The Curious Tale of Morton’s Neuroma, Pt. II

Finally here it is, the second part of the tale about my bad foot.

If you haven’t read the first part, go here.

Today I want to talk about something that I find ultimately more interesting: the process of diagnosing a Morton’s neuroma. Morton’s neuroma is described by one podiatrist as a “perineural fibrosis, sort of a misplaced overgrown protective ‘scar’ tissue surrounding and compressing an otherwise normal nerve.”

Here’s the fascinating part of making the diagnosis, which really got my mind whirring when I fully realized the implications:

Morton’s neuroma is typically a diagnosis of exclusion.

So a podiatrist will check for multiple issues when the patient complains of ball-of-the-foot pain. Is there swelling? A bone fracture? A possible tear in the plantar plate? Etc., etc.

If nothing is found, many doctors will diagnose the problem as Morton’s neuroma. But it’s important to appreciate why: Probably not because there is definitely evidence of a neuroma, but because all other suspects were eliminated. So you may have capsulitis or some difficult-to-detect issue. But the diagnosis: Morton’s neuroma.

If this sounds familiar to a knee pain sufferer, there’s a reason. Patellofemoral pain syndrome is a similar kind of diagnosis, in a way. If your knee doesn’t have a clear structural problem, if an orthopedist can’t figure out what the issue is, you may be told you have patellofemoral pain syndrome. But notice my qualifying phrase “in a way” -- Morton’s neuroma is actually more dangerous as a catch-all diagnosis because it purports not to be one. In other words, it claims to know what the underlying problem is (unlike the infuriatingly vague “patellofemoral pain syndrome”).

My first diagnosis was made by a podiatrist using an ultrasound. He showed me the fat nerve and his diagnosis seemed like a slam dunk. There was the evidence, on a medical imaging device. Not until a year and a half later did I ask a general physician, “How can you tell the difference between a neuroma and a nerve that’s simply inflamed because you’re injured?” His reply to me:

You can’t.

Wow. That was a revelation.

If Morton’s neuroma is a diagnosis of exclusion for many podiatrists, it almost surely is overdiagnosed because of that alone. Further, here are five more reasons to believe it is overdiagnosed.

* Podiatrists, in reflective moments, are themselves wondering as much. Check out this long online discussion between foot doctors that was prompted by one’s question, “Am I overdiagnosing Morton’s neuroma?”

* Some aren’t even wondering: they’re pretty sure they know. Listen to this comment: “It has been my experience in 44 years of practice that this is the most overdiagnosed foot malady. In the years that I have been in practice I have found no more then 10 true neuromas.” Think about that -- that’s about one case every four and a half years.

* Follow the money: extracting a “neuroma” is a surgical procedure that probably pays well. Might this influence doctors, especially those trained to remove neuromas, to find more of these than otherwise?

* There are various comments online about about surgeons cutting open a foot to find a “no roma” or a very small neuroma, or about surgeries that fail to end the patient’s pain, or about neuromas that podiatrists say “grew back,” which doesn’t even make sense.

* Also you’ll find a number of people online who claim to have “healed” from their neuromas. This strikes me as implausible for a true neuroma. Once you have scar tissue hindering a nerve in your foot, I don’t see how it can just disappear, though of course you can take pressure off the nerve for temporary relief. But heal? If you healed, I’m betting you had some other issue.

As for what was wrong with my foot, I don’t know. I’ll probably never know. I did have a long period of the nerve being irritated, so it’s possible the nerve did change in some way. But I don’t think that was my main problem.

Anyway, the important thing is, thankfully I’m no longer contemplating neuroma surgery!

Update: The question was asked below how I healed my “neuroma.” I didn’t get into that originally, as this blog is “Saving My Knees,” not “Saving My Feet,” and most people who drop by aren’t that interested in foot pain issues.

