Recently I had a patient come in the office and over 26 years ago she had a neuroma surgery. Shortly after she continued to have pain and needed a revision surgery and has felt good. Ever since then she has not had much pain and she came into the office with foot pain over the area of the old incision.
When I felt her foot I saw the incision it was not hard but the skin under the incision was quite hard. Most of her pain was on the bottom of the foot and not when I squeezed her foot.
At that time I was thinking that it could either be scar tissue or a stump neuroma. We had done a couple of cortisone injections in the past with temporary relief but now her pain came back.
What to do now?
My plan is first treat it as scarring in the foot from the previous surgery. I have had great success with deep tissue massage to scar tissue to loosen it up. One of the locations I commonly refer to in the area is Greendale Physical Therapy. If that doesn't work we will probably order a MRI to look at the inner tissues of the foot to see if there is a stump neuroma.
If you would like more information about this condition called a stump neuroma I have included some information below excerpted from an article from Podiatry Today.
This is from Podiatry Today in an article about "How to address stump neuromas" by Stephen Schroeder, DPM.
An Overview Of Initial Treatment Options And Injection Therapy
Treatment for painful stump neuromas should begin with conservative management. Researchers have had varying success with physical therapy modalities such as mechanical desensitization, transcutaneous electrical nerve stimulation (TENS) and iontophoresis.11Additionally, offloading with specialty shoes or custom designed orthotics can be beneficial. Also consider medical therapy with medications like gabapentin (Neurontin, Pfizer) or duloxetine (Lyrica, Eli Lilly). One can also utilize topical nerve desensitizers such as capsaicin.
Injection therapy can be a useful adjunct for treating these lesions. Agents such as alcohol, steroids, phenol, pepsin, formalin and hydrochloric acid have had varying success. Corticosteroids are widely accessible and are the most common injectable.
Of these injectables, sclerosing alcohol injections, popularized by Dockery, are the most intriguing.12 Mozena and Clifford reported on 49 Morton’s neuromas that they injected multiple times with a 4% sclerosing alcohol solution.13 They reported a 74 percent success rate with a series of at least five injections given at weekly intervals. Although this technique has not been specifically studied for stump neuromas and the histological makeup is slightly different between the two entities, one might surmise a similar success rate.
Key Surgical Considerations
There is nothing clinically available that stops nerve regeneration completely. Most surgical treatments are geared toward reducing the abnormal interaction regenerating nerves have with the surrounding connective tissue. When considering surgical intervention for stump neuromas, the first goal is complete excision of the abnormal stump proximally to the level of healthy nerve tissue. Using a sharp scalpel or scissors, one should make a single, uniform, 90-degree cut.
Additionally, the surgeon should attempt to minimize scar formation at the operative and implantation site. One can achieve this with good surgical planning and meticulous dissection technique. Try to employ sharp dissection, creating full thickness flaps when possible. Avoid blunt dissection or creating multiple layers.11
The surgeon should relocate the nerve away from weightbearing areas and toward locations that will minimize motion on the distal segment. Ideally, one should attempt to discourage axon regrowth at the transected end. Although we cannot completely stop this process from occurring, there have been many studies exploring techniques to minimize this.
Surgeons have utilized epineural sleeves for many years with good success. After transecting the nerve, fold the epineurium back on itself, exposing the underlying fasicles. Sharply transect the fasicles. Then fold back the epineurium distally, covering the exposed fasicles. Close with a minimally reactive 6-0 or smaller suture using a “purse string” stitch technique. The goal is to limit the axonal proliferation into the non-neural connective tissue.14
Stump neuromas are a naturally occurring event after a nerve is injured or transected. Luckily, they rarely become symptomatic unless there is an abnormal interaction with the surrounding soft tissue. Conservative measures are usually adequate for treatment. However, when these fail, one should consider surgical intervention.
When performing surgery, one should attempt to minimize scar tissue around the nerve, limit axonal regrowth and reduce stress on the nerve by redirecting it to areas with less tension. When removing nerves as a primary surgery, such as with Morton’s neuroma, avoid over-dissection to minimize scar tissue and allow the terminal end to retract deep into the arch of the foot.