Hi Clive
There will almost always be momentary pain as the manipulative proceedures
are performed but these are usually very mild. I would suggest that if the
pain is too uncomfortable for the patient then you should opt for an
activator method. This is a hand held tool which delivers its thrust at
such a high velocity that the required lever is very small. I have yet to
find a patient who cannot toloerate an activator. The tool itself is quite
expensive ( around £200) but I find mine invalauble. As regards the
statement that manipulation will not help in these cases, I can only say
that this is ill-informed. I have just completed a clinical audit and I can
tell you that of my last 100 neuroma cases I have had just two failures from
manipulation. Many of these patients had already tried orthoses, cortisone,
NSAIDS and much more. A few of them were on the surgical waiting list and
have now removed themselves.
I would also say that if you are finding a lot of patients find this painful
then perhaps more attention needs to be paid to firstly putting the joint
into "joint tension" if this isd not done then every proceedure will be
painful. The most important thing is to set yourself up carefully to ensure
that joint tension is achieved and that your line of drive is correct prior
to attempting the thrust. You should find that this makes the treatment
fairly comfortable for most patients.
Kindest Regards
Dave Cashley
----- Original Message -----
From: "Clive" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, November 28, 2004 5:50 PM
Subject: Re: plantar digital neuroma
> 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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