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Morton's Neuroma Questions: dancer researching options

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  #1  
Old 13th August 2005, 06:38 PM
dancer dancer is offline
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Default Morton's Neuroma Questions: dancer researching options

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Hello all,

I am a dancer and college student and was diagnosed with MN 16 months ago. I am doing some research about it from every possible source of knowledge out there to be familiar with my options. If anyone is interested in offering personal experiences regarding treating neuromas in thier practice I would be very thankful.

My questions are:

1. What are the signs of a later-staged neuroma -in general?

2. Is it possible to fully recover from a neuroma with non invasive treatment and regain a very active lifestyle if in a later stage?

3. Is there a certain type of patient who tends to recover? What qualities do they have/things do they do that help recovery?


Originally I bruised the tissue beneath the metatarsal joints 2&3 while dancing and started having the typical sensations (tingling, throbbing, rock in the shoe etc...). I went to a Pod who said, "CORTISONE!" so I got 3 injections, stayed off of it for a couple months (wearing Dansko clogs everyday with no inserts) and after short term benefits of pain relief it slowly deteriorated: The tissue around the injection area looked thin and white a few weeks later and the fat seemed to dissapear, my foot felt weak in the area and the symptons returned. (I wasn't dancing at this time either, but would go for walks.) My pod shrugged, said we could strap it, and offered no further advice or treatment options, encouraging me to keep up my lifestyle and not let it get in the way (!!!). So, I stayed off of it for 5 months, wore comfortable shoes and added a gel pad in the front of the shoe which helped a little. My dance training consisted of static poses, standing movements and walking slowly through motions w/out pain or irritation. Symptoms dissapated and after 4-5 months the foot seemed 90% better. I resumed dance training, somewhat aggresively, trying to "make up" for lost time. Three or four months went by with mild symptoms (such as post training tenderness) which I learned to get around (not training as long, icing etc...). Well, those months are over and I'm back in the worst stage again for no apparent reason other than obviously driving myself too hard too fast.

Symptoms: some swelling in the area, a feeling of thickness/fatness between the toes (that wasn't there before) occasional tingling while sitting, occasional pain that travels up the foot, and it pretty much hurts to walk (on a 1-10 scale, about 6) -all the time. Pulling the toes back is diffucult b/c it feels swollen and pulling them forward is very painful; mobility seems limited about -30% from normal. I am strapping daily while wearing soft-bed Birkenstocks (I have wide-ish feet) and icing daily after walking from normal daily activities. I'm doing no extra activities at all. I've found a "good" local Podiatrist who specializes in athletes and non-invasive treatment and have to wait for 3 weeks to get in to see him. I am terrified my foot is in some later irreversable stage and want more than anything to dance again. Any advice is highly appreciated. I want more than one opinion this time, but I am student and do not have the money to go around town to multiple doctors, so I am seeking other ways of finding more about this condition.

THANKS!
Angel
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Old 9th September 2005, 06:01 PM
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Angel,

As another option, you can do massage and/or manipulation. The area of interest is the 4th metatarsal cuboid joint. On the plantar area try rubbing distally on the plantar ligament.
The purpose of this is to repair this damaged ligament. When this is damaged the 4th metatarsal cuboid joint does not function properly and predisposes to this condition. For years I have manipulated this joint with about 75% success. The ligament work is the next step in the evolution of treatment.
In the 25% that does not fully respond, I will use a metatarsal pad with an extension under the 5th metatarsal (this reduces the pressure on the 4th metatarsal cuboid joint and lifts and seperates the metatarsal heads) The use of 4% ethanol injections are now used to stimulate the nerve to heal and are also a useful adjunct. In the last 10 years I have had one patient that required surgery. Let me know how you do.

Stanley
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Old 11th September 2005, 10:16 PM
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Thomas Novella, DPM Thomas Novella, DPM is offline
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What type of dance (I presume modern or jazz) do you do?

Get away from the Birkenstocks as they have a berm right where your bruise is.

Does barefoot walking (not releve, just walking) hurt?

Anyway, the fact that it calmed somewhat to rest then recurred on resumption of dance, and that you have a tingling/fullness at the webspace, sounds like you have a mature neuroma.

