“I’ve been to two other doctors for this pain in the ball of my foot and I have to say doc, if you could…you know…skip the needles…maybe…I sure would be happy.”

This is the first thing a lot of patients say to me.  Pain in the toes or ball of the foot is very common, but making the right diagnosis is harder than you might think.  This part of the foot has only one muscle running from outside (little toe side) to inside (big toe side), but there are 7 tendons surrounding each joint, bones, joint capsule, ligaments, nerves, and fat.  Every step you take transfers weight across the ball of your foot as you move forward.  The 3 bones on the inside of your foot move as a unit and the two on the outside are another unit.  Each bone also has motion of it’s own besides the motion of the toe on the metatarsal bone.

Enough of the anatomy lesson, let’s get to the point.  A neuroma is a pinched nerve.  Plain and simple, there is nothing more to it.  The nerve lies in the space between your metatarsals (those are the bones in the ball of your foot) and divides to send a smaller nerve into each side of the two toes in front of it. The nerve gets pinched against a ligament running sideways from one metatarsal to the other.  Easiest way to think of it, the nerve is constantly irritated by pinching against this ligament.  That causes inflammation and then scar.  The longer this keeps happening the scar gets bigger and bigger until there is a lump.  Sometimes you can feel this lump “click” as it rubs against the  ligament,  ouch!!  If your toes are bent upward the nerve is more likely to rub against the ligament so pain is usually worse in heels, going down stairs (you land straight onto the ball of your foot), or hiking up hill.  Why does the nerve get pinched?  There are two reasons.  First, if you have toes that are buckled, bent, sitting on the top of your foot, the nerve is always pressed up against the ligament.  Second, there is abnormal motion between your metatarsal heads (that means an unstable foot).

Treatment for neuroma is: 1.  Relieve inflammation, 2.  Stabilize your foot so the pinching stops, 3.  If all else fails surgery.

1. Every article on this website talks about relieving inflammation.  Do you remember why?  That’s right, because, at Desert Foot Surgeons, I always say, you can’t heal until the inflammation is gone.  Ibuprofen, Naproxen, Celebrex and other pills can be prescribed to fight the inflammation.  Steroid injections can be given if the lump is really big or your pain is just that bad.  The steroid can shrink the scar a little bit. Note:  Sclerosing injections are different from steroid injections.  These use a chemical to destroy the nerve leaving you numb in that area.  Before considering a sclerosing injection seek a second opinion to make sure the diagnosis is correct.
2. The underlying problem causing the pinched nerve is your unstable foot.  Arch supports are a good place to start, but if your foot is hard to control expect me to suggest custom molded foot orthotics.
3. Surgery for neuroma is something that I find controversial.  I have surgically removed very few neuromas throughout my career, while colleagues of mine seem to remove a few each week.  Why do so many doctors surgically remove neuromas?  In my opinion it’s because the orthotics are not made correctly or the diagnosis is wrong.  Remember I’m the doctor seeing the patients who have failed treatment by other physicians, or were deemed too difficult or too sick to treat.  Be cautious when considering surgery for a neuroma.  With that said, surgery consists of either removing the nerve that is damaged by scar or cutting the ligament that the nerve rubs against.  If you’re the type of person who has toes that are buckled, than the treatment is to straighten the toes and not touch the nerve.

So there you have it.  Morton’s neuroma is a pinched nerve in the ball of your foot as the result of you having an unstable foot.  If you relieve inflammation and stabilize your foot using orthotics the pain goes away.  At Desert Foot Surgeons, I have not needed to surgically remove neuromas.  Before you have surgery I would suggest you get another opinion.  The diagnosis might not be correct.  Think about all of the things in that area of your foot.  I will discuss other problems in the ball of the foot in later articles.

I love when art and science come together to make something beautiful.  Wine, food, boats, and skis are just some of my favorite examples.  Custom molded foot orthotics are an area I deal with everyday where art and science collide, but not everyone sees it my way.  In previous articles I have taught you about unstable feet and the related problems.  I have mentioned that orthotics are used to make your feet more stable and treat problems like plantar fasciitis, heel pain, flat feet, pain in the ball of the foot, and neuromas.  I guess it stems from a general lack of understanding or the desperation of being in pain for so long, but lots of people seem to think that an off the shelf arch support is the same as a custom orthotic.

I’m not saying off the shelf inserts do not have their place.  I prescribe off the shelf arch supports for many of my patients.  These are not made to anyone’s foot in particular, and the materials used in construction are less expensive.  For these reasons off the shelf inserts might not work for you.  For one thing they don’t last very long because the materials are weaker and lose their shape sooner.  It is not made to your foot so might not work for your problem depending what that is.  Do some people get better using off the shelf arch supports?  That depends on what’s wrong.  At Desert Foot Surgeons, I exam your feet sitting, standing and walking.  If your foot is easy to control, than an off the shelf insert might help.

Custom orthotics are an art form.  First, I take a mold of your foot using plaster.  It is very important to hold your foot “just right” to capture the true shape of your foot.  The mold is then sent to a laboratory where it is scanned into a computer.  The lab now has a model of your foot.  The technician has to be an artist as well, which is why I only use one lab to make my patient’s orthotics.

Unfortunately art alone won’t make your foot stable.  The science is called biomechanics and takes many years to learn.  The clerk at a shoe store does not have training in biomechanics.  Remember at Desert Foot Surgeons, I examine you walking, standing, and sitting.  I take what I learned during your exam and write a prescription so the orthotic will control your foot.  Based on my prescription, adjustments in the computer image of your foot are made and the orthotic constructed to make your foot stable.

Not everyone treats you like I do at Desert Foot Surgeons.  For one thing, some molds are taken from pushing your foot into a box, onto an image scanner, or standing on a platform.  The problem with these methods is that any pressure on the sole of your foot causes the muscles to spread out and the foot to change shape.  Hence, the orthotic will not match your foot.  A tracing, thermal print, or pressure map of your foot cannot be used to make a custom orthotic because there is no model of your foot.  Standing won’t help, because I am trying to control the way you stand not accept any deformities or imbalances in your foot.

Don’t be fooled:

Have you seen any infomercials where they are selling arch supports?  They always show you how much more stable the person is in the arch support by pushing their arms down.  Here’s the trick.  You can try it at home:

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You will need a partner and a piece of paper.  Keep your partner barefoot and standing with their arms straight out in front of them.  Push their arms down.  It should be pretty easy to move their arms.  Next put the piece of paper under their heels.  Again standing with their arms straight out in front.  You push their arms down.  Wow!! Like magic it is harder to push their arms down.

Unfortunately this is not because your friend is now stable standing on the piece of paper.  This is a physiologic principle called “muscle memory”.  The first time you push your friends arms down, their muscles don’t know what to expect.  The second time the muscles remember what is going to happen and respond more appropriately making it harder to move the arms down.  Notice in the infomercials how they never test their product first, because there is no muscle memory.

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So don’t be fooled!  If the arch support is cheap, it’s not custom made.  If no 3-dimensional model of your foot was made, it’s not custom.  If you were standing while the mold was made the orthotic is custom, it just won’t fit your foot the way I need it to in order to help you.  If no exam was done with you sitting, standing, and walking, then there is no way to write the prescription.  You are paying for custom orthotics.  At Desert Foot Surgeons, that is exactly what you will get.

I love when art and science come together to make something beautiful.  Custom foot orthotics might not look beautiful to you, but being able to create a piece of plastic that can stabilize your foot and relieve pain is pretty beautiful to me.  Let me show you how I combine art and science to fix your feet at Desert Foot Surgeons.