Save the Nerve! : Alternatives to Nerve Excision for Morton's Neuroma

The nerve entrapment in the foot known commonly as "Morton's Neuroma" has been treated the same way for over 100 years...until recently.

This common source of forefoot pain is caused by pinching the intermetatarsal nerve going to the 3rd and 4th toes most commonly (occasionally can involve the 2nd and 3rd toes as well). There are several theories for why this painful foot problem develops and one common theory revolves around a ligament that connects the heads of the metatarsals (long thin bones in the forefoot) together. The thought is that the nerve becomes tethered on this ligament causing nerve irritation, sometimes leading to structural changes (thickening) of the neural tissue. These nerve changes can make the problem worse by causing the nerve to take up more room in the tight spaces in which it travels. Patient's complaining of this problem describe "burning" or "tingling" and even "stabbing pain" that feels like a "hot poker". These descriptions almost invariably describe neuritic or nerve related pain, which is very different than the dull ache we tend to associate with other musculoskeletal injuries in the lower extremities.

Initial treatment options can involve steroid injections, custom or over-the-counter orthotics, anti-inflammatory medication, etc. If these modalities do not relieve the pain most surgeons elect to excise the nerve. Interestingly, this remains the ONLY nerve entrapment in the human body where the initial surgical intervention involves cutting the nerve out. Unfortunately, excision of the nerve can lead to devastating results in some patients where "stump neuroma" formation can be extremely painful and sometimes debilitating. Stump neuroma formation can sometimes take years to develop and the patient may do quite well initially but note returning pain 4, 5 even 8-10 years later as the nerve tries to regenerate out to the end of the toes again. The best way to avoid this complication is to address the nerve entrapment without excising the nerve. This can be accomplished with the EDIN Procedure (Endoscopic Decompression of Intermetatarsal Nerve). This procedure uses two tiny incisions to allow the surgeon to insert a retractor and a camera to visualize the ligament creating the entrapment. Under direct visualization the ligment is released (cut) and the nerve is spared. Two stitches are placed and a light dressing. Patients are generally back in athletic shoes in 4 days. The nerve healing can take 6-12 months but most patients notice a difference in just a few weeks.

So if you or a loved one is suffering from a neuroma get all the facts before having the nerve excised. Save the nerve!

Dr. Damien Dauphinee
Fellow, Association of Extremity Nerve Surgeons