Squash Magazine Articles
by Michael Schumacher, DPM, FACFAS
It started out as "numbness" in the ball of your foot. It was an odd feeling that you had trouble describing. Like most squash players, you did nothing about it. A few weeks later you noticed a stab of pain where the numbness was. This pain felt like a hot coal in your foot. You took off your shoe, massaged your foot and the pain went away. This goes on for a few weeks. The more narrow your shoe, the more pain you have.
Soon it starts to hurt all the time and you find yourself rubbing the ball of your foot several times a day and taking your shoes off while you are sitting at your desk. If this sounds familiar, you probably have a neuroma.
The neuroma that affects the foot is called a Morton's neuroma. This is a swelling or entrapment of the nerve that gives sensation to the adjacent sides of two toes. Typical symptoms of a Morton's neuroma are the above-mentioned pain in the ball of your foot, which can also be accompanied by tingling in the toes and/or burning. It arises as the nerve travels below the intermetatarsal ligament ("Metatarsal" means of, relating to, or part of the human foot). This neuroma usually occurs between the third and fourth toes, but can occur between any two toes. Activity that shifts pressure and body weight to the ball of your foot (such as playing squash, wearing high heels, climbing stairs) tends to make the problem worse. Women are much more likely to have a problem with neuroma, mostly due to narrow shoes with heels.
When someone with a Morton's neuroma presents to my office, I usually take an x-ray to rule out any osseous (bony) problems, such as a stress fracture. The entrapped nerve does not show up on x-ray, although often decreased space between the metatarsal heads (toe-side ends of the metatarsal bones) or splaying of the adjacent toes can help confirm the diagnosis. The main diagnostic tool is the physical exam. Squeezing the foot from side to side and pushing up in between the involved toes will usually cause severe shooting pain and a "click," which is caused by the nerve being squeezed between the metatarsal heads. This is the classic presentation of a neuroma. If the diagnosis is unclear, MRI or diagnostic ultrasound can give more information.
After the diagnosis has been made, the first line of treatment is a wider shoe. I often see squash players who are playing in shoes with a narrow toe box. Changing into a wider squash shoe can resolve the pain. Further treatment can consist of cortisone injections, NSAIDS (Non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen), and custom foot orthotics to help take the pressure off the ball of the foot. If these fail, the next step is destruction of the nerve, either through a series of sclerosing alcohol injections or surgical excision. I have had success with the alcohol injections, which cause the nerve to stop functioning; because this nerve is a sensory nerve only, you trade pain for numbness. This process has eliminated the need for surgery in many patients. The nerve is a sensory and not a motor nerve, so removing it does not affect function of the foot.
If you suspect you may have a neuroma, make an appointment with our office, and together we will prescribe the appropriate treatment plan.