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10 Articles in Volume 9, Issue #4
Application of Spinal Segmental Physiology to Evaluating Chronic Pain
Dental Consequences of Pain Management
Facility Profile: Casa Palmera
Intellectual and Moral Tasks in Intersection—Part 2
Milnacipran: A New Treatment Option for Fibromyalgia
Neuroma Pain of the Foot Successfully Managed with Laser Therapy
Opioid Treatment Longevity Study: Interim Report
Pain Management in a Palliative Care Setting
Precursor Amino Acid Therapy
Prolotherapy for Sacroiliac Joint Laxity

Neuroma Pain of the Foot Successfully Managed with Laser Therapy

Using exclusive laser treatment, a foot neuroma case—for a patient that was not effectively treated by conventional medicine—was resolved to a pain-free state over the course of six weeks.

In this issue we have a well presented case study on the treatment of a Morton’s Neuroma utilizing laserpuncture. This case study illustrates the potentially profound benefits of laser acupoint stimulation in the treatment of this painful condition. Please refer to the May 2008 article in Practical Pain Management on laserpuncture for more information about this effective therapeutic laser procedure.

William J. Kneebone, CRNA, DC, CNC, DIHom

Neurological pain in a foot neuroma case is the result of the swelling of the nerve—in this case a non-neoplastic tumor of the foot previously called a Morton’s Neuroma. At one time, the term Morton’s metatarsalgia was used thus avoiding the usage of the term neuroma and association with tumors. Nevertheless, we shall stick to the term neuroma of the foot because this was the diagnosis given by the three medical specialists—a podiatrist, a neurologist and a neurosurgeon—that this patient had seen before coming to our office.

When typical in presentation, a foot neuroma is not difficult to diagnose (see Tables 1 and 2). Early in the course, numbness of the area between the involved toes, usually the third and fourth (see Figure 1), and the middle of the foot occurs. This is followed by constantly changing levels of burning pain to the middle of the foot. Sharp, shooting pain that starts under the metatarsal region begins and then pain often radiates to the two adjacent toes. Pain upon palpation of the inflamed intermetatarsal nerves and the classic metatarsal “click” on manipulation of the involved digits were found.1 Satisfied that this was a case of a benign neuroma, further diagnostic imaging techniques were not repeated as they were already available from the previous examining doctors.

In a certain percentage of the population, the neuroma pain seems to get better then returns with a vengeance for no apparent reason. The involved area may develop severe prolonged burning pain with occasional “fire-like” stabs of pain. This protracted pain is what brought the patient into our office. The significance of this condition lies in the fact that it is one of the most common conditions that drive people to a pain management specialist.1,2 This is especially true of the active lifestyle person. They may be athletes or former athletes that want to continue their exercise routine or their selected activity but the pain has become unbearable.

Figure 1. Illustration of the foot neuroma with the typical inflamed nerve at the 3rd and 4th digits of the right foot.

Case Report

Mrs. MB, a 48-year-old Caucasian, former athlete, not overweight, and in good general health, was at the end of her rope. She had tried everything the medical profession had suggested: corticosteroid injections, alcohol injections, and several prescriptions from each doctor. She decided not to resort to the surgery the neurosurgeon had suggested. She still had numbness and a burning pain that she could no longer endure after three years of going from specialist to specialist. She thus decided to try an alternative approach she had read about that offered good relief…acupuncture therapy. Her primary doctor agreed.

Table 1. Foot Neuroma (Morton’s Neuroma): Essentials of Diagnosis
  • Numbness of the area
  • Burning pain in the involved area
  • Radiation of pain to the adjacent toes
  • Metatarsal “osseous click” upon palpation
Table 2. Foot Neuroma: Differential Diagnosis
  • Acute contusion
  • Low Back Pain
  • Sciatica
  • Metatarsal fracture
  • Metatarsal subluxation/ malposition

Figure 2. Laser Therapy with Luminex 500 for Morton’s Neuroma (2009).

The primary lesion was on the right foot with a similar pain beginning on the left foot in the same area. The pain had begun to cause her to have an abnormal gait and, in turn, had caused her low back to begin to bother her. She wanted to take care of the foot pain and then, hopefully, everything else would disappear.

At the time she was first seen in our clinic, the pain was constant and extremely severe, which she described as a 10 on a 1 to 10 point scale of pain intensity. The patient could not be touched in the area and had to wear a very light shoe covering. She could not sleep well and had to be heavily medicated for pain reduction. No formal assessment of the patient’s chronic pain had been made since under medical care.

Upon examination, the patient’s posture was mildly kypothic and away from the painful right foot. She had a continuous aching and burning of the distal foot associated with hyperpathia and dysesthesia. This was increased with light palpation of the area. There was a feeling of fullness and edema of the distal foot and toes and episodic pains shooting out in a 13 mm circumference around the inflamed area. There was a definite daily pattern of increased pain during weight- bearing activity.

Examination of the integument revealed rubor, parlor, and dolor of the third and fourth toes of the right foot. Movement of the trunk did not increase pain unless the foot was planted on the floor. When she stood on her foot, or walked more than two or three steps, the pain increased and there was rigidness transferred to the spinal musculature all the way to the neck. Neurological examination of the cranial nerves and extremities were unremarkable with the exception of the feet. Ophthalmic involvement was not noted on examination. Acupuncture examination of the tongue and pulse revealed the following.

  • Pulse: wiry, slow, thin
  • Tongue: pale, thin, red

Methods and Materials

Treatment consisted of a brief introduction of acupuncture theory and principles to reduce her pain. We usually begin treatment with acupuncture for three to five treatments and then switch to laser therapy once the pain has started to reduce. However, this patient threw us a curve ball: she could not tolerate the idea of needle acupuncture nor was she willing to try. We had previously wanted to use laser therapy for an entire case of neuroma pain and this was an opportunity. We discussed the options with the patient and she agreed.3

Patient informed consent was obtained before the start of the investigation. The patient was not under any social or psychological treatment. Bilateral acupuncture points were selected based upon the author’s 35 years of acupuncture knowledge and experience (see Table 3). The points selected were used throughout treatment.

The Medical Laser Systems Corporation was contacted in Branford, Connecticut to ask for permission to use the laser system in the case study. Permission was obtained and treatment outlined for the case with the patient.

The Luminex 500 impulse time was 35 per point for two rounds. Treatments were given two times per week for four weeks, reduced to one treatment per week for three weeks and one treatment for the month following the last two-week session, for a total of twelve treatment sessions (see Figure 2). Before each treatment session, the patient was asked to rate her pain according to a 10-point scale (see Table 4) adapted from the McGill Pain Questionnaire.4

Table 3. Selected Points
ST 36 (Tsu Sanli)
SP 6 (Sanyinchiao)
ST 42 (Chungyang)
LV 3 (Taichung)
ST 44 (Neiting)
KI 1 (Yongquan)
Table 4. Pain Evaluation Criteria*
0-1 No Pain
1-2 Little Pain
3-4 Moderate Pain
5-6 Bad Pain
6-7 Excruciating Pain
8-10 Severe Pain
*After the McGill Pain Questionnaire.4,5

Results

The patient’s evaluation of her pain according to the pain questionnaire criteria is shown in Figure 3. Initially, she rated her pain as 10+. The positive results began to show after the fourth treatment session.

She became more talkative on the second week and began to smile and discuss other things in her life. We talked of shoes and how they had hurt her feet. After the fifth treatment, she talked of now being able to sleep through the night for the first time in over a year. Her gait was noticeably closer to normal by the fourth week. She almost walked at a full stride, something she had not been able to do in over a year.

The previously edematous and painful 13 mm circumference area of the foot still had slight edema and a 5mm circumference of pain in the third week. By the fourth week, the pain area was at 3mm or less with no edema and abated completely after the fourth week. She exhibited a complete pain-free full range of motion at the end of the fourth week. In the fourth week it was reported, “she could live with this pain” and ready to be dismissed as a patient. We had designed the investigation of the case to continue for six weeks and she reported her remaining time as pleasant.

