Neville,
I learned from a paper by D Cashley -"Manipulative therapy in the treatment
of plantar digital neuritis (Morton's metatarsalgia)", British Journal of
Podiatry, August 2000, pp. 67-69. The explanation of the technique is very
clear, and it seems harmless enough to practice it on colleagues - I did
that, and on myself in order to know what it feels like. It's a bit like
cracking the knuckles on your hands but on your toes instead - uncomfortable
but not really painful..
I found in some cases on whom I intended to use manipulation that it was
very painful as I plantarflexed the toe and got close to the end of the
range of motion; in such cases I do not manipulate but go straight to
acupuncture. In the normal process of manipulating these joints there is
some minor discomfort and sometimes some apprehension in the patient, but if
it is very painful that puts me off proceeding further ("first - do no
harm").
Are there any experts out there who can comment on the appropriateness or
otherwise of proceeding when it is painful in such circumstances? - You -
Dave Cashley - if you are there?
Clive Chapman
ph. 0208 885 2289
----- Original Message -----
From: "Parker Neville" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, November 26, 2004 11:55 AM
Subject: Re: plantar digital neuroma
> Hi Clive,
>
> Manipulation of neuroms is something I've not tried but any information on
you have would be much appreciated so it can be added to our practice. Are
there any courses for that type of thing?
>
> Thanks
>
> Neville
> Neville Parker
> Senior I Poditrist
> Podiatry Department
> Therapy Unit
> Royal Bolton Hospital
> Minerva Road
> Farnworth
> BL4 0JR
>
>
> -----Original Message-----
> From: A group for the academic discussion of current issues in podiatry on
behalf of Clive
> Sent: Fri 26/11/2004 09:14
> To: [log in to unmask]
> Cc:
> Subject: Re: plantar digital neuroma
>
>
> In my practice in the NHS with referrals from GPs, a good 15% of referrals
proved to be either classic plantar digital neuromas or painful lesions
strongly suspected to be neuromas.
>
> My approach for the last few years has been initially to manipulate the
adjoining MTPJs (for those not familiar with the technique - stabilise the
metatarsal and plantarflex the proximal phalanx to the end of its range of
motion and then a little further). Initially I do three manipulations at
intervals of more than 3 days, if some relief is obtained I continue
manipulation until the symptoms have gone. If there is no relief after 3
manipulations I go on to acupuncture. I have about a 70% success rate with
this approach.
>
> I put 30mm needle directly into the neuroma from the dorsum of the foot, I
also put a 15 mm needle into the point "liver 3" (a commonly used "toning"
point) between the proximal area of the 1st and 2nd metatarsals. I leave
the needles in place for 5 to 10 minutes depending on the patient's reaction
and stimulate them every minute for 30 seconds. Again 3 treatments at
intervals of at least 2 weeks and continue treatment if helpful. I abandon
acupuncture if no relief after 3 treatments. I have around a 70% success
rate with acupuncture.
>
> If manipulation or acupuncture o not work I treat any biomechanical
pathology with functional orthoses.
>
> For what it is worth I have observed that most plantar digital neuromas
seem to be associate with forefoot valgus.
>
> Clive Chapman.
>
> ----- Original Message -----
> From: Dr. Stanley Beekman <mailto:[log in to unmask]>
> To: [log in to unmask]
> Sent: Thursday, November 25, 2004 7:26 PM
> Subject: Re: plantar digital neuroma
>
> Dave,
>
> I agree that you should get an MRI or some other soft tissue scan to help
with the diagnosis because of its unusual location. I have been to a seminar
where the lecturer talked about a neuroma in this exact location, and the
recommendation was a plantar approach. Of course the differential can
include, fibroma, lipoma, giant cell tumor, etc.
> Biomechanically, Morton's neuroma occurs on the short side (I read this in
a book called Peripheral Neuropathy) In a lesion this large, the
biomechanical prognosis is not good. I am not a proponent for surgical
treatment for neuroma, but in this case, your options seem limited.
> I was wondering how our colleagues treat neuromas conservatively.
>
> Stanley
>
>
>
> At 06:34 PM 11/25/04 +0000, you wrote:
>
>
> Dear all
>
> As a referral from orthopaedic consultant I have a lady patient of 55yrs,
presenting with left foot, pea sized swelling in the 4th interspace, not
fixed to any other structure, exsquisitely tender to palpate, and with
paraesthesia and severe pain in the 4th digit ("like griped in a vice") when
playing golf or long walks. Diagnosis = plantar digital neuroma.
> Unusualy though the lesion is aprox 5mm proximal to the met heads.
>
> First, as I have not seen a neuroma in this position before is this likely
to be a correct diagnosis.
> The reason for referral is to make orthoses to relieve pain until surgery
can be performed to excise the lesion, which may be quite some time.
>
> Second, I have suggested a soft tissue scan, which has not been made
previously, might be helpful for difinitive diagnosis before surgery. What
would be your opinion here.
> Due to f/foot and ankle equinus coupled with a large genu valgum and L.L.D
= long left leg, there is a lot of lateral f/foot loading, bourne out by 4th
& 5th plantar mpj callosities.
>
> Cheers Dave Smith
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