CURE Morton's Neuroma, Metatarsalgia & Ball of the Foot Pain FAST!

This is Dr. Tom Biernacki And today I'm going over the ball of the foot pain, the famous Morton's Neuroma. This is a swollen nerve that can cause crippling, radiating numbness, bunching up like a sock pain, sharp shooting, zaps soreness that just does not go away in the ball to foot. If you have this, you have to watch this because we're going over all our best tips, all our best tricks. And we're starting now down here underneath, you have two major nerves that these are called your medial and your lateral plantar compressions in your foot with the nerve are very common. Along the inside of the ankle. You can get Tarsal Tunnel along the bottom of the heel. You can get what's called the Baxter's neuropathy. You can get compression through these branches as they come to the front of your foot. If it's in the ball of the foot, you can actually take an ultrasound and measure it. There is a thick, fat nerve between the knuckles, specifically in the ball of the foot right here. It's very common. This is an image of a pretty large neuroma between the third and fourth metatarsal head. Here's another one that's even bigger. This is a big, thick nerve. A lot of people get this, but there's a lot of tricks to it. The thing is, a Morton’s Neuroma is not like a tumor. It's not like a cancer. So that name neuroma is not really true. There's a lot of misconceptions and a lot of wrong things that people are doing to treat this disease. So let's go over the symptoms first. The ten signs that you may have a Morton's neuroma, the Morton's neuroma is a term that refers to the thickening of the nerves in the tissue right here. It can cause sharp shooting, zapping, pain. The pain usually worsens with a lot of activity. So as you're running and your foot's pressing, you're going to have more pain, numbness, tingling. Do you have numbness in the ball of your foot? Sometimes a crushed swollen nerve such as a Morton's neuroma can cause that. Do you feel like there's a lump or a pebble in your toe? Specifically between the second, third, fourth toes that can happen on the bottom of the foot. Do you have pain relief when you remove your shoe and massage the ball, the foot area? Do you have pain that's often described as a burning, cramping, pain that may radiate into the toes When you wear high heeled shoes or heeled shoes or shoes without a lot of cushion in the front? Do you get more pain and tenderness? Pain that is localized between the third and the fourth toes? Those are the ten signs of a Morton's neuroma. Another thing I hear is it feels like his socks are being bunched up in the ball, my foot, but it's not actually getting bunched up. So the causes are a Morton's neuroma. The primary factors are the foot structure. People with a higher arched foot or a flat foot are more likely to get it than people with a neutral foot, high arched foot actually puts more of an angle on the front of the foot, whereas a flat foot, as your feet flatten out and you walk forward, you lean into it. As you lean into it more, even though you don't have a flatter foot, you're leaning and it's bruising up that nerve. That's called excessive over pronation and puts pressure. People, certain types, especially women who wear high heeled shoes, narrow shoes. It's more likely to happen in women, but it also happens a lot in men with dress shoes, because we hey, we guys wear heels to, you know, a one inch heel in a dress shoe like an Oxford shoe. Or if you stand on your feet a lot, if you have tight hamstrings, glutes, calf muscles, if you have repetitive stress, if you're in an activity where you're standing, like running dancing jobs that require, you know, standing on hard concrete like a janitor or working at one of the auto plants here in the Detroit michigan area. So take a look at this pressure map in shoes. The left foot is the much tighter foot. And look at that red spot. That's exactly where the pressure develops. The neuroma, these feet in the middle have it more under the big toe joint pain. So they're going to have bunion, big toe joint pain. But these two feet on the right, you could see both balls of the feet have pressure where the neuroma is. And he look at this person develops trauma, pain in exactly that spot. And when I look at this under an ultrasound, you can see at the top is the skin. As you go down about a centimeter, you have the two bones in between. The third and the second bone in this case is an aroma. So this is not your standard. Third inner space, Morton's neuroma, but this is a second inner space, inner Roman. What about injury and trauma? If you had a previous sprain fracture that change the biomechanics, if you hurt your knee, your hip, you're going to lean into the front of your foot more and get problems. Genetics. Genetics can also do it. So if your mom and dad had it, you are more likely to have it, especially if you have bunions. HAMMER toes, bunion pain. Check out our guides on all of