Figure 3. Patient evaluation of pain during treatment of a foot neuroma.

It was recommended that she return in one month for follow-up to her regular family physician and to our office, which she did. Our office received a report and a thank you from her physician stating, “the condition had resolved while under conservative care.” At the three month follow-up, the patient has remained essentially pain free (0-1 on a scale of 0 to 10). She was then scheduled for a six-month follow-up examination.

Discussion

There is little in Chinese Medicine literature regarding Morton’s Neuroma or the description of a similar type foot pain. There are opinions stated in “Peter Deadman’s Manual of Acupuncture” (2000)6 where ‘Yongquan (KI 1)’ is indicated when there is pain in the toes and inability to tread with the foot while ‘Neiting (ST 44)’ is indicated when there is pain and swelling of the dorsum of the foot.

Treatment of symptoms from a western diagnosis and perspective of Morton’s Neuroma on the kidney and stomach meridian areas was accomplished by the Luminex 500 Laser. Our objective was to tackle the disturbance at its origin. Obviously, if the patient is in great pain, as in the case of Mrs. M, symptomatic intervention is justified to alleviate the pain first, or at least quell the pain as much as possible.

The universal dictum in Oriental Medicine “drain for pain” clearly had to be applied in this former athletes case. Pain is a clear indicator of excess activity, or an accumulation of excess activity, or excess energy at the pain site. This situation required that excess energy be drained away from where it was manifesting.

Pain is not a simple, straightforward, sensory experience. The definition of pain selected by the International Association for the Study of Pain (1990) is “that it is an unpleasant sensatory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”6,8

Therefore, it follows that the intensity with which the pain is felt varies from person to person and, with regard to this, a distinction must be made between an individual’s pain threshold tolerances. This becomes a challenge for each of us when treating our patients. It is for this reason that this case is important for others to consider.

In the pharmaceutical-dominated western medicine there is no consistently reliable, preventive therapy or definitive treatment for permanent pain relief of pain from an established Morton’s Neuroma. In fact, debate still continues in the literature over the optimal therapy for this disorder.8 The primary goal of treating chronic pain of a Morton’s Neuroma should be to afford the patient as much pain relief as possible, as soon as possible, regardless of Eastern or Western philosophy.

As indicated by Liberman in his book “Light Medicine” of the Future (1991), there is little scientific data currently available to adequately explain in western nomenclature how or why acupuncture points can effect relief of the pain.9

This case study suggests that the treatment of Morton’s Neuroma with the Luminex 500 laser may be an effective medical alternative for those searching for treatment options. The Luminex 500 laser was the only change made in our procedure and protocol in the past 25 years of using acupuncture methods for the treatment of Morton’s Neuroma. This change has clearly improved the results of treatment especially for those with needle phobia. It suggests that the person may benefit on several fronts with the addition of laser therapy: no contraindications for use with the laser for those that cannot be palpated due to the degree of pain or those who may have needle phobia.

Conclusion

Pain from a neuroma may lead to extensive unnecessary surgery. This case reviews the results of using laser as a viable method to control this difficult to manage neurological pain. This middle-aged woman had done everything short of surgical intervention to control the intense pain in her feet. After four treatments, she began to show dramatic improvement. After a course of ten treatments over a period of one month, she reported no further pain in the previously painful areas.

Neuromas—especially Morton’s Neuroma (also called plantar neuroma), intermetatarsal neuroma, and interdigital neuroma first described in 1876—are a perineural fibrosis and nerve degeneration of the common digital nerve. Although the cause is presently still under debate,10 we felt comfortable that the pain had been abated and we now wanted to prevent the pain from returning regardless of the medical cause.11,12 We felt this could be achieved by fitting her with a pair of custom-fitted orthotics from the Foot Leveler Company, Roanoke, Virginia. After checking the fit and comfort of the orthotics of Mrs. MB at her third month review and examination, she was very pleased to report she had no pain and was back to dancing and recreational activities again.

Last updated on: December 13, 2011
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