Nerve compression syndromes result from a nerve conflict with another tissue, e.g. a degenerative-productive lesion, an overgrown muscle belly, swollen inflamed tissue, scarring or a soft tissue nodule. Neuralgia is characterized by symptoms of numbness, tingling or pain in the area supplied by the pinched nerve. The most common ankle and foot neuralgia are Morton's disease, tarsal syndrome, Baxter neuralgia, and anterior tarsal syndrome. Conservative treatment options include rehabilitation, wearing orthopedic insoles, administering an anti-inflammatory agent, or performing a nerve block. In most cases, however, it is necessary to undertake surgical treatment consisting in surgical decompression of the nerve or removal of the resulting neuroma.
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Morton's neuroma
Morton's neuralgia is also referred to as Morton's metatarsalgia or interdigital neuritis, in the course of which pathological inflammatory changes in the perineural tissue occur. The cause of the disease is entrapment of one of the common plantar nerves that run between the metatarsal bones and supply the toes. Nerve compression occurs most often at the level of the metatarsal transverse ligament. A risk factor for conflict and the formation of nerve microtraumas is changes in the mechanics of the forefoot bones in the course of transverse flatfoot. People with dorsal elevation of the first radius of the foot and deformity such as hallux valgus are more likely to suffer from Morton's disease. Then, the pressure is incorrectly transferred to the head of the second metatarsal bone. Narrowing of the nerve canal may also occur due to synovitis of the metatarsophalangeal joints or the presence of a cystic nodule (ganglion).
Morton's neuralgia usually affects the nerve located in the second or third metatarsal space. Numbness and pain may radiate to the second or third toe. A common symptom of Morton's neuralgia is pain worsening when walking in narrow toe shoes or high heels. Initial diagnosis is facilitated by the Mulder test, which involves lateral compression of the foot at the level of the metatarsal heads. A sudden reduction in the space in which Morton's neuroma runs provokes pain and may cause a characteristic audible click. Imaging tests (ultrasound of the foot or MRI of the foot) show the thickening of the nerve structure and help determine the cause of the conflict.
Treatment of Morton's disease
An attempt to alleviate the symptoms of Morton's neuroma is to wear orthopedic insoles with a metatarsal arch to relieve the transverse arch of the foot. The pelota raises the metatarsal bones between which the interdigital neuroma runs. This creates an opportunity to increase the space between the metatarsal bones and decompress the nerve. In the case of contracture of the triceps muscle of the calf, it is advisable to perform stretching exercises, thanks to which the overload of the metatarsal heads during walking is reduced. The shoes worn should have loose, wide toes to avoid lateral compression of the forefoot. Shoes with narrow toes and high-heeled shoes should be absolutely avoided.
In the case of inflammation in the forefoot, non-steroidal anti-inflammatory drugs (NSAIDs) are administered. A nerve block is also performed, which is the injection of bupivakine or lidocaine proximal to the pressure site. Apart from confirming the diagnosis, the lidocaine injection causes temporary pain relief. The nerve can be injected with a corticosteroid to prolong the analgesic effect, but too frequent repetition of this procedure is inadvisable due to the possibility of local soft tissue atrophy or even necrosis.
If conservative treatment is unsuccessful, surgical treatment is undertaken. Surgical access is most often from the dorsal side of the forefoot and includes a small 2-3 cm incision in the skin. After visualizing Morton's neuroma, the surgeon removes pathological changes in the perineural tissue. If necessary, he resects the tissues causing mechanical conflict, i.e. scarring lesions in the nerve area, or cuts the metatarsal transverse ligament. Morton's neuroma can also be completely removed as part of the so-called neurectomy surgery.
Tarsal canal syndrome
The essence of the tarsal canal syndrome is the compression of the posterior tibial nerve or one of its branches: the medial plantar nerve, the lateral plantar nerve or the medial heel twigs. The posterior tibial nerve runs in the so-called tarsal canal located behind the medial ankle of the ankle. The tendons of the posterior tibial muscles, the long flexor of the fingers and the flexor of the long toe also run in this channel. Inflammation of the tendon sheaths can cause local swelling and shrinkage of the tibial nerve space. A similar effect may be achieved by scar tissue overgrowth as a result of a healed injury to the medial ankle joint. Tarsal canal syndrome is more common in people with squamous valgus feet because with each step the heel tilts inward and the medial malleolus bulges, causing the nerve to overstretch and mechanically irritate the nerve.
Tarsal syndrome manifests itself as a tingling, burning, or painful sensation under the medial ankle radiating towards the sole of the foot or towards the lower leg. If there is compression of one of the branches of the lateral plantar nerve, the pain is mainly located on the medial side of the heel - this condition is known as Baxter's neuralgia. The plantar nerve branch is trapped most often between the toe abductor and the plantar trapezius, and in the presence of plantar fascia edema.
Conservative treatment of the tarsal canal syndrome includes correction of the squamous valgus foot with orthopedic insoles, physical therapy and drainage to reduce the swelling of soft tissues, and the possible use of non-steroidal anti-inflammatory agents. When imaging tests reveal a conflict that causes a direct conflict for the tibial nerve or its branches, the pathological changes are resected. Surgical decompression of the nerve gives the best chance of permanent pain relief.
Other compression syndromes
The anterior tarsal syndrome occurs when the deep peroneal nerve is compressed at the level of the lower flexor retinaculum or in its further course due to a conflict with degenerative and productive changes in the foot joints. The reason may also be too tightly tied shoes causing excessive pressure on the arch. A typical symptom of deep peroneal neuropathy is pain and hyperesthesia in the area of the first interdigital space between the big toe and the second finger.
The superficial sagittal nerve is often trapped at the puncture site of the fascia of the lower leg, which may be caused by scarring changes. Direct trauma to the anterior region of the shin can also lead to nerve dysfunction. A common symptom is a feeling of numbness and tingling on the dorsal surface of the foot.
Treatment of compression syndromes of peroneal nerves (deep or superficial) mainly includes rehabilitation - fascia mobilization and fibula mobilization. Surgical treatment consisting in local decompression of the nerve is used in rare cases.
Frequently asked questions about nerve compression in the foot area:
Morton's neuroma belongs to the so-called pressure neuropathies, i.e. diseases manifested by impaired sensation in the area supplied by the compressed nerve. Morton's neuroma forms a pathological thickening of the common plantar nerve innervating the toes of the foot. This thickening is caused by mechanical irritation by misaligned metatarsal bones, transverse ligament of metatarsal heads or, less frequently, by the presence of a cystic nodule (ganglion).
Common symptoms of Morton's neuroma include a feeling of numbness and burning sensation in the second or third metatarsal spaces. Pain can radiate to the toes and is worsened when walking in narrow toe shoes or high heels. Initial diagnosis is facilitated by the Mulder test, which involves lateral compression of the foot at the level of the metatarsal heads. A sudden reduction in the space in which Morton's neuroma runs provokes pain and may cause a characteristic audible click. If Morton's neuroma is suspected, you should see an orthopedist who, in addition to clinical examination, will order imaging tests (ultrasound or magnetic resonance imaging).
Conservative treatment includes wearing shoes with wide toes and the use of orthopedic insoles that relieve the transverse arch of the foot. In the case of severe discomfort, a nerve block is performed. Surgical decompression of the nerve or complete excision of the neuroma is the best chance for a permanent cure.
