Most patients with plantar digital neuritis/neuroma (a painfully enlarged nerve) complain of a sharp shooting pain affecting the ball of the foot, radiating into the toes. Some patients also experience numbness. The symptoms are often brought on by wearing tight fitting shoes and normally occur after prolonged walking or driving. The pain can often be relieved by taking the shoe off and resting. The cause of neuromas is not clear, although local irritation has been suggested.
The diagnosis is made by the examining the foot in combination with your description of the symptoms. Sometimes the diagnosis is less clear cut and an injection of local anaesthetic or an ultrasound scan may be required.
- Wide fitting shoes
- Anti inflammatory tablets and analgesics
- Local steroid injections
This involves excision of the thickened nerve.
You are admitted to the hospital on the day of your operation. You will be shown to the ward and asked to change into a gown. Miss Feeney will confirm your consent form and mark the surgical site(s).
You have the option of having a local or general anaesthestic/sedation. In either case the operation is normally carried out as a day case.
Here you would be put to sleep by the anaesthetic team for the duration of your operation waking up in recovery. Prior to having a general anaesthetic, you would be reviewed by the nurses to ensure that you were fit and well. You will be given all the relevant information on general anaesthesia and the opportunity to ask questions.
Miss Feeney will anaesthetise your leg via an injection in the back of your knee (Popliteal block). This will be carried out on the ward with adequate time given to allow the local anaesthetic to take effect.
As the anatomy behind the knee varies a little from person to person we use a nerve stimulator to locate the nerves. This sends a small electric current down the needle which stimulates the nerve. This means that the muscles controlled by the nerve begin to contract and relax causing the foot to ‘flick’. Whilst this is a strange sensation it is not uncomfortable and helps us to deliver the anaesthetic with precision.
Local anaesthetic at the level of the knee not only blocks sensation but also movement of your foot. This is temporary lasting for 24 to 36 hours and has the advantage of providing long lasting pain relief and numbness.
The standard incision is on the top of the foot over the site that is painful. The incision is about 4-5 cm in length and is placed on the top to reduce the likelihood of a painful scar on the sole of your foot. The surgeon will use a dissolving suture to close the skin. The operation normally takes about 30 minutes.
Before you leave the hospital you will be given a post operative shoe and shown how to partially weight bear using crutches. Post operative painkillers will be dispensed by the nurses.
You should arrange to go home via car or taxi with an escort. You are advised to have someone with you for the first twenty four hours in case you feel unwell.
You must rest with the leg elevated for the first 48hrs (essential walking only). It is important that you do not interfere with the dressings and keep them dry. You can buy a purpose made waterproof cover to keep the leg dry, from your chemist. You will be seen for a dressing change 3-5 days post surgery, most patients can then return to walking to tolerance around the house. You will be seen by the team 2 weeks following the surgery when the dressing will be removed and the suture tags cut. Range of motion exercises will be instigated and you can return to a trainer. From this point on you can wash your foot. A gradual increase in your activities will reduce the likelihood of local scarring aiding your recovery. Once out of the post operative shoe you can drive your car as and when you feel safe.
After this type of surgery you will have permanent numbness between the relevant toes. However, we hope to improve or eliminate your pain. A published departmental audit reported a 94% satisfaction rate.
Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital. Most patients have an uneventful recovery. Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit, we have used published results from the podiatric literature. These are accompanied by an asterisk *
- Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
- Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
- Thick and or sensitive scar – no audit data is available.
- Adverse reaction to the post operative pain killers. 1 in every 50 patients report that the codeine preparations can make them feel sick.*
- Infection of soft tissue. The incidence is 1 in every 83 operations*
- Delayed healing of soft tissue No audit data is available.
- Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
- Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition. Deep vein thrombosis incidence is 1 in every 900 cases.
- Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident. This normally requires management by specialists in this condition and doesn’t always resolve. This is a rare complication with no audit data available.
Specific complications following neuroma surgery
- Reoccurrence of symptoms.
- Localised scar tissue, this normally resolves with post-operative massage or physiotherapy
The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.
Pre operative screening of your health allows us to determine whether you are fit for surgery. It is important that you disclose your full medical history. If there is a question mark against your health then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.
You can improve the healing process and reduce the risks of complications by:
- Adhering to the post operative instructions which include resting and elevating the operated leg. Keeping the wound clean and dry until advised otherwise is essential. Please ask the nurse or the team if you are not sure what to do.
- Having a healthy diet is important; this provides the nutrition required for healing.
- Smoking is associated with a 20% increased risk of delayed or non-healing of bones.
- Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
- Post-operative mobilisation will be advised, this helps improve the flexibility, strength and stability of your foot.