But in brief, I did the following:
(1) Tried to avoid activities that stressed my foot.
This is kind of obvious, but worth mentioning. So, for instance, I tried not to stand around too long on the bad foot.
(2) Put better padding (Spenco insoles) in some of my shoes.
(3) Modified my cycling shoes and socks. This may have helped a fair bit. I cut a slit in the side of the right shoe, to relieve the pressure. Also I “faked up” a cycling sock. They tend to be tight, so I cut a comfortable white athletic sock off at the low ankle to make it look like a cycling sock.
(4) Modified my other walking shoes. I actually cut holes out of the side of them at first (to copy someone on the Internet who did this). But then I realized – d’oh – all you have to do is cut a slit in the side; it accomplishes the same thing without looking so ugly.
(5) Modified my dress socks. I actually stretched them out overnight on the end posts of exercise equipment so they wouldn’t be so tight.
(6) Bought new footwear. This, I think,  was important. I bought some Altra Instinct 2 Zero Drop sneakers to walk to work in (very wide toe box, great cushioning, and zero drop too of course) and to wear on weekends. Also bought some Crocs. Fell in love with the Altras; they are superb.

I also used Hapad pads for a while, but toward the end (the period when real healing took off), I wasn’t using them, as they got hard to position exactly right and tended to annoy my foot.

Knee Pain and the Ghost in the Machine

I’m going to delay part two of the Morton’s neuroma thriller just once more, which I imagine no one will protest, as I’ve received no comments specifically on the issue of neuromas.

I want to go back to last week’s subject, because TriAgain made an important comment.

First, I have a fear sometimes of becoming facile, of lapsing into can-do boosterism and tired platitudes (“Just move! You just need to move!”). That’s one reason that I liked last week’s subject, on breakdown points, because I remember doing some hard, original thinking for the first post, a few years ago.

However.

What TriAgain put his finger on (“there may also be other systemic problems”) was a really difficult, intriguing piece that I honestly don’t have much of a clue about (and neither do your doctors, I suspect). Yes, there are breakdown points, and when you lurch beyond one, you can suddenly go from the blissful absence of any pain whatsoever to a nagging injury that just gets worse and worse.

But once you’re on the wrong side of no pain/pain, is it simply a matter of fixing an overstressed structural component (cartilage or whatever) to return to a previous healthful, pain-free state?

Maybe not. As anyone who read my book knows, I turned into a bit of a mess. At one point, it wasn’t just my knees but tendinitis in both forearms, along with terrible back pain. Happily, once I conquered the knee issue, I also managed to get on top of the other problems. So I did succeed in crossing the no pain/pain divide in the right direction.

But what exactly were those other problems? Were they related? And, if they were, perhaps once some malevolent systemic genie has been released from its cave, it can be really hard to get that thing quieted down and back inside again.

I know TriAgain suspects that complex regional pain syndrome is at least partly to blame for what his knee pain has morphed into. After checking out the CRPS symptoms, I can say that most of them don’t align with what I had.

But still.

When I had the chronic knee pain inflammation/irritation, I started to get the feeling that I was chasing a poltergeist that was loose in a many-roomed house. If my knees felt a little better on a particular day, some other joint would feel a little worse. Very weird, I thought. So I asked my general physician if all the joint pain could be related, and he assured me “no,” with this look as if he were humoring a naive child.

But the more I read everyone’s stories here, the more I am convinced that there is very often something systemic that slips in through the back door with chronic knee pain. It isn’t there at first. And it isn’t there for everyone. But I almost get goose pimples on my arms on reading all these accounts of knee pain sufferers who thought they too had rheumatoid arthritis.

So sometimes, when I’m rattling off my thoughts on healing and feeling a bit facile (in that way you can be when your chronic pain recedes to a distant memory), I get a little jerk-back to reality and sense of humility on realizing there’s a whole lot I never did understand. Like whatever that systemic issue was.

With knee pain, I believe there can be a kind of ghost in the machine, a nasty something rattling around inside you, wreaking havoc. But how that thing works, I really don’t know. Hopefully, in the years to come, someone in the medical field will discover some answers to the questions we have about that systemic part, and I can report back the findings.

Why Did My Knee Pain Come Out of Nowhere?

I’ll run Part II of Morton’s neuroma next time. I realize that since this isn’t a “Saving My Feet” blog, people aren't so interested in trouble-shooting problems with their metatarsals. However, I will note that PFPS is mentioned briefly in the second installment :).

Anyway I recently got a long comment at the end of “On the Virtues of Going Slooooowwwww” that included a line I found interesting:

It just seems strange that I had zero issues with my knees up until someday 15 months ago and they were to never be the same.

Yes, this does seem strange, I agree.

But yes, this is also very common, I’m convinced as well.

I referred the commenter to another post I did, one of my favorites. Sometimes I like to scratch an epistemological itch and try to figure out something important. In Saving My Knees, such a moment occurred when I realized that when measuring rate of change, the perceived rate will be greater as your measuring instrument becomes more precise. (I’m sure others have noticed this same phenomenon, and some statistician’s name is appended to a law stating as much.) This has huge implications.