those things below and age. As you tend to get older, you get less flexible, you have less fat pad on the ball, your loss of fat pad in the ball, your foot with age. It's going to put more pressure on those nerves and gender. I kind of mentioned this, but women, especially because they wear usually less supportive shoes and narrow shoes, contribute occupational factors. I kind of mentioned that overuse of sports activity combined with that footwear, that's the cause. So what do you do at home? There are tests that you can do. There's something called a molders click. If I squeeze the front of the foot together while pressing with my other hand in between the third and fourth toe, I can actually feel that nerf popping up and down. That's called a molders click. I can do this even before imaging with patients. I can do that. Mulders click, and while I squeeze the foot together and move it up and down, I can feel that fat, swollen nerve move up and down. Now, the nerve should normally be like one millimeter or less, like zero point five millimeters to one millimeter, swollen, painful neuroma can be as big as 22 centimeters all the way through. It can basically come up above the bone and below the bone. Studies do show that usually the more swollen the nerve is, the harder it is to get better. But even small, thin nerves can have a lot of pain. Another one is the Sullivan sign. So I think of, you know, I can't do it with my hand comment down below if you can do it. But you know, like the live long and prosper thing that Spock does, I can't quite do it. But a Sullivan sign is exactly like that. The toes spread out to the sides because the nerve is too fat and swollen in between the toes. Down here, a lot of times the shoulders click and Sullivan sign are ways to look at it. What I would do in the clinic is when you come see me, we would get an x ray to start with. Is there spurs? Is there broken bones? Do you have a stress fracture? Because a lot of the times when people come in looking for a morton's neuroma, it could be capsulize, this could be a hammer toe, could be a stress fracture. And we want to treat these. We want to get an x ray, even though the x ray doesn't see soft tissue to see, hey, is a bone broken? Is there a stress fracture? Is there a damage? We want to definitely check that out. And number two, we want to check for swelling in the ball of the foot. That's where I would use an ultrasound in the office. I would put some gel on it. I would use an ultrasound. And I actually check for that swelling and that thickness through there. Look at how big this neuroma is. This is a huge one. Usually I don't see them that big, but I always do an ultrasound because people come in for second, third opinions. These foot neuromas are usually stubborn and they're not getting better. Before you start expensive treatments, you want to make sure you're actually treating the correct thing. And that's the tough part about doing this from home. If you're having a hard time getting it better, find someone who can ultrasound. Scan this for you. It should be cheap, quick and easy. When I check for that swelling in the ball of the foot, I actually measure it. Is it more than one millimeter? Is it six millimeters? I usually find it's usually two, three, four or five millimeters. And the ultrasound, not only does it diagnose it, but it helps us with treatment. There is a study in 2019 that basically showed if thinner almost over five millimeters, it's less likely to get better with things like injections and therapy and it can take longer to get better if they're still concerned we could order an MRI is much more accurate than an ultrasound, even though for my purposes, because you can do it real time. The ultrasound is very effective in the office. I do the ultrasound really quick. We'll do the X-ray to rule out joint fracture MRI gives you a much better image. Take a look at that neuroma. You can see it pretty clearly there. But it is more expensive. Usually have to go through pre-authorization an ultrasound you can do in the office pretty quickly and easily. look at that nice image. then we can look at the size to the size, predicts how long the neuroma will take to get better. A lot of the times, if you have numbness in the ball, the foot, there's another condition called peripheral neuropathy. If you have numbness in both feet and for example, you have diabetes, thyroid disorders, you drink a lot of alcohol. Other things we might want to test you for peripheral neuropathy. Now peripheral neuropathy is your nerve sensation in your toes is not as good. That's something we want to look at and that includes nerve conduction velocity studies. We can look at nerve conduction velocity, but this is a more advanced test. We rarely need to do this. An easy thing that I like to do is something called the diagnostic injection. This can both be a treatment and a diagnosis. If we're confused whether this is the treatment or not, I use my ultrasound to find that in enrollment