Trapped nerve in foot makes shoe wear painful

Conway McLean, DPM

The subject of our discussion today is a hard-working woman named Sally, who works in a local law office. Like so many in this type of work environment, the dress code required is rather strict, with well-defined standards. For Sally, this eventually became a source of great pain and frustration. Not the job itself; she loved the work, her employers, even her co-workers. The difficulty she dealt with every day of her working career, at least after the first few years, was the pain in her feet.

After a couple of years of work, always wearing this type of shoe, she began to notice an aching pain in the ball of her right foot. Every time she stuffed her feet into her work shoes, the slim, dressy kind with a heel of “reasonable” height, there was pain. By the end of a busy day (weren’t they always?), it had progressed to a pretty significant burning pain. The weekends were bliss since she never had pain in her sneakers, despite the fact she was quite active, with bike riding and her fencing lessons.

A recent promotion unfortunately led to more pain, since she now accompanied an attorney to court. This somehow entailed a fashion upgrade with tight skirts and tighter shoes as part of the deal. It had become clear. The tighter and dressier the shoe, the more pain she experienced. Work became an ordeal, a daily lesson in torture and how to live with it. But live with it she did; a year of agony.

A trip through her neighborhood pharmacy led to the discovery of a foot pad practically guaranteed to relieve her pain. The packaging was so filled with hyperbole, she was certain the pad would make her smarter and 10 years younger! Actually, the first week with the pad there was a noticeable decrease in her pain. But the reprieve was momentary. Within a month, the pad only served to make her shoe tight and uncomfortable, with no respite from the aching and burning.

It was around this time that Sally began to notice a lump developing in her shoe. But how could it be the shoe when she was getting this very annoying sensation in all her work shoes? If she were wearing socks, she would have sworn the sock was balled up, but nylons couldn’t possibly cause this. Nor could they produce the cramping sensation in her toes. This was a new type of pain, one she had not had previously, and it demanded that she take her shoes off to massage her foot. This was not a good look in the middle of a large, busy law office!

A friend told Sally about a pain-relieving cream which worked wonders for her friend, but only managed to produce for her an over-powering menthol smell. The next treatment attempted was a miraculous foot massager. It was rather pricy but would be money well-spent if it could help her survive work. The device actually felt quite good when in use but made no appreciable change in her pain levels when at work.

Her yearly trip to the primary care doctor produced a surprising verdict: he announced that she must have gout, although she had no family history. And her diet was primarily vegetarian, with only an occasional glass of wine, so it did not make sense to her. Naturally, this led her to some internet research. If this diagnosis was correct, which she now doubted, some pain should be noted even with use of “healthy” shoes. This was not the case, nor were any of the other facts revealed to her by Dr. Google.

A work associate recommended a specialist who, after an extremely thorough exam, produced a very interesting conclusion. Sally was told she suffered from a trapped nerve problem, a condition termed a neuroma. Apparently, according to the foot specialist, these can happen anywhere in the body, but when occurring where her pain was, the label applied is that of a “Morton’s neuroma”. A relatively common malady, said her new favorite doctor, a lofty position he attained due to the administration of some medicine into her foot which relieved the great majority of her pain, and did so for many weeks.

This new sensation, freedom from pain, was something Sally had not experienced for such a long time, she was taken aback. She felt like a new person at work and was able to concentrate on her job better than she had in years. Unfortunately, as she had been warned it might, the pain started to gradually increase over the next few months, although she remained encouraged by the simple fact relief was possible. Another injection at the specialist’s office again provided tremendous relief. But, again, relief was transient.

A subsequent visit to the specialist included a detailed discussion of all the possible options for treatment, as well as information about the nature of the condition. It boils down to the fact that nerves do not deal well with chronic pressure. The covering of the nerve, the nerve sheath, will thicken and enlarge, producing the “balled sock” sensation she had been experiencing. The nerve which runs between the metatarsal bones was getting trapped by these bones and a ligament which is found between the metatarsals. These three structures were pressing on the nerve, a condition markedly worsened by her narrow, dressy shoes.

She was given several treatment options for the neuroma, after the failure of the required steroid injections that is typically utilized. A course of physical therapy does not generally have a good success rate resolving the symptoms of a neuroma. One suggestion by the doctor was completely untenable: use prescription arch supports inside sensible shoes! The very idea! This may work for many people suffering from neuromas, according to the specialist she was seeing, but it simply was not a consideration. Whatever treatment she utilized had to allow her to wear her “business” shoes.

Sally underwent a new surgical procedure recently developed for her Morton’s neuroma, performed minimally invasively. This meant she was able to return to work sooner than with the older procedure, which apparently is still used by many. The older technique entails simply cutting out the enlarged nerve, but this is the only place in the body where we do that. Most importantly, the complication rate is uncomfortably high. Her doctor’s procedure involved a release of the ligament trapping the nerve between the metatarsal bones. The recovery was a breeze, and she is planning to get the other foot done, even though the pain from this foot was mild in comparison.

Nerve problems are challenging, often maddening. They tend to cause symptoms past the site where the problem is, or the pain is diffuse, hard to localize. New surgical techniques and materials are being developed, but nerves remain a source of frustration for physicians and patients alike. They don’t respond well to trauma, regardless of the type. That includes surgical trauma. Subtle repetitive trauma can do as much damage as a single traumatic event, although both are difficult to treat. If you have burning or cramping in the ball of your foot, don’t ignore it. As is the case with many nerve problems, the longer you wait, the more difficult to resolve. So, see a specialist who knows the problems associated with that part of the body. Relief may be a tiny incision away.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with an upcoming move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments