Question
Dr. Katz,
I hope you can answer a couple of questions for me.  I tried to get to you on ask the experts, but cannot.  I know you are busy, but I am starting to lose hope.

I had neuroma surgery in January, 08.  The orthopedic surgeon removed a pea sized neuroma in the 2nd interspace and we were scheduled to remove the neuroma in the 3rd interspace 4 weeks later, but I opted out because of pain and swelling.  I have had cryo twice on the remaining neuroma and it is ok for now.  I have a neuroma in my left that is starting to flare, but nothing like the first one.

The neuroma pain is gone from the removal, but since then I have been having pain the my 2nd MTPJ.  I have been diagnosed with capsulitis and had one cortisone injection in that joint, which did provide some relief.  I still feel like I am walking on my 2nd MTPJ all the time... barefoot, it is obviously worse, but even with my multiple pairs of orthotics, I can still feel the pressure on that joint.  I sometimes also feel pressure on the 3rd joint.  I also feel like I am putting pressure on the space between my first and 2nd mets and the space between those and my 1st and 2nd toe does seem bigger than it was or on my other foot.

One podiatrist fabricated my orthotic with a cut out to take pressure off of that area, it helped a bit, but not enough.  He said that the surgery caused the misalignment of the metatarsal heads, based on the MRI, my tendons and ligaments are all in tact.

I had an MRI - there is swelling and inflammation around the 2nd MTPJ, and tendonitis around my first metatarsal.  

Here are what some of the doctors have said:

An orthopedic surgeon says I have Morton's Foot (which I do) and wanted me to wear carbon inserts and suggested shortening my 2nd and 3rd mets with surgery... he was in the room for 5 minutes.

A podiatric surgeon suggests bunion surgery.  My bunion doesn't hurt me all of the time, but he says that the joint is moving away from the 2nd and that is why I have 2nd met overload and capsulitis.  He gave me a budin splint, but that puts pressure on that already sore area.  He suggested PT with ultra sound... the PT I saw didn't seem to really know what to do with me or didn't seem to believe that ultrasound would provide any relief.

I thought that bunion surgery can cause 2nd met overload and am concerned that that would make it worse.  He didn't think that my 2nd met had "dropped" - you can see all of the heads about the same in the top of my foot.  If anything, the 3rd met head is a little lower when looking at the top of my foot and bending my toes down.

A chiropractor/kinesiologist is working with my gait mechanics and has me doing some exercises to change my foot mechanics... I have had some improvement, but I still have pressure and pain whenever I walk or stand.

I can only wear athletic shoes, but they do not provide complete comfort, I have hard orthotics, 3/4 orthotics, full length, full length with metatarsal pads and none of them seem to be working for me.

Do I have a fat pad issue?  How do I know?   Would that have shown up on the MRI?  I have had a total of three cortisone shots in that area and 1 cortisone injection to the joint and 7 alcohol injections.

I am trying to decide what to do next - bunion surgery, osteotomy(s), injections?  I do not want to worsen the situation, but I am worried that I will never be without pain and that if the capsulitis continues, I am looking at pre-dislocation and more problems.

Thank you for your help,
Cindy

Answer
Hi Cindy,

After neuroma removal there are often damaged ligaments which cause movement of the toe and metatrsal.

First I would avoid any metatarsal surgery at this time.  I would absolutely avoid bunion surgery if you have no bunion pain.  After bunion surgery there is typically more pressure on the 2nd metatarsophalangeal joint.  I would say that physical therapy may be helpful short term.

It is possible to be examined to determine if you have lost some fat padding.  I would expect loss due to the neuroma surgery and the multiple injections.

In my opinion, I would attempt further cryosurgery in the area of the capsule and avoid any further bone surgery if possible.  Injections will also lead to worsening of the condition.

Sincerely,

Marc Katz, DPM
Tampa, FL
Advanced Podiatry
www.thetampapodiatrist.com
www.tampacryosurgery.com

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