Neuroma surgery: A guide for patients

What is a neuroma?

A neuroma, sometimes known as a Morton's neuroma, is a fibrous thickening of a nerve between one or more of the toes. The nerve becomes irritated and compressed, which results in moderate to severe pain, often experienced as a tingling/burning sensation of the ball of the foot and toes which can lead to the affected toes feeling numb.

The pain is often worse when wearing shoes that constrict the foot or press onto the affected area when walking.

What treatment is available?

Treatment can consist of both conservative and surgical options:

Non surgical treatment

• Alteration of footwear: Changing to a wider fitting shoe can reduce the compression of the forefoot and the nerve.
• Insoles: Insole may help by correcting your foot position and reduce compression of the nerve – results can be variable
• Steroid injection: A steroid injection can help by reducing the inflammation associated with the neuroma.

Surgical treatment

• Neuroma surgery involves making an incision generally on the top of the foot, over the problematic area. The thickened nerve is then identified and removed.
• The skin layers are stitched together with stitches that dissolve. If your skin is sensitive or you are prone to problem scarring, non dissolvable stitches will be used.
• Throughout the operation you will have a tight band (called a tourniquet) around the ankle to keep the blood away from your foot. This is sometimes uncomfortable but is released immediately after the operation.
• As the operation involves removing the nerve there will be a reduction in sensation beneath the affected toes. Removal of the nerve does not have an effect on your ability to move the toes or your perception of pain i.e. if your toes trod on a sharp object you would still feel it.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation but a screen will prevent you from seeing the operation.

To numb your foot you will either be given some injections around your ankle (ankle block) or behind the back of the knee (Popliteal block).

You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to 30 minutes but you should be prepared to be at the hospital longer than this to allow for preparation and recovery.

You must have a competent adult at home for the first day and night after surgery.

If you decide on surgical management you will be invited back to attend a pre-surgical clinic. A member of the nursing team will take a medical history and if you are on any medication please bring a list of these with you. This is a good opportunity to ask questions and discuss any concerns you may have about the procedure.

Recovery after your operation

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only and if you have been given crutches you must use them in the way shown. You may be able to bear a little weight on the foot.
• You should take the pain killers that have been prescribed and if you experience pain it is usually worse for the first two days.
• After three to four days if you are still experiencing pain that is not relieved by the pain killers you should contact the department directly.
• If you have any concerns over your foot you should contact the podiatric surgery department.
• The department is closed over the weekend, during out of hours you should contact your GP or attend your local accident and emergency (A&E) department.

Two weeks after surgery

• Two weeks after the operation your stitches will be removed.
• Approximately two days after the stitches have been removed you can start bathing your foot.
• You should no longer need a bandage and will be able to wear a normal shoe. This shoe does need to be roomy (ideally a trainer) because your foot will be quite swollen. If you do not have any you will need to purchase some prior to the surgery.
• At this stage you can gradually and gently increase your activities. You will still need to rest between your activities.
• You will be given an information sheet and shown how to massage the operation site so as to reduce the incidence of scarring.

Between two and six weeks after surgery

• At three weeks, and if your job is relatively sedentary, you can think about returning. However, if your job involves periods of extended standing, walking or manual labour this would be an unrealistic expectation and a return at four to six weeks would be required.
• During this time the foot gradually returns to normal and you may be able to vary your footwear.
• Sixty percent of patients have returned to roomy shoes at six weeks, and ninety percent in eight weeks.
• There will still be noticeable swelling especially towards the end of the day. This is quite normal at this stage.
• At four weeks you can return to driving. However, you must feel able to perform an emergency stop. (It is worth checking with your insurance company about when your policy covers you to drive).
• Although normal everyday activities will be possible, sporting activities are still restricted at this stage.

Between six and twelve weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some slight swelling.
• You can return to sporting activities / gym work at six weeks but if this produces pain and excessive swelling you will need to delay this further.

Six months after surgery

• The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after surgery

• All healing is now complete.

Frequent or serious risks

Unfortunately, all operations carry a small risk of complications.  In foot surgery complications are uncommon and most resolve without permanent disability or pain. General and specific complications of this procedure include:

• Infection (two in 100)
• Delayed healing of the skin (eight in 100)
• Non-compliance of patients (four in 100)
• Prolonged swelling post operatively (four in 100)
• Thick or sensitive scar formation (four in 100)
• Stump neuroma: A stump neuroma occurs when the nerve tries to regenerate, this is rare. If this does occur the original symptoms that you experienced can return. Treatment can involve a course of steroid injections or re-operation.

Complications following foot surgery are rare events but can occur. It is important to remember that if a complication arises you will be required to visit the hospital more frequently and there could be a significant impact on your recovery pathway and return to work time. Therefore, foot surgery should be avoided if for cosmetic gains only.