and we put a little bit of numbing medication down there. If all your pain goes away with that numbing medication, it's probably the neuroma. But if it's not, it might be something in your ankle, in your back, it might be a different problem. This can be a real benefit in diagnosing it. If it's not getting better, let's get into the treatment for a Morton's neuroma. Number one injections can be really good. I like to use an injection right away because this is a diagnostic tool. It tells us whether we're wasting our time treating the neuroma or if it might be something else. So, for example, if it's a stress fracture and you have a lot of pain putting a little bit of anesthetic in the front of the toe will not make all your pain go away. But with an aroma, it can make that pain go away. At that point, we might as well just put some steroid in it that will cool down the neuroma. We'll see how much of the pain goes so an injection can work really well. There are other injection types there. There is PRP, which is platelet recombinant plasma. There is Botox injections. There's also stem cell injections. I usually keep it easy. We go with the lighter cane, which is the numbing medication and the steroid that usually calms it down. Now, surgery, who needs surgical therapy? If you go through months and months of doing all this stuff and it's not working, in my opinion, it works almost all the time. But if it's not, there's two major types of surgery. There is basically injection or ablation. You can inject a series of alcohol injections into the neuroma site. This essentially kills the nerves. Studies can be very beneficial. I don't really do this because a lot of visits, a lot of injections and ablation therapy. You can essentially use a radio frequency wine to burn and kill the nerve. Another one is decompression. You can cut the ligament between your two knuckles so that there's more room for the nerve to move up and down. Or you can excise the nerve. Now these work well because they cut out the nerve. If the nerves cut out, then you're going to do well. The success rates like 90 plus percent over a ten year period, You're like, Hey, I'm out of options. Nothing's working. Surgery is a decent shot. The problem is you're cutting out the nerve. You're not really fixing the biomechanics. There's two types of incisions. You can go through the bottom. I don't like doing this because it leaves a wound on the bottom of your foot and you can't walk for at least like a month, comfortably, probably even more as it heals. But essentially you go in there and you cut out the nerve. Probably the more common way to do it, and this is how I've always done it, is you locate the nerve from the top and you essentially make an incision from the top. You would transect the nerve. You could even coat the nerve. And there's another way to do it. I don't necessarily do this way, I've heard of a lot of people just going in there and cutting out what's called the transverse ligament. that leaves the neuroma. If that's the case and it gets better, then why not just get pressure off there in the first place? That's why we always focus on the orthotic anyway. It just makes more sense to me. And the complication of surgery is something called the stump neuroma. Now, what if you cut the nerve out and it's not better you develop scar tissue where the nerve is. This is called a stump neuroma. I drew that little stump myself. You don't actually develop a stump, but it's called a nerve root stump. It's basically scar tissue. I use shockwave therapy to massage it. I've had so many people come in for second, third opinions of scar tissue not getting better. This works really well for me. Plus, injections plus orthotics usually gets the job done without having to do more surgery. Now, that's not going to be the only thing we do. We also want to combine it with these treatments. The best shoes for Martin's neuroma. Barefoot walking can be beneficial. But you've already probably tried this before. You've watched this video. Now, in my opinion, if you're a 20 year old, 30 or there's a lot of videos about how Barefoot Walking strengthens your feet, and that's true if you're healthy, if you don't have hip tightness, knee tightness, foot tightness, anything like that and you walk, it's going to make you take shorter, choppier steps. It'll help you with your foot sensation, keeping pressure off of it. But most of my patients that come in with Martin's neuroma and again, this is my findings and studies I would tend to agree with this is they usually have a tighter back hips, hamstrings, knee pain, and they have a hard time keeping pressure off the front of their foot. What they want to do is wear something supportive with metatarsal padding almost right away. That gets a ton of pressure off the front of the foot. That makes a big difference. That makes the front of the foot feel a whole lot better. They get pressure relief. Their feet are progressing. Shoes and insoles. This is where shoes