I was diagnosed with this a few months ago, and endured burning and just plain "hurting" on the ball of my foot and 3rd and 4th toes when walking. By the end of the day, it was hard to stay on my feet. A cortisone shot didn't make very much difference (temporary), and inserts helped a bit, but I had unacceptable pain. I gained weight because I mostly had to sit; I couldn't walk for exercise, couldn't wear but one pair of shoes - unsightly tennis shoes with inserts. I researched, and came up with cryotherapy;i.e., freezing the nerve to make it disintegrate. The nerve sheath is left intact so the nerve can regenerate normally. This is quick and recovery is quick. If you haven't had it very long, this is a good conservative step. My regular podiatrist wanted to do a tendon release, which was a form of open surgery, and would have required a week of wearing a surgical boot. Also, that in my opinion changes foot mechanics and cannot be undone. I found a doc who does neuroablation with a Cryostar 2 hours from my home, drove there, had it done, and a week later I am 90 percent better, walking a lot again, and am a happy camper. Anybody else on this site who has experienced cryosurgery for this problem?
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Your post appears to indicate that either you misunderstood or have been mis-informed as to the specific details of the procedure which you cite. First of all, as it is a closed and essentially blind procedure, the technique is one of guestimation as to precisely where the cold is applied, leaving open the possibility of affecting tissues not intended for destruction. Secondly, as the nerve sheath is the outermost portion of the nerve, it would be impossible to destroy the nerve and leave the sheath intact . . And even if it were possible to leave the sheath and destroy the nerve, it would not result in nerve regeneration. Thirdly, I'm quite sure that your regular podiatrist did not tell you that he would do a tendon release for a neuroma, as that would have no bearing on the problem. Perhaps he wanted to do a decompression procedure where the ligament near the nerve is transected, and the neuroma repositioned, but I'm quite sure it wasn't anything to do with a tendon. At any rate, it's still surgery that you had, and as with any surgical procedure, there is always the possibility of complications and failures, but I'm pleased to hear that so far you are doing well. Continued good luck!
I did use the wrong term (tendon) instead of ligament, which is cut in the decompression technique to make room for the neuroma. It was my opinion that it's best to just get rid of the neuroma itself. With Cryosurgery, I believe that has been done. However, if the ablation of the nerve is not complete, I'll have it redone since it is quick and recovery is only 3 days. Also, this procedure doesn't not cause stump neuritis, as other ablation methods may. The Cryostar machine comes with a nerve stimulator to find the nerve during the procedure. Thanks for your reply.
As a podiatrist, that has performed well over 1000 procedures I would like to clarify and give my opinion. Cryosurgery is probably one of the best options for resolving neuroma pain. While it is a surgery it is minimally invasive and there is not cutting of ligaments or any other structures for that matter. Infections rates and complications are much higher for any other type of neuroma surgery.
Most importantly, it is absolutely not a blind procedure. That is totally incorrect. Myself and several other podiatrists use high powered vascular ultarsound to guide the procedure exactly to the nerve. There is direct visualization. Secondly, the outer sheath is preserved and inner protion of the nerve is destroyed. This is a proven physiologic response to freezing and have ice crystals for within the inner nerve cells. The sheath does not succumb to the freeze in the same way.
Perhaps there are drs doing this blindly, however, that is not the state of the art method for the procedure.
FootDoc, I am glad to clarify this for you and the person posting because the public should be informed correctly with regard to this procedure.
One addition to my last post. As mentioend by mahopkin2, there is a nerve stimulator that can also put you directly on the nerve. This cryo technology will change the treatment course for all nerve related pain in the foot.
