#583 2 types of injections after failed neuroma surgery - DOC

#583 2 types of injections after failed neuroma surgery

Today on the Doc On The Run podcast we’re talking about two different types of injections your doctor might offer you after a failed neuroma surgery.



Let’s consider you’re a runner and you’ve got a neuroma and you’ve been running. It gets more painful. It starts with a little weird sort of sensations. It gets more numb. It starts to have more tingling, starts to have more burning pain and then your doctor talks you into surgery. You just want the problem fixed. So you go to the operating room and then you’re shocked to find out that you still have pain later.

Now this does not happen all the time and if it happens to you, it doesn’t mean it’s malpractice. It just means you had a bad outcome. That can happen to anybody. It can happen to any doctor and any patient, but if you’re the runner and you’re the patient, you’ve got to figure out what to do. Now, there are a couple of different kinds of injections you can have after you get a neuroma surgery that fails in the neuroma is still painful. So I thought it might be helpful to explain a little bit about how that can happen.

When we look at your foot, if you think about where the neuroma happens, you’ve usually got in the metatarsal bones, it’s usually between the third and fourth metatarsal bones where you get a neuroma. When you have the neuroma what you have is a nerve that goes between those metatarsals and divides and goes out to the toes like that. When you get the neuroma, you basically get a big lump that becomes painful. So the idea is to actually take the nerve and we cut it here and here and there and we take it out. So when you have the neuroma surgery, your doctor actually removes the neuroma and it looks something like this when they actually take it out of your foot.

How do you get pain after you have a neuroma? Well, after you’ve had the neuroma removed, of course the nerve’s gone. It’s not there anymore. In theory, it’s just gone, but you could actually get a neuroma because sometimes what will happen is where you’ve had the surgical incision on the bottom of your foot, you can get scar tissue. If you have scar tissue forming that actually tethers the nerve and adheres to the nerve, it can start to get painful and irritated. So two ways you can get pain after neuroma surgery is number one is from scar tissue. The second one is what we call a stump neuroma. They’re two different problems and the injections are for different things that we’re going to talk about.

When you get scar tissue, the way you can think about this is that if you look at the bottom of the foot in cross section, you got the metatarsal bone sitting here like this. So this is one of these metatarsal bones and the nerve that comes down is gone now. It’s been cut. So you have some of the nerve in the toe and you have the nerve here where it was cut and that’s where it was removed. But if you get scar tissue, what starts happening sometimes is that you get, we make an incision, we go all the way down to the nerve to remove the nerves. You’ve had an incision on the bottom where you had stitches, but if you start getting scar tissue that sort of attaches to the nerve and tethers the nerve, then what happens is when your foot moves, when your toe comes upward, when your heel comes up off the ground when you’re walking, when you’re moving, the tissue planes can actually adhere to the nerve.

What happens is that on the bottom of your foot, you have four different layers of muscles. You have distinct layers of tissue that kind of slide past one another and if you have surgery and we successfully remove the neuroma but some scar tissue kind of gets wrapped around the nerve,, then when you take a step, and you move, and you twist, and you bend your foot, then it can kind of tug on the nerve and you start getting mechanical irritation of the nerve that we refer to as neuritis or inflammation and irritation of the nerve.

Now it’s not yet a true neuroma again, it’s just that you’re getting irritation from scar tissue. So one of the options for that is that if we go in and we inject cortisone, well a cortisone injection is basically an anti-inflammatory. So it’s a corticosteroid and the corticosteroid or cortisone injection is supposed to stop inflammation. So if you have mechanical neuritis, well, neuritis, “itis” means inflammation. So we know it’s going to help that part of the problem and it can help reduce some inflammation and irritation in the nerve and calm it down so it doesn’t get more inflamed and become a stump neuroma later.

The other thing is that corticosteroids are very good at breaking up collagen bonds. So scar tissue is nothing but disorganized collagen. So all these little red strands that I’ve sort of drawn as an illustration of the scar tissue just collagen. So if you think that the nerve is actually sort of stuck and tethered in some scar tissue and your doctor injects corticosteroids or cortisone, then it can actually break up some of that scar tissue around the nerve and stop tugging on it. Then it can start to calm down. That’s option number one.

Option number two is alcohol. When you read about alcohol injections, what you’ll probably find is something that describes a thing called alcohol sclerosing injections. Alcohol injections basically demyelinate the nerve and the nerve withers away and dies. Basically when you do the alcohol injection, you’re trying to kill the nerve and cause it to stop being a sensory nerve, stop picking up pain sensation, stop sending pain signals to your brain that tell you it hurts.

So with the alcohol injection, it’s a different approach. So what you’re trying to do is basically kill off the nerve that’s getting fired up and aggravated and potentially becoming a stump neuroma. Because believe it or not the neuroma, if you keep irritating it, and it stays irritated long enough it starts to grow additional nerve endings. It actually forms a big lump of really angry nerve right in this area that then becomes this thing that we call a stump neuroma. It’s where you have the stump of the nerve that the doctor has cut off and it grows into this big painful lump and all those little nerve endings in that lump start to send signals to each other that your brain perceives as pain.

Stump neuromas are typically more painful than the original neuroma. That’s why you don’t want one. So again, one approach is to inject it with a series of alcohol injections to actually kill off the nerve and stop communicating with your brain that you have pain. The second option is the cortisone injection, which basically is trying to free up the scar tissue around it and stop the inflammation so it doesn’t become a stump neuroma. Two completely separate approaches, but both of those are reasonable if you’ve got a surgery where your pain’s not gone, your pain starts coming back. It feels like it’s stuck. It’s painful. It’s pulling. It feels like you’re getting those same sort of neuroma type pains you were having before, you might want to talk to your doctor about these two different options and see which one might be right for you and your particular circumstance.

But those are just a couple of injections you might find helpful if you’re a runner who had surgery to remove a neuroma, but then it seems like your neuroma’s coming back. So talk to them about your doctor, check it out and if you found this useful, please share it with one of your friends. Please like it, please subscribe and I’ll see you in the next training.