Anyway, back to the matter of knee pain coming out of nowhere. The post I referred to is about breakdown points. The knee is a load-bearing structure, subject to forces in multiple planes. Physical structures can have breaking points, or tipping points, up to which everything may seem fine externally. So just before that tipping point is reached, there may be the absence of any discomfort whatsoever. But there could be a fine line between no pain and the emergence of some pain that then goes on to worsen to chronic pain rather quickly, which then proves practically incurable.

The tipping point analogy is intriguing, I think, because it can be analyzed in a number of ways in the context of structures. Imagine a cup that withstands the impact from being dropped say 16 inches, but from 17 inches shatters into pieces. Obviously, that’s a dramatic change in state, from whole to irreparably broken, that's caused by a small shift in our initial variable (the height from which it's dropped). That’s not what happens to your knees (especially because they’re not inaminate objects with no ability to heal), but if your knees exist in a condition of precarious homeostasis when you are pushing them too hard, maybe you are close to crossing a thin line that will send you into a downward spiral of pain and misery.

And once you hit that tipping point – once you land on the wrong side of that slim divide that separates no pain and pain – the unfortunate thing is it can take a long time to get back on the right side. But I would argue that your knee pain didn’t exactly come out of nowhere. Instead,  you approached a dangerous line, probably multiple times, that you didn’t even know you were nearing – and finally pushed across it, with disastrous results.

The Curious Tale of Morton’s Neuroma, Pt. I

In June of 2013, more than two years ago, anyone reading this blog for ideas on how to beat knee pain would have been astounded to see me in person. I was a mess -- a limping mess. At the time, I thought (my dark sense of humor) that if someone posted a video of me walking on YouTube, sales of Saving My Knees would evaporate overnight.

But it wasn’t my knees.

It was my right foot.

Here’s the narrative of what happened (which, during a search for a cure, I later repeated to three different podiatrists).

One Saturday morning in mid-June, I went for my usual grueling bike ride of 45 miles or so. That afternoon, about five hours after I climbed off the bike, I got out of a chair in my apartment and began limping. Right out of the blue. It felt like I had pulled a little muscle in the ball of my foot. I remember shrugging and thinking, “Ah, just walk it off.”

But the nagging little injury persisted. Over the next week, it got better, but didn’t go away. Then, the following weekend, I made what turned out to be a huge blunder. I was house hunting and ended up walking for hours, checking out homes and neighborhoods in a town we were thinking of moving to. The next morning, my foot was really hurting. I was limping badly.

Now let’s fast forward about six months, or this will get really long.

The foot still hurt, though the pain had subsided to an occasional numbness/soreness. During the summer, I had taken a month or so off from cycling (I should’ve taken a few months, right after the initial incident, but I was dumb in that macho male way). I had experimented with a few things, at one point even taping a partly inflated balloon to the bottom of my foot for relief (this actually wasn’t a bad idea, but I never found a balloon made of sturdy-enough material to avoid popping). Still, I had that numb feeling in the ball of my right foot that came and went, as if I were walking on a bunched-up sock.

So I went to see a podiatrist.

He checked me out, did an ultrasound, pointed to a shape on the scan and said, “There, you have a Morton’s neuroma.”

A what?, I’m thinking.

It turns out that Morton’s neuroma refers to a nerve in the ball of the foot that develops a bunch of scar tissue around it after chronic irritation. A numb feeling in the bottom of the foot is a typical symptom. Depressingly, once you have a neuroma, you always have it. It doesn’t magically vanish if you stay off the foot for a month or two.

I let the podiatrist shoot cortisone into the area (not without some reluctance, I might add). The cortisone did little good. So at this point I had a bad foot and cortisone residue in my joint. Great.

Of course by then I was reading a lot about Morton’s neuromas online. That led me to observe some oddities about my “neuroma.”

* A typical Morton’s neuroma (in fact, one podiatrist online claimed the only true Morton’s neuroma) occurs between the third and fourth toe joints. Mine was between the second and third.

* The same online podiatrist said a Morton’s neuroma is never the result of injury. I was pretty sure my condition was, even if it wasn’t a dramatic, foot-caught-in-the-door type of injury.

