23-year-old neurectomy/3rd & 4th toes, left foot

by Karen
(California)

I had a neurectomy for a neuroma in December of 1993 to relieve pain from between the 3rd and 4th toes on the left foot. The surgery was performed on the bottom of the foot (the scar runs from right under the toes, starting with the middle of the second toe and running to the 4th toe - where the scar ends at the 4th toe, is still completely numb; however, the toe itself is not numb anymore), those two toes remaining numb for many, many years - no pain - no problem, until yesterday when the 3rd toe started hurting excruciatingly so upon walking. It hurts to the point where I'm limping. The scar doesn't hurt. There is no pain in the 4th toe, only the 3rd. There is no bruising, no other marks, no swelling, nothing. It hurts where the pad of the toe is down to the bottom of the toe, but definitely not the scar. The pain is hard to describe - sort of a combination of being sharp and very ouchy (which gets worse the longer/further I walk). I'm sitting in a chair right now, and the toe is kind of achy and throbbing. I do not wear heels - I don't wear tight fitting shoes, and I don't wear thinly soled shoes (I gave all that up when I had the surgery). I don't remember a lot about the surgery because it was 23 years ago, and I had just had a baby via C-section 3 weeks earlier - I've been perfect until yesterday, and am getting concerned b/c of the increase in the amount of pain only since yesterday. I'm definitely going to have to be seen for this, but wanted to try to get an idea of what might be wrong for when I talk to the doctor. I wasn't even really sure where to start, so I appreciate being able to email someone for a little help :-)

Karen

RESPONSE

Hi Karen,

Obviously I cannot make a diagnosis without examining you, but my first thought would be a recurrence of the neuroma.

Nerve tissue is one of the few body tissues that regenerate over time. The "second" time around the symptoms do not have to be exactly as your original symptoms of 23 years ago, so just because the fourth toe does not hurt, does not mean it is not a neuroma.

Very few surgeons remove neuromas through a plantar incision simply because of the chance of scarring and the pain associated with the scar. Evidently that is not the source of your pain, simply because if you were to have had pain from the scar, it would have begun years ago.

Now I cannot predict if this pain will continue or not (there is a chance that by the time you read this response, the pain may have subsided), but if it does continue, you will need to see a foot specialist.

If there was no history of trauma to the forefoot, and the pain kind of occurred spontaneously, then I would be leaning towards a neuroma.

Other possibilities would include capsulitis and intermetatarsal bursitis, both of which you can read about on this site. (use the Search Box on the Home Page)

Now, if you walked into my office and I determined it was a recurrence of a neuroma, the first thing I would offer you would be a series of denatured alcohol injections which attempt to sclerose or deaden nerve tissue. Even though you could also consider a cortisone injection, I think denatured alcohol injections is a more permanent approach to the possibility of neuroma.

If you are looking for an even more conservative approach to the problem, you could consider adding a metatarsal pad to your shoes. This pad attempts to "spread" the metatarsal bones, which then takes pressure off the neuroma and reduces pain. It is not a cure, but it is a simple way to reduce pain without any invasive procedures.

Surgery in this case could be very difficult as looking for a regrowth of a neuroma is like looking for a needle in the haystack in many cases because of the small size of the offending nerve. Your doctor might consider an MRI or ultrasound to see how large, (or small) a neuroma you may have.

If your pain persists and you have to seek medical attention and the diagnosis ends of being one of neuroma, start with the most conservative means first and see what happens.

Marc Mitnick DPM
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