morton’s neuroma are acceptable but may not be as good as earlier studies suggest. Surgery at several sites can be undertaken safely but caution should be exercised when considering revision surgery.”(3)
Doctors at the University of Tennessee suggest that approximately 80% of patients require surgical excision of Neuroma’s for symptom relief. Although 50% to 85% of patients obtain relief after primary excision, symptoms may recur because of an incorrect diagnosis, inadequate resection, or adherence of pressure on a nerve stump neuroma. They suggest counseling patients of increased possibility of more than one surgery.(4) It should be pointed out that the title of this research paper is “The recurrent Morton neuroma: what now?”
In our research paper we answer the question, What now? By suggesting Prolotherapy, a non-surgical injection therapy.
Our Research on Prolotherapy for Morton’s Neuroma
This is a summary of research from Caring Medical and Rehabilitation Services investigators published in the medical journal the Foot and Ankle Online Journal.5
This study investigates the effectiveness of Dextrose Prolotherapy injections on a group of patients with “Morton’s neuroma.”
The patients in the study had reported other previous treatments prior to beginning the Prolotherapy treatments.
Some patients had tried:
- wide-toed shoes,
- and steroid injections.
Some patients had had MRI and radiographic diagnosis. One of seventeen had seen a podiatrist. A physician told three patients that surgery was required, but only one had surgery to remedy the pain on the other foot.
The average length of time patients experienced the pain of Morton’s neuroma was 20 months before entering the clinic.
- Patients received an average of 3.7 Prolotherapy treatments.
Before treatment patients were asked to rate their pain levels on a scale of 0 to 10—with 0 being no pain and 10 being severe crippling pain (this scale is referred to as VAS).
All 17 patients reported pain as a symptom. Thus, patients were asked to report pain levels before and after Prolotherapy in these four categories:
1) pain at rest;
2) pain with normal activities;
3) pain with exercise, and
4) pain while walking barefoot.
Concerning 1) pain at rest:
Prior to Prolotherapy treatment, pain levels averaged VAS 4.68. None of the patients had a starting pain of less than three.
- After Prolotherapy treatment, VAS pain levels averaged 0.95 (less than 1 out of 10).
- Significant improvement was recorded.
Concerning 2) pain with normal activity and mobility:
Prior to Prolotherapy treatment, 15 of the 17 participants reported walking with some degree of pain, and a VAS pain level of 6.89.
- Eleven of 17 patients were unable to walk fifty feet without pain;
- 14 of 17 could not walk a half-mile without pain.
- Four of 17 patients reported an inability to walk barefoot.
After Prolotherapy, all patients reported improvements in walking without pain, and a VAS pain level of 1.89.
- Fourteen of the 17 participants walked normally again and rated their pain relief at greater than 74%.
- Sixteen of the 17 could walk one block or more.
Concerning 3) pain with exercise:
Prior to Prolotherapy, 15 of the 17 patients reported decreased ability to exercise, and a VAS pain level of 7.27.
- Of those 15, eight were totally compromised and unable to exercise;
- five were moderately (only 30 to 60 minutes possible) to severely compromised (only 0 to 30 minutes possible).
Nearly half of the patients were totally compromised in their athletic abilities prior to treatment.
After Prolotherapy, 5 of the 17 patients reported being able to exercise as much as they wanted without impediments and with satisfaction, with a VAS pain level of 1.73.
Other physical improvements occurred, notably, decreases in stiffness and numbness (burning). Thirteen to 14 patients reported a 100% improvement in the activities of daily living that continued to the end of the study. None reported an inability to exercise.
Concerning 4) pain while walking in bare feet:
Prior to Prolotherapy treatment, 10 of 17 patients could not walk barefooted without severe pain at levels eight, nine, or ten, and an average VAS pain level of 6.47.
Furthermore, 12 of 17 patients could walk less than 50 feet before they experienced noticeable pain, with or without shoes. Only 3 of the 17 patients could walk more than a half-mile without pain.
After Prolotherapy, all patients had a pain level of four or less walking barefooted, and a VAS pain level of 1.65. As for walking distances without pain, all patients could walk at least one block or more. One patient was restricted to walking between 50 feet and one block. Among the 19 treated feet of the 17 patients in the study, eighteen feet could manage walking a half-mile or more, eight of the treated feet reported no walking restrictions.
When comparing the four previous categories before and after Prolotherapy, all reached a statistically significant outcome.
This study justifies the desirability and use of Prolotherapy for Morton’s neuroma pain. Future studies need to further substantiate these findings, especially if Prolotherapy enables Morton’s neuroma sufferers to avoid surgery and its possible adverse effects.
Although a study with more patients in a controlled empirical setting is needed to document the efficacy of Hackett-Hemwall Dextrose Prolotherapy, this treatment should be considered, based on the substantial advantages and minimal drawbacks (e.g., aversion to needles), as well as the reduced risks and increased rewards of Prolotherapy over conventional treatments.
(Please see our article on Nerve Release Injection Therapy). They are a noncancerous (benign) growth of nerve tissue, or a nerve entrapment.
1 Mahadevan D, Salmasi M, Whybra N, Nanda A, Gaba S, Mangwani J. What factors predict the need for further intervention following corticosteroid injection of Morton’s neuroma? Foot Ankle Surg. 2016 Mar;22(1):9-11. [Google Scholar]
2 Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton’s Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot & Ankle International. 2017 Jun 1:1071100717709569. [Google Scholar]
3 Bucknall V, Rutherford D, MacDonald D, Shalaby H, McKinley J, Breusch SJ. Outcomes following excision of Morton’s interdigital neuroma: a prospective study. Bone Joint J. 2016 Oct;98-B(10):1376-1381. [Google Scholar]
4. Richardson DR, Dean EM. The recurrent Morton neuroma: what now? Foot Ankle Clin. 2014 Sep;19(3):437-49. doi: 10.1016/j.fcl.2014.06.006. Epub 2014 Jul 17. [Google Scholar]
5. Hauser RA, Feister WA, Brinker DK. Dextrose Prolotherapy Treatment for Unresolved “Morton’s Neuroma” Pain