I read your postings on cryoneurolysis for neuroma. I'm currently in the process of publishing three papers on the molecular biology, applications and short and long term effects of cryo, the first which is in press as we speak. Your questions are very similar to what I hear throughout the country. Modern cryoprobes are made of an inner and outer tube I'm which nitrous oxide gas is released in a controlled environment. Cooling through this particular probe reaches between neg 50-neg 70 degrees celsius. This is optimum temp for controlled neurolysis not neurectomy and cold tip neurolysis is the only mechanism to spare the nerve outer sheath. This neurolysis occurs at the cellular level via direct injury to nerve cells by ice ceysral formation and then through microcirculatory failure after thawing enhancing apoptosis. Mechanical and biochemical damage occur at the cellular level. This what makes cryo unique that it works at the cellular level hence sparing potential side effects and unwanted tissue exposures whether you believe in the procedure is a matter of choice. The biology of cryo has existed 40-50 years and our understanding improves with every study and is a matter if fact. An upcoming paper will discuss the cellular biology of cryo and the factors that must be understood for appreciation of the technology. Its understandable to question what we don't know but all I ask is before we start using terms such as destryoing unwanted tissue without fully understanding the histopstjalogical effects and microbiology effects of biological tissue undergoing cryogenic treatment, may send the wrong message
Dear Footdoc,
Cryoanalgesia As It Was Taught And Fairly Widely Written About By Dr. Fallatt Has Changed Quite A Bit. The Actual Cryostar/cryopac Instrumentation Is Still The Same, But Everything Else About The Procedure Has Changed. I Have Trained Dozens Of Dpm's On This Procedure Nationwide. The Newer Procedure, As Dr. Katz Said, Is Performed Under Ultrasound Guidance. Black And White Ultrasounds Just Do Not Give The Proper Visualization For The Nerve Tissue To Be Picked Up Even With The Most Well Trained Eye. When We Visualize The Vascular Tree Instead, We Are Easily Able To Find The Nerve Structure. Each Nerve Travels With A Corresponding Vessel. This Procedure Makes The Nerve And Only The Nerve Much More Easy To Find. Once Found, The Probe Is Placed Through A 2mm Incision From Between The Toes And Guided Into Place On The Nerve Trunk. As The Procedure Progresses, An Iceball Approximately 5mm In Diameter Is Formed Around The Nerve Structure. The Freezing Affected The Most Fluid Structures Most And The Least Fluid Structures Least. The Contents Of The Axon Are Frozen And A Normal Wallerian Degeneration Ensues. This Is The Same Exact Degeneration Seen When The Nerve Trunk Is Transected. This Degeneration Starts Between 1-3 Weeks After The Procedure And Continues For 3-4 Weeks. Immediately Following The Degeneration, A Regeneration Occurs. The Nerve Heals And The Pain Is Gone. The Perineurium Remains Intact As It Has More Fibrous Tissue Components. As For Healing, It Is An Essentially Painfree Procedure. We Are Performing A Prolonged Conduction Block Of The Nerve That Would Sense The Pain Of The Procedure, So With Rare Exception There Is Minimal Pain. To Date, There Are Only 3 Dpm's In The Country Performing This Procedure As I Have Described-dr. Katz, Dr. Cavazos And Myself.
We Each Have Websites That Would Prove Very Informative. Mine Is Actually Geared As A Teaching And Information Site For Dpm's And Other Physicians. I Will Not Post The Website Address As A Matter Of Good Taste. I Hope This Proves Informative For You And Your Posters.
I refuse to get into the shouting matches which were once a feature on this site when invaded by some self-promoting doctors who seemed to be more specialists in practice management than in podiatric care. My Google search of your name revealed that you have tended to be a vociferous advocate of cryotherapy on other podiatry sites, and, as I believe to recall, have already run afoul of the moderator of one of them who I believed found it necessary to delete some of your posts asserting that you were using the site for self-promotion of your practice and web site. If my recollection is incorrect, you will surely let me know.
My problem here is that I have seen the sort of rush to use of many new technologies, often by those quickly trained in its use who then employed mass advertising, TV "news reports" and web promotion, ostensibly for public education, but in reality, for the benefit of their own financial interests. I have too often in my decades of practice of podiatry witnessed overuse of privately owned costly technologies.