My guess is you have a less than 50% chance of satisfactorily reducing symptoms conservatively for the duration of your career. Make sure your shoes are all wide and pass the squeeze test at the ball, Don't tape your toes together. Don't massage the area (you know a neuroma is like a "cauliflower ear" on the nerve, an accumulation of scar tissue due to trauma). I never found a bruise which responded favorably to massaga, a la, "Mike Tyson just punched me in the nose, now massage it". I know about rolfing and tf massage, I've used physios for 30 years in my practice. But you don't massage something which enlarges when it gets pushed around.

Are you a keloid (abnormally large scar) former? This speeds neuroma formation.

It doesn't bode well because you had all thet cortisone, and rest, and some resolution of symptoms, but then it recurred. How did you bruise your foot in the first place? Has anyone tested your toe strength? Maybe the ball of your foot is a sitting duck to impact. Someone should check your toe strength. It may be too late to avoid invasive treatment. This is not a career threatening operation. It sounds to me that invasive treatment is your best hope at career preservation, in fact.

You should have the site checked via diagnostic ultrasound for a neuroma. If one is indeed present, and large enough to be culpable for the symptoms at the site of your complaint, some pain management doctors have recently been using a cold probe, directed exactly at the neuroma to freeze it to death, using ultrasound guidance, with good success.

Standard neuroma surgery has a 70-80% success rate. The chief reasons the surgery may not succeed are 1/ the diagnosis was incorrect and the source of your symptoms is still present despite eradication of the neuroma, so be sure of the diagnosis (remember what all I said about the ultrasound); 2/ entrapment or stump neuroma, ie, the remainder of the nerve is still being pinched by your metatarsals or has entrapped in scar tissue at the operative site;3/ phantom limb...your brain tells you it's still there, though it's been discarded a long time aga. A high percentage of revisional neuroma surgeries are succesful (90th percentile), so don't let my side effects paragraph dissuade you if this neuroma is glitching your career.

In my practice, a fair number of patients go on to neuroma surgery...about 50%. In your case, the recurrence after abject rest does not bode well. It's hard for a dancer to realistically consider padding or taping the foot for the duration of the career, especially if they are a modern dancer or a pro who will be called upon to rehearse all sorts of contorted steps for hours upon hours.

I'd call the nearest major ballet company and ask to visit their foot consultant.
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Old 11th September 2005, 11:26 PM
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Angel (What a lovely name)

My questions are:

1. What are the signs of a later-staged neuroma -in general?

recalcitrant pain on the plantar surface of the foot (radiating towards the toes).

2. Is it possible to fully recover from a neuroma with non invasive treatment and regain a very active lifestyle if in a later stage?

Plantar digital neuritis can have a reasonable prognosis without surgery but elstablished neuroma less so.

3. Is there a certain type of patient who tends to recover? What qualities do they have/things do they do that help recovery?

No one yet knows the cause of neuritis/neuroma. Whilst many will attribute pronation during propulsion there is no actual proof. In both cases of neuritis and neuroma the fibres of the nerve are thickened and this is thought to arise due to stretching and compression. Hence its association with the foot moving during stance. Provide rest can be enforced the symptoms may subside. This rest is not being wrapped up in cotton wool but reducing activity to tollerable levels. Incouraging lateral stability with wedge foor orthoses may help but are not a panacea. I prefer toe props made from silicone. These are applied to the middle three toes with the foot manipulated into a subtalar neutral positon. The plane under the toes is set parallel to the three middle metatarsals (which is parral to the heel plane). Any podiatrist will explain. Worn during the day (with or without foot orthoses) the bulk assists compression of the toe tendons and appears to reduce the neuritis symptoms. Patients are advised to exercise to tollerance and extend their program daily. Have worked with marathon runners and have had remarkable success in increasing distances without pain. No reason to assume the same could not be achived with dancing. However patience might be required. remeber pain is nature's way of telling you to rest so caution is required and as you have found out overuse will result in pain. The two props are not a cure but can keep you going in the case of our runners they were able to complete painfree but recommended to have the neuroma surgically removed if symptoms returned.



Hope this helps.

Cameron
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Old 12th September 2005, 06:50 PM
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Hello and thanks for the responses everyone. I will fill you in as to what my new Podiatrist has said then I will try to answer all the specific questions the best I can.

