Jewish World Review May 2, 2003 / 30 Nissan, 5763

When foot pain turns fiery, the cause may be a neuroma


By Marlene Cimons

http://www.NewsAndOpinion.com | These days, I think a lot about Dr. Louis Durlacher, a 19th-century English chiropodist. I feel a certain kinship for him, even though I only recently learned of his existence.

It was Dr. Durlacher, I discovered, who in 1845 was the first to accurately identify the foot ailment that has been the nemesis of my running in recent years, and no doubt that of countless others: the neuroma.

And all these years I thought it was an American fellow named Morton. Dr. T.G. Morton of Philadelphia, for some reason, wrongly got the credit in 1876 and has held the title ever since. Hence, "Morton's neuroma.''

Why do I care? I guess it's because neuromas have so disrupted my running life that I feel I must give credit where credit is due. I've had five foot surgeries to remove them: three from my left foot and two from my right. A sixth remains untouched in my right foot. My doctor has recommended against any more operations -- he says the accumulated scar tissue would be more painful than the remaining neuroma itself. I may not hold the record for neuromas, but I must certainly come close.

A neuroma is a benign swelling of a branch of the nerve that runs across the bottom of the foot and out to the toes. "It looks like a piece of gristle,'' says Eliot Sherr, a podiatrist who runs a sports medicine practice in Peabody, Mass. "It hurts when the nerve gets jiggled because you've got something in there that's much larger than it should be in a very small space.''

The most common symptom is a fiery pain in the ball of the foot that hurts during weight-bearing activities, such as walking, using stairs, running, even just wearing shoes. It typically develops in the space between the third and fourth toes, although neuromas also can arise between the second and third toes.

Many people discover that going barefoot helps, as the pressure from confining shoes is released. For me, it was just the opposite; for a time I was studying karate -- which is performed barefoot -- and the pain was almost unbearable.

Neuromas can afflict anyone: young adult or senior, athlete or couch potato. It is caused, generally, by biomechanical irregularities, such as bunions, that force the foot to move improperly, putting pressure on the nerve and irritating it.

"The problem is that it is very hard to prevent because most people don't recognize that they have poor foot function,'' says Dr. Jared Frankel, a Chicago podiatrist. "If your eyes don't work right, you'll walk into a wall. If your feet don't work right, you won't know until you develop pain.''

Some foot specialists believe women seem to suffer disproportionately, because of high-heeled or other confining shoes. Trauma and inflammatory conditions, such as arthritis, and repetitive stress from job-related and recreational activities, can also contribute to the formation of a neuroma, according to the American College of Foot and Ankle Surgeons.

It is almost always diagnosed clinically by a foot expert, who takes a history and often presses on the area to pinpoint the pain. This can be imprecise because the location of pain can seem vague to many patients.

"Many people say, `You're going to think I'm crazy, but I don't know where it hurts,' '' Sherr says. "They'll say, `It feels like a lump under my foot,' or, `It's like walking on a cushion or socks stuck under my toes.' ''

X-rays are useful only to rule out other conditions. An MRI can find a neuroma but is rarely used because it is so expensive. In recent years, however, some radiologists have become adept at using ultrasound to locate a neuroma. This can be especially valuable in determining its exact location. It's a relatively new skill; most radiologists are trained to detect abnormalities above the ankle, not below it.

I was lucky to have found a trained radiologist who was able to detect several of my most recent neuromas. This was a good thing because I couldn't tell where they were or even that I might have more than one. I thought maybe I had a "stump'' neuroma -- a remnant left over from previous surgery. This can happen on rare occasions when not all of the neuroma has been removed.

Surgery is highly successful in treating neuromas, although it does require a running layoff of about four to six weeks. The procedure is performed using a local anesthetic and takes only about 20 minutes. The surgeon goes in through an incision on the top of the foot, so weight-bearing is possible almost immediately.

The only side effect of the surgery -- supposedly -- is a permanent numbness between the two toes where the nerve is removed -- although I've never noticed it.

To be sure, most experts suggest treating a neuroma with conservative measures first, such as switching to a wider shoe, using orthotics or having a cortisone injection. I tried the shot for my first two neuromas, and they became worse. After my later neuromas developed, I wouldn't even consider cortisone and opted immediately for surgery.

If caught early, non-surgical measures can be effective, but few sufferers seek help early enough, experts say. The longer you wait, the thicker and more painful the nerve becomes.

"With conservative measures, I find only about 25 percent or fewer of patients get better,'' says Dr. Sheldon Laps, a Washington, D.C., podiatrist. "Many come back and say, `You know I've tried to live with this, but it's killing me.' ''

Sherr agrees, saying, "A lot of runners think it will go away and then try to run through it. Usually, it only gets worse. And when you've had enough, you've had enough. Generally, the patient comes in to me and says, `Get it out because I can't take it anymore.' ''

So, Dr. Durlacher, I think of you often, especially during those rare moments when I feel a suspicious twinge in either of my feet. Fortunately, my one remaining neuroma has been fairly quiet for the last couple of years, and I hope it will stay that way.

Dr. D., you was robbed. I feel a personal responsibility to set the record straight since probably few people in the world have ever heard of you. "Durlacher's neuroma.'' It has a kind of resonance to it.

But then again, why would anyone want to have his name attached to something that looks like a piece of gristle? Perhaps you are better off staying anonymous.

And to you, Dr. Morton, a question: When all is said and done, wouldn't you rather have discovered a comet?

Judi Sheppard Missett is CEO of Jazzercise Inc., an international aerobic-dance instruction company. Comment by clicking here.

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