* This podiatrist also said a Morton’s neuroma becomes apparent very slowly, over months to years. My symptoms manifested themselves rather quickly.

* He maintained as well that a Morton’s neuroma is never accompanied by swelling. But at one point, a podiatrist observed swelling in my painful foot.

Had this been Me before my ordeal in Saving My Knees, I probably would have just gotten my three recommended cortisone shots, spaced weeks apart, then scheduled surgery to extract the nerve (the only permanent solution) when they failed (which I suspect they would have).

Instead, as a smarter patient who knows doctors can sometimes be wrong, I wound up seeing two other podiatrists.

#2 didn’t think it was a Morton’s neuroma and put me in a boot, which helped a lot. But, as luck would have it, she wasn’t in my PPO network, so I chose not to see her again. Some months later, still hurting, I saw #3. He didn’t think it was a Morton’s neuroma either, and ordered an MRI, which came back clean. The next time I saw him, he greeted me, looked at the test results, and changed his mind, telling me, “You have a neuroma!”

Argh. So I really did have a neuroma?

I began mentally preparing myself for some kind of surgery (I was leaning toward cryosurgery). In the meantime, I decided to try my hardest to beat this thing. I bought wide, well-padded shoes and Crocs to wear. I also bought a roll of Neoprene padding to cut out inserts for my shoes, for even more cushioning. I cut a slit in the side of my right cycling shoe, to give my foot more freedom.

I did more stuff, but I’ll spare you the details, as this post has already gotten really long.

The critical thing you need to know: My foot got better. It feels pretty much normal again.

So my neuroma healed?

I don’t think so. I don’t think I had a neuroma in the first place, or if I did, it wasn’t the primary issue.

If you’ve read this far, you’ll want to come back for Part II in a couple of weeks. I’ll explain what I learned about Morton’s neuroma. And, in doing so, I’ll tell you why Morton’s neuroma is almost certainly one of the most overdiagnosed conditions in podiatry offices everywhere.

Sometimes It Pays to Keep Things Simple

I recently had Internet issues that reminded me of my old battle with knee pain.

My desktop PC connects wirelessly to our home router through an adapter that plugs into a USB port. The week before Christmas, my Internet browser started to hang after anywhere from three to ten minutes. This happened repeatedly. However, my laptop computer could still connect wirelessly.

Hmm, I thought. What the heck can be causing that?

I’m fairly good with computers, so I used Google to help me try to figure out what was going on. But my sleuthing proved frustrating. Possible causes abounded. Every time I eliminated one, another two or three would pop up.

The list of suspects was all over the map. Could it be a virus? A software conflict with my antivirus software? A power saver setting? An update from Windows that created issues? And on and on.

Then, while pinging websites from the command prompt, I discovered a significant amount of packet loss. That led me to connect the PC by cable. The Internet worked fine.

Ah hah.

I went to the back of my computer, where a wireless adapter smaller than my thumb, poking out of a spare USB port, should have been grabbing the Internet signal. I suspected it wasn’t – or at least not reliably.

So I replaced it, and everything was okay again.

What I realized later was it took me a long time to get to the solution. I should have investigated the faulty hardware as a culprit early on. I got that little device from the company that provides our Internet service; the installer handed it to me as if it were some throwaway lagniappe when I asked about connecting wirelessly.

That should have been a clue that it didn’t have much of a lifespan.

Instead of zeroing in on the adapter though, I chased a lot of other theories around, some a bit wild. I didn’t look at the simple thing first: namely, something that wasn’t built well in the first place just failed and needed to be replaced.

Similarly, when I had chronic knee pain, I remember Googling my symptoms a lot. I bet that anyone reading this right now will recognize themselves in that sentence. We all do it, desperate to find answers. In my book, I even mention getting tested for rheumatoid arthritis, wondering if I had some autoimmune disorder.

But Google can be more curse than blessing. It can lead you in a thousand different directions, none of them profitable. It will convince you that you have some extremely rare disease.

The simple thing to consider when you have grumbly, achy knees and medical tests don’t turn up a clear culprit, like a tear in a ligament, is that you simply have a damaged, weakened joint that can no longer tolerate the burden placed upon it.

In that scenario, you have to modify activity, scale back activity – but stay active somehow. You let go of all the weird little symptoms that don’t make much sense. You focus on bringing back your knee joint, little by little. It will take a long time. There will be more ups and downs than a world-class rollercoaster.