Of course, having never heard of you or any of the others who have come here to promote this technique, I certainly cannot, and I do not have basis to attribute such unscrupulous motives to you. But past history has made me quite wary of such seemingly promotional techniques. It has been my firm belief that I should never be one of the first or one of the last to employ a new technique, and to let the dust of real evaluation settle before subjecting my patients to such. As a prime example, I have seen the rush to lasers in podiatry and their fade as well.
It could be that the technique you promote is a worthwhile addition to the podiatric medical armamentarium, but I find it curious that, although you state that you have "trained dozens of DPM's on this technique nationwide," and you state that only you, Dr. Cavazos and Dr. Katz currently use the technique . . . and even more curious that all three of you have suddenly chimed in here.
You've had your opinion and I've had mine. Let's not turn it into a battle of words. Potential patients can research this procedure on their own before seeking its use on them, hopefully from independent investigators who have no personal, financial axe to grind.
I meant that I have trained dozens of DPM's on how to perform the old procedure. We are only now starting to train others on the new ultrasound-guided technique. For the record, neither Dr. Katz, nor Dr. Cavazos, nor I have any financial interest whatsoever in any of the companies that make any of the equipment we use for the procedure. If anything, I am active in talking to the manufacturers to try to bring the cost of technology down and make it affordable to all podiatrists who want to perform the procedure. I am also talking to the health insurers nationwide to try to increase reimbursement for the procedure, which is the other stumbling block for its acceptance in the podiatric community. Lastly, with so few of us doing the procedure, it is difficult to educate the public, the medical community and publish data all at once. We all have busy practices. Between us, we have performed more than 5000 procedures with extremely high success rates. It is not just us touting the procedure. Its our patients. If the patient feels better enough to laud the praises of the procedure, who can argue with that?
Dr. Rampertab, you mentioned that the degeneration of the nerve after cryo ablation occurs for up to 4 weeks. I was curious about that, for I had the surgery July 8, and though most of the pain is gone, I still have some pain on the bottom of the ball of my foot - like stepping on a marble. I was afraid I had not rested enough and started walking too soon, but perhaps there will be even more improvement. Do you think this is possible? Thanks for your time.
I did not imply, nor should it have been inferred that you or the others had financial interest in the companies producing the equipment. My alluding to financial interests had to do with what might be seen as self-promotion for financial gain when participating in forums such as this under the perhaps guise of merely altruistic educational motives, as is the defined purpose here. The mention of or directing of readers to proprietary business websites, the use of or encouragement of anecdotal testimonials and even efforts to increase insurance coverage for a procedure in which one has an undeniable profit motive could certainly be seen as such. But as I have stated, neither knowing you nor of you, I can only rely on my past experiences for such judgments and warning flags. With that clarification, I will conclude my participation in this thread.
__________________ Foot Doc
Last edited by FootDoc; 23rd July 2008 at 12:34 AM.
Dear mahopkin,
Actually for cryo as a whole, meaning specifically non-ultrasound guided cryo, 80% of my patient population related 80% improvement in symptoms within days, but it does take 10-12 weeks typically for the pain level to reach 0/10. The "lump" you still feel in the area is actually the enlarged trunk of the nerve. That takes several months (3-6 months) depending on the original size to completely go away, but it usually does. It does not cause pain, though. You are still very early on in the post-op course and should see continued improvement from week to week. Happy healing.
I agree footdoc, we shouldn't get into a match here. Thank you for being so open minded and willing to consider the procedure. After all it may be in the best interest of patients. I know that the university setting may have its limitations but we are in real practice and have patients that are thrilled with the excellent results. Feel free to send any questions regarding cryosurgery so that myself, Dr Rampertab and Dr Cavazos can properely inform the general public and other physicians.
Morton's neuroma, successful cryo ablation
Re: Morton's neuroma, successful cryo ablation
Re: Morton's neuroma, successful cryo ablation
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