New diagnosis:

I went to a Podiatrist who does mostly runners (who himself is a runner) and he said I do not have a neuroma. He squeezed my metatarsal heads and this created some pain, then he pressed firmly between the 2nd&3rd joints where the neuroma was supposed to be and there was no sharp pain. He pressed rather firmly and did the test for a later developed neuroma and there was no click. He pressed around more and we found that the pain seemed to be radiating from the joints, particularly the 2nd metatarsal head was tender and when he pressed deeply in there pain radiated through my foot the way it has been when I walk. We did xrays and found that there was what he said "might be arthritis" on the inner edge of the 2nd metatarsal joint (about the size of a dull pencil tip) plus the metatarsal bone (#2) was inflamed slightly all the way down my foot. He said I probably tore some fascial (spllng?) tissue off the bone when I traumatized it in dance practice over a year ago (stomping my bare foot onto the floor while in the upright position, heel up, ball of foot down, creating black bruising on the bottom of my foot) and it never recovered since I kept practicing, creating irritation in the area causing neuroma-like symptoms. Since arthritis has developed in that spot and since I have been letting it sit lately -thinking it was a neuroma and not doing anything that caused pain- it has become stiff and limited my mobility in my toes quite a bit.

So, he said I should be moving it a lot after deep heat and wear shoes that flex a lot. I am now in some flat rubber Crocs w/ metatarsal support which, since I started wearing them, has caused my feet to crack while I am walking. It feels pretty good, actually, like they are loosening up. I have been daily doing Tiger Balm and stretching my feet really good (the tops of the toes on the floor, trying to bring the knuckles down to the floor). The first time I did it I was crying because it hurt so bad to move my toes, like they were dead and coming back to life. Afterward though it felt better and after a week and a half of this daily my mobility is coming back -I can squeeze my toes forward and flex them with minimal pain. It still hurts to spead them like a fan, or to pull the 2nd&3rd toes back and forth horizontally. There is still pain in metatarsal joints 2&3 and the area is slightly swollen between them. When I walk barefoot on the floor it feels like I am walking on bone and skin, as if there is no cushion between my bone and the floor, not super painful, just tender, so I am not doing that. He told me not to dance yet but is confident that I can get my foot up and going again. My new questions are:

1. Do you think I should get a 2nd opinion?
2. Will arthritis prevent me from dancing, or, will it worsen with dance?

Stanley:

Actually, massage has been helping, as long as I am careful. I have been standing on a tennis ball for the inside of my foot and it has helped everything loosen up tremendously.

Dr. Novella:

Thank you for your thoughtful and detailed reply. I perform Classical Indian dance from South India called Bharata Natyam. It is done barefoot in a plie-type position and we slap our feet on the ground for a clapping sound. You can see it being performed here:(though you might need to look a bit for a 'pure dance' sequence, there is a lot of expressive dance stuff on this site).

http://in.geocities.com/medhahari/bh...video-dvd.html

I injured it while practicing a sequence quickly and struck my foot when I was supposed to rest it in an upright postion with heel up and ball of feet down. There was dark bruising and tenderness for days, then the bruising went away but the tenderness stayed. The upright postion of the foot (heel up, ball of foot down) is imperative for this dance style, I must be able to put weight on it in that postion and right now I still cannot. I will ask my Dr. if he thinks it would be smart to do the ultra-sound to just be sure. Any other thoughts on the new diagnosis?

Cameron:

What is "Plantar digital neuritis?" I will ask my Doctor about the props you have suggested. Thanks.


Thanks for your help everyone.

Regards,
Angel
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Old 12th September 2005, 08:03 PM
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Angel,

I am happy to hear you have gotten some relief with the massage. A greqat time to do it is just after the deep heat.

Another thing that may be helpful is reverse-strain counter stain of the plantar interosseii. Between the second and third metatarsal proximal to the heads, feel plantarly for a sore spot. While pressing on the sore spot, dorsiflex the toes. If the pain decreases, then you can proceed. Pinch the areas just distal and proximal together while dorsiflexing the toes. Hold this for 30 seconds.

Reverse-strain counter stain is used for stretch injuries.

