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Revision Surgery After Failed Neuroma Excision

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What is a neuroma?

A neuroma is simply an enlargement of a nerve on the bottom of the foot. This enlargement of the nerve begins when abnormal pressure during walking is experienced or trauma to the bottom of the foot occurs leading to swelling of the affected nerve. Neuromas are common in people who frequently walk barefoot, wear very high heels or have a foot type that causes increased pressure in the pads in the front of the foot. Painful symptoms are often described as burning, tingling, or walking on a pebble in the shoe.  

 

 

The vast majority of neuromas are improved with conservative care. This care should always include removal of pressure to nerve with appropriate size and shoe type, an offloading pad or insert, and avoidance of barefoot walking during recovery. Your physician often will treat condition with a injection of steroid to the site to allow the nerve inflammation to decrease. In some cases physical therapy can be utilized to reduce pain.  

In cases where neuroma pain does not improve with conservative care, surgical removal of the affected nerve can be chosen as definitive treatment.  While this surgery is successful in the vast majority of cases, in some rares situations nerv pain may not improve or return.  

Causes of pain after neuroma surgery and associated treatments

Recurrant pain after neuroma surgery has several possible causes. In the majority of cases the pain is due to a condition called a "Stump Neruoma" which is an enlargement of the nerve at the site of nerve resection. This condition is a known complication that can occur as often as 15% of neuroma surgeries. Below are the most common causes of pain after neuroma excision and their associated treatments. 

  1. Hematoma - this is a localized blood clot. Treatment includes moist heat, physical therapy, and evacuation of clot in office if severe. 
  2. Incomplete removal of offending neuroma - nerve is not cut far back enough and inflamed nerve remains. Treatment can include steroid injection but usually repeat surgery is required. 
  3. Nerve is not cut sharply - cutting a nerve with a dull knife or scissor crushes nerve leading to inflammation. Treatment can include steroid injection but usually repeat surgery is required. 
  4. Incorrect original diagnosis - if pain is unchanged after surgery, previous pain could have been from inflamed joint tissue or tearing of an adjacent joint. Treatment includes re-evaluation and possible surgery to repair causative condition. 
  5. Stump neuroma - common complication that can occur despite meticulous surgical technique. Treatment most often requires surgery, but steroid injections can be attempted prior to surgery. 

Neuroma surgery revision 

The decision to return to surgery is usually not scheduled earlier than 3 months after the original surgical date. This is because normal postoperative pain can last this long, and conservative therapy should be attempted first. Confirmation of neuroma recurrence or stump neuroma formation can be made with an MRI prior to surgery.  

Surgery for recurrent neuroma pain involves either creating a slightly longer surgical incision on the top of the foot or using a incision on the bottom of the foot. The goal of this surgery is similar to the original surgery with special care taken in these areas:

  1. Nerve is cut farther back in foot.  This removes inflammed nerve endings and allows remaining nerve to retract into the foot where it is surrounded by soft muscle.  
  2. Nerve is cut with sharp knife to reduce inflammation to nerve. 
  3. Steroid is injected about the end of remaining nerve to inhibit postsurgical inflammation. 

Revision neuroma surgery recovery

Recovery after a second neuroma surgery is typically the same as the first surgery. The only exception is if an incision was made on the bottom of the foot, 1-2 weeks non weigh bearing in required,  where an incision on the top of the foot allows for immediate weight bearing in a protective shoe. A protective shoe is worn for 4 weeks after surgery and then return to walking in an athletic shoe. Return to full normal activity occurs at 6- 8 weeks after surgery. Discomfort  and swelling can be present for up to 6 months after surgery but should slowly improve each day.  

You do not have to suffer from pain after a neuroma surgery. If you are experiencing pain after this procedure come in for an evaluation and treatment.

  

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