For a lot of us though, I think the simple approach makes a lot of sense. And, at least in my case, when I got better the weird little symptoms that made me suspect some systemic disorder went away anyway.

It's That Time of Year Again!

Yes, time for my annual holiday message.

First, I hope you're all looking forward to the Christmas break. It's a great time to celebrate family and community. Smiles and kindness and hugs and good cheer have their own healing power.

As the old year turns to a new one, for knee pain sufferers it's a good opportunity to look back and assess, and then gaze hopefully forward.

Are you in a better place on Dec. 31 than you were on Jan. 1? What was the dumbest thing you did to your knees this year? What was the best thing? What was the best lesson you learned? Did you find a low-stress, high-repetition activity and figure out how to make it work for you?

Looking ahead: Do you have a plan? Even better, maybe you have a Plan A, a Plan B, a Plan C, and even a Plan D if none of those work out. Are you feeling optimistic? Remember, negativity exacts a tax on the healing process.

Also, something I consider very encouraging: Any time you're in a better place on Dec. 31 than you were on Jan. 1, guess what? You're getting better! It may not be much better, and maybe you wanted to be all healed in three months, but it's a gain, no matter how small.

Next year, I'm going to talk about a few things other than my knees. For one, I now have a "frozen shoulder" that I'm dealing with :(. But, on the happier side of things, the Morton's neuroma I was diagnosed with in my right foot is no longer an issue.

I'm going to share some of my other ordeals here, because for example the odd tale of my Morton's neuroma really should be told. I came to understand a LOT about the Morton's neuroma diagnosis in the past couple of years. So if you've been told you have MN, stay tuned.

Okay, that's it from me for now. All my best, and a big thank you to all the good people who take the time to comment here, and help others!

More Evidence That Cartilage Can Heal

As you all know, nothing cheers me like a good success story – or even a small yet significant victory on the long road to healing.

Well, one member of our small community here who uses the handle gcoza posted this comment this week:

Today I went on my second MRI of my left knee. The first was prior 27 months and showed significant chondromalatia patella on the upper medial side of the patella in the area of 12x9 mm. New MRI medical report showed no sign of chondromalacia patella. Nothing!!!

He even posted the before and after images of his knees here.

This is great news, but if the irregular cartilage has really filled in, I’m not that surprised. As I mention in my book, clinical studies show that cartilage defects can change A LOT over two years. Places where the cartilage is worn almost to the bone can suddenly look almost as good as new.

I can remember reading all this and thinking, “Damn, this is big. I’m reading all these articles and books about healing bad knees. Why doesn’t anyone mention this?” Instead, much of the prevailing thinking cleaved to a sort of “car part” model, if you will. That is, you could think of your knee cartilage like the tread on your brand-new tires. After time, it simply wears down.

It’s a simple, fatalistic, and profoundly flawed way to analogize about human bodies, which are full of cells that are constantly renewing. Hell, if we weren’t built that way, all of us would die of senescence at the age of three or so.

So congrats to gcoza. He is quick to note that he hasn’t beaten knee pain yet. He’s better, but still has a good way to go. But man, it must feel unbelievably good to stare at an MRI that essentially says, “Hey, all your hard work at recovery is paying off.”

Now, granted, that fill-in cartilage is probably of the inferior fibrocartilage variety that’s less durable than the original. But as I have mentioned before, over time fibrocartilage has been shown to begin to take on characteristics of normal hyaline articular cartilage.

Update: I feel that I should share this. Gcoza has now said that the MRI was faulty and that the cartilage didn't completely heal. Here are some excerpts from his latest comment:

Unfortunately, I went for another MRI because my orthopedist said that the pictures are not of sufficient quality. This time images are much better quality and revealed chondromalacia patella 1b.- 2 grade on both knees. Im feeling about the same. Neither better nor worse. Status quo. My next step would be stem cells treatment because I tried more-less every other possible option ... Conclusion is: chondromalacia is irreversible, but with time one can feel better. Now, three years from the beginning of my knee problems , constant pain was reduced by at least 50-70%, and the function of the knee is also improved by at least 50%. Now I can squat. Three years ago I could not walk up and down stairs.

Okay, so this isn't the success story I was hoping for. However, he has reduced his pain and improved the function of his knee. That's some progress. Getting better can take a long time unfortunately. Maybe he'll have success with stem cell treatments. If he does, I'll report back.