and insoles are very beneficial in the first appointment. I think this is the most important critical thing because shoes, insoles, braces or boots are what? Stop the punch. So we talk about pain relief, a good biomechanical exam. If you're a young, healthy person with good muscle strength and you just want to Disneyland for like three days and walked 6 hours a day and more minimal shoes can be beneficial for you can be conscious of your walking and you're going to get better no matter what. But if you're an older person who basically has arthritis in your ankle, your knee and your hip, you're going to have a hard time walking with barefoot shoes. That's where a more maximalist, supportive shoe will come in. And I'll tell you, over 75% of my patients fall more into the maximalist shoe category. Maximalist shoes means a lot of cushion under the heel, a lot of support. The heel is usually a little bit higher. It means they have a strong arch. The back of the heel holds you straight so your feet don't over prone or turn out. And at the same time, I like to put an insole in there with a little bit of padding under the heel. It's a lot, but basically right away people feel better, their pain starts to disappear and that lets you be active and move around while you preventing new damage. Previously we had maybe done an injection, maybe some cream, maybe some shockwave therapy, just doing these things along for like 90% of people. You're going to feel like a million bucks. You're going to feel really good. These things are what's important. If, for example, you have a limb length discrepancy, if one signs taller than the other and you put a big, thick, bulky shoe, the heel might not fit, it might not ache. That's where a biomechanical exam is really important. And at the same time, if you have knee pain, hip pain, a big, thick, foamy, cushioned shoe might put more pressure on your knee, your back or your hip, rather than just getting the maximally supportive shoe in the world. The most aggressive insole you want to maybe start soft and light until your knee and hip gets used to walking. I always take people through about a three month journey. I start soft and gentle for most people and then gradually move to a firmer, more supportive shoe as time goes on. And it's not that you have to buy three or four different shoes, but when you come see me in the office, I go start with a soft gel insole, then maybe a softer, less supportive insole, then gradually a softer, more supportive insole, then gradually a firmer, more corrective insole at the end of three months. And during that time people get more flexible through their knees, their hips, their hamstrings. They start gentle stretching. During that time they start walking so their hips and knees loosen up. My favorite shoes for people like this are linked down below, but one brand that I work with and that works really well is called OrthoFeet. Now OrthoFeet comes with soft, flexible shoes, with a wide toe box with padding put in there to take pressure off the front of the foot. At the same time, these are easy to fit a custom orthotic into a pre-made orthotic, which we'll talk about in a second. These are just really good shoes for especially older people. You know, if you're 20 years old, is it a great shoe for you? It's still be a good shoe. There's probably trendier looking shoes out there. For my purposes, I see mostly people 50 age or later. These work extremely well. It has a lot of benefits. It's built for deformities like Martin's neuroma. You can get those inserts in there. I link all my favorite shoes down below. There are other shoes too. It doesn't have to just be ortho feet. But the good news is ortho feet makes the shoes, They make sandals, they make slippers. They can get pressure off the front. There. They can take a ton of room off that Morton's neuroma. And gradually as one month, two months, three months goes by, that swelling and tenderness tend to decrease. Sandals and slippers in the house especially, can take a ton of pressure off the front of the foot. And if that's not working, night splints, stretch splints, there's massage devices to loosen up your plantar fascia, your calf, your hamstring, your knee, your hip. Because these biomechanical deficiencies, such as tight hamstrings, tight knee's tight calf muscles, this is what puts pressure on the ball of your foot. It causes over pronation and unequal foot pressures. This is what's causing your morton's neuroma repeatedly. At the same time, there's orthotics. You want two types of orthotics, there's pre-made orthotics. So for most people, a pre-made orthotic for a lower price is going to be very beneficial right off the cuff link down to my favorites. But essentially, if you have a higher arched foot, the padding gets pressure off that front of the foot. If you have a flat foot, it prevents you from turning out and leaning on the front of your foot. So for those two feet, it takes pressure off. And even the 70% of people in the