Let me know how you progress.
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Old 14th September 2005, 09:07 AM
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Hi Dancer

It sounds like you may have something called capsulitis of the 2/3rd metatarsal head that is impinging on a nerve which is why you are getting the numbness and throbbing etc. I would imagine this is due to repetitive trauma caused through you dancing and has imflammed the joint capsule. In my experience and having experienced this myself i found the best resolution was an orthoses with a full length top cover to provide cushioning to offload the 2/3 rd metatarsal heads and get you propulsing more through your big toe joint allowing the pressure to decrease on the painful areas. This is presuming your hubsher is 0/1 and you over pronate. Cortisone injection only gets rid of symptoms where as orthoses are altering your gait cycle and foot pressures so i believe the cause is due to the way you walk.
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Old 14th September 2005, 11:19 PM
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Dear Dancer

I have read all the postings. One thing sticks out. You never had a diagnosis proven or disproven.

Things that spring to mind and in order of chance.
- dancer : poor diet: over use : stress reaction
- stress fracture
- osteoporosis collapse
- tendinosis
- capsular disruption :
a) acute trauma
b) chronic low grade repetitive injuries eg. due to poor techniques etc.

low priority : neuroma

Order of investigation:
1. X-Ray looking for bone remodelling or even injury joint shape changed due to occupation
2. ultrasound (musculoskeletal) this will show if there is a neuroma, all the tendons, abnormal tissues etc
3. CT scan with reverse imaging.

I would be very suprised if you cannot have an accurate diagnosis with these images.

What's left
1. Bone scan (15 to 20 years background radiation)
2. MRI. Definitive diagnosis, but expensive

You must get a diagnosis, remeber it is your career you are talking about.

Once a diagnosis is made, get a few referrals to people who deal with your type of problem.

I suggest that you ring a ajor dance company and ask who looks after their injured dancers.

Good luck

musmed
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Old 17th September 2005, 09:02 AM
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Hello everyone:

I am going to post my x-rays here over the next few days, so please check back in a few to give your opinion.

Slaveboy,

Thanks for your thoughts. I'll read about capsulitis


Mr. Conneely,

I am going to take this list to my Dr. and see what he says about these possibilities after I read about them. You are the 3rd person that has mentioned capsular disruption to me. I am going to ask for the ultra sound/CT scan. Please check back shortly as I am going to put pics of my x-rays up here.


Thanks again
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Old 17th September 2005, 09:17 AM
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Mr. Dieter Fellner:

I could not send a PM, it said your box was full. So, I post my response here, thanks.

"I am not sure I would call this arthritis. Also I am not certain how he can diagnose 'inflammation all the way down the second metatarsal'. If you paid to see himprivately ask him for the x-ray films - they are your property - if you have a digital cam you can take a pic and send it along."

--Thanks for your advice. I am going to take a pic of the x-rays with my digital camera and post it on the thread so everyone can see. The metatarsal bone connected to the metatarsal joint on #2 was thicker than the rest.

"Always worth considering - I am dubious about the diagnosis of 'arthritis' - you are getting a good deal of pain and my gut feeling is this might be capsulitis (this would also respond to the measures you have described) but really its hard to say witout examination of the foot seeing x-ray films etc. What treatment is he proposing and what is the prognosis he gave to you and what is the likely recovery period?"

--Treatment: wear new shoes that are flexible with metatarsal supports (to get strength lost in my foot due to wearing stiff clogs for years), deep heat massage b/f activity, stretch the toes and foot (top of toes on the floor, bringing knuckles down to floor) to regain flexibility (he said my toes were very tight and the tendons on the front of my foot were really tight). I think the idea is that when everything is moving and loose again it can heal itself. He gave me no recovery time frame but told me to come see him in a few weeks to see how it is going.

--I am going to read about capsulitis.

Thanks for your continued interest and help. I'll post xrays and pics of my foot in a few days.

Angel
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Old 19th September 2005, 05:14 AM
slaveboy slaveboy is offline
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Hi dancer

just a thought but Freibergs disease sprung to mind after you mentioning that your X-ray showed thickening. Not sure though but maybe another possibility.

slaveboy
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Old 19th September 2005, 02:25 PM
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SB,

Hi, yes, he thought it might be that but after looking at the xrays said "no." Thanks for the suggestion.
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