Sunday, September 15, 2013

High Heeled Danger!

Attention female shoe lovers- if your closet is packed with high heels, especially those with pointy toes,  you may one day find yourself dealing with a medical problem known as a Morton's neuroma. A Morton's what, you ask? Morton's neuroma- a little balled up group of nerve endings (perineural fibrosis, if you want the medical lingo) along the small digital nerve as it passes between your toes, most commonly in the space between your third and fourth toes.

This malady is most common among women in their mid to late 40's. High heels cause more weight to be transferred to the front of the foot, and the pointy toes squeeze in from the sides, pinching in on the nerve, causing inflammation. Often the patient first notices the problem as a sensation of a pebble in their shoe, but typically this progresses quickly to pain, cramping, numbness or shooting sharp pains of the area with weight bearing. Can you get a Morton's neuroma without high heels? Sure- anyone who "overuses" their feet- ballet dancers, basketball players, runners- can develop this problem, but high heels greatly contribute to this problem.

How is a Morton's neuroma diagnosed? Xrays might be obtained if there is concern of a stress fracture or other bony issue, but the neuroma itself does not show up on xray films. Often this condition is diagnosed based on your history and a thorough exam, but occasionally clinicians use ultrasound to further evaluate the problem. Ultrasound is very accurate at identifying neuromas (98% sensitivity) but not always accurate (65% specificity). MRI scanning is rarely needed to help with surgical resection, for resistant cases.

How about treatment? First and foremost, it's time for "sensible" shoes- wear flat shoes with a roomy toe box. Inserts such as metatarsal pads may help ease symptoms, as well as arch supports for those people with flattened arches. Taking NSAIDS (ibuprofen or naprosyn) often will ease the discomfort temporarily, and nearly half of patients (40-50%) will respond to these simple measures within three months. The primary treatment from the medical end when conservative measures are not effective enough, however, is a steroid injection into the top of your foot (just above where the pain is located). This injection may be repeated in 1-4 weeks if there is a partial response.  Another 40-50% of patients will respond to these injections. For those 20-25% who continue to have pain despite all these measures, surgery may be indicated to go in and remove the actual neuroma and free up some space (releasing a ligament) in between the toes, and happily around 96% of surgical patients obtain relief.

BOTTOM LINE: Once again, prevention is key! Enjoy your high heels in moderation, but consider a more generous toe box and wedge (less slope) for daily use if your profession calls for dress shoes. Also, go see your family doctor when you START feeling that "pebble"- don't wait for it to become intense daily pain!

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