middle with more neutral feet, concussion your heel, your that you don't put as much pressure on the front of your foot that can be extremely effective. I also use a company that does a really good job scanning your foot off your phone. This is real advanced prosthetics lab with certified prosthetist and podiatrists that take a look at these orthotics and we look at your foot type based on the scan. This is a much lower price. It comes straight to your house and there is telehealth available through that device. This is kind of the future. If these early problems are not working, you still want to go see your podiatrist to rule out, you know, stress fractures and other problems. But if you know you need an orthotic, this can be a really good option. I link exactly how to do that below and my videos on how to do these and what I recommend with these This is a pressure map. Look at the left foot and left hand side. Here you can see that red pressure. That's exactly where the neuroma develops. On the right side, it's green. So the pressure is not too bad in orthotic. Or a good shoe will dramatically reduce that pressure. Now, take a look at this foot on the right here. See those red spots? That is a very common pressure spot. And hey, look, look at where your neuroma is developing. So that's the thing. You can use these foam boxes or you can use the skin. There's easier systems now. That's why I showed the scan and the box crossed out. The box can work great, but there's ways to skin it now, ideally in the office, that's something we can do. It's easier because I can adjust it. We can modify it. We can get it. Very aggressive. But if you're stuck somewhere where you can't come into the office. These phone scanners can work really well. And now these are places that do have prosthetic labs. So this is not a cheap product. And the beauty is these biomechanical exams, these prosthetic devices, they can be returned for a full refund. But if you can see me in Michigan, come see me there. and other thing I like to do in the office. I like to use something called shockwave therapy, or we could even use ultrasound therapy. But these are sound based therapies that essentially massage the area and stimulate more blood flow there. There are a lot of great studies about how well shockwave therapy can work on your essentially between the injections or between the shockwave therapy and between the orthotics and kit and pressure off of it. The inflammation lowers the size of that nerve, shrinks down, and with the good shoes, the slippers, the orthotics, you're preventing new pressure from developing on the front of your foot. And that's really the secret. That's the secret of the Morton's neuroma. Almost everybody I see with Morton's neuroma pain, it's on the foot that's tighter. The tighter calf, the tighter hamstring, the tighter hip that you're leaning into that ball of foot. That's why going to see your podiatrist and getting a biomechanical exam, your hips, your hamstrings, your thighs, your knees, your calf muscles and get them all assessed. This is the true underlying cause. I like to think of that neuroma like somebody punching you. You want them to stop punching you and the pain will go away. If you try to heal someone shoulder, put creams on it, injections, all this kind of stuff, it all helps. Getting rid of the punch is really what stops the damage. You want to stop that on equal pressure loading. That's where things like physical therapy can come in. Physical therapy very well proven. Lots of good studies, surgeries to correct biomechanical deformities like me, problems, contractures. You can use injections essentially to cool it down like alcohol, steroid, Botox, PRP, steroids. You can use shockwave therapy to cool it down. All of these things help, but unless you start that punch, it will not go away. Now, on the other hand, shoes, orthotics, metatarsal padding help get the pressure off of it. But if that's still not doing it, you have to get pressure off your calf, your hamstring, your glute muscles. And that's where a biomechanical exam comes in. That's really the secret in this case. It's also important to do exercises and Morton's neural. My self-care that includes working on your stretches, your flexibility. There's foot specific exercises, ankle, leg and knee. I put guides on that below. I don't get into that in this specific video, but check out those courses down below. There's something called ankle joint equipment, high calf, a tight hamstring and a tight foot is really what makes you lean into it. So you want to take care of that ankle joint quickness and get pressure off that foot. on how to test your biomechanical exams, how to get those custom orthotics. And we came out with a 30 day course. How to reset your muscle strength, your muscle function. We go over that below. That's for subscribers. I do that with my good friend Ryan, who's a Division one basketball star, great athlete. He hosts this course with me and we have that down below.