Foot pain has the power to ruin everything from your morning walk to your business day to your sleeping time. While everyone has heard of Mortons neuroma there is a good chance that very few people have come across the term Joplins Neuroma foot which sounds quite specific and not unlike what it actually is – an all too common misdiagnosis. This condition known as Joplins Neuroma foot is a nerve disorder that impacts the medial aspect of the hallux, can result in burning, prickling and stabbing pain that is otherwise liable to be mistaken for any number of other foot conditions.
Knowing what Joplins Neuroma foot actually is, where it occurs, what causes it and how to treat it could be vital to identifying a suitable course of action quickly. This article helps to explain it in straightforward terms.
Understanding Joplins Neuroma Foot Condition
Joplins Neuroma foot is a perineural fibrosis which means a thickening of the tissue around a certain nerve in the foot. It was named after an individual called George Joplin, who published on the condition in 1971. It is also different from another common nerve problem called Mortons neuroma because Joplins neuroma affects the medial plantar proper digital nerve near the great toe, whereas the common Mortons neuroma affects the third and fourth webspaces of the toes.
This is an extremely important distinction because the location of the problem dictates everything else. Symptoms, diagnosis and treatment all depend on location. Many patients are treated for bunion pain or nerve inflammation for months before the actual problem is pinpointed to be Joplins neuroma.
Anatomy: Where Joplins Neuroma Occurs in the Foot
In order to learn how this condition occurs, it is useful to have some knowledge of foot anatomy- more specifically, the nerve involved and why that nerve may become entrapped.
The Medial Plantar Proper Digital Nerve
The medial plantar proper digital nerve of the first toe descends along the medial border of the hallux carrying sensation to the medial border of the hallux. A branch of the medial plantar nerve, which originates from the tibial nerve of the leg. The nerve runs in an area where pressure from footwear, ground reaction forces and mechanical stresses across the toe joint are prevalent.
Its superficial position and proximity to a weight bearing joint predisposes the nerve to irritation from a shoes that are a little too narrow, a hallux valgus deformity and ongoing friction leading to hypertrophy.
Joplins Neuroma vs Other Foot Neuromas
However, the main difference between Joplins Neuroma and Morton’s neuroma is the location and nerve. Morton’s affects the common digital nerves between the metatarsal heads, usually between the third and fourth. Joplins is medial, in-line with the medial side of the hallux.
The pattern of symptoms is different. Morton’s affects the ball of the foot and pain radiates into the lesser toes. Joplins affects the medial side of the hallux.
This distinction must be established, as treatment to the wrong area won’t be effective.
Causes and Risk Factors of Joplins Neuroma Foot
Multiple factors can cause the medial plantar proper digital nerve to become compressed or irritated repeatedly and rupture resulting in the fibrous thickening mentioned in this condition.
Footwear, Bunions, and Mechanical Stress
Clogged or tight shoes are among the most common offenders. Shoes that constrict the forefoot curve the great toe medially, applying direct pressure on the nerve. Bunion deformity—a bony protrusion at the base of the great toe—may accomplish the same thing in the absence of narrowing footwear.
Surprisingly, cases have also been reported following bunion surgery, where scarring or altered anatomy following the intervention contributes to nerve compression. Repeated trauma to the medial great toe, whether through long-distance ambulatory activity, weightbearing occupations or toe-off propulsion, slowly worsens the nerve. In time, the body’s response to that irritation is fibrosis—the same sort of response to neuromas like that is.
Other Contributing Conditions and Activities
Repeatedly kicking or pivoting sports- soccer being an obvious example- can place the medial great toe in constant mechanical stress. The build up of callus on this toe can cause additional localized pressure over the nerve itself. Gait abnormalities- for example over pronation- can alter weight distribution throughout the forefoot and sometimes therefore exert more force on the great toe then it can tolerate.
Hypermobility of the first metatarsophalangeal joint has also been associated with this lesion. Repeated compression or stretching of that nerve in any way can be responsible.
Signs, Symptoms, and Differential Diagnosis
It is important to be aware of the the location and nature of the pain when identifying Joplins Neuroma foot as all of this information is easy to miss.
Common Symptoms Around the Big Toe
Patients usually present with a burning and/or prickling sensation along the medial side of the great toe. Sharp shooting pains can occur in some individuals, especially when shoe pressure is applied or during push-off phase while walking. Numbness at the tip of the great toe is also described in some cases.
In general, pain tends to be increased by close fitting footwear and relieved by walking barefoot or in broad shoes; the presence of this phenomenon is in itself diagnostic. Symptoms can be episodic initially, provoked after prolonged walking/standing, before becoming persistent.
Distinguishing Joplins Neuroma from Other Foot Pain
The pain of a bunion is often concentrated in and around the joint and is usually associated with a deformity. The symptoms of Morton’s neuroma are entirely different. In the first metatarsophalangeal joint, osteoarthritis causes stiffness and ache rather than the burning, electric quality of nerve pain.
Tarsal tunnel syndrome involves a larger area of sensory disturbance across the sole. It is in detailed history taking – specifically asking about location, character and precipitating factors of pain – that Joplins Neuroma differs from these other diagnoses.
Diagnosis: Clinical Evaluation and Imaging
Established diagnosis requires complete hands-on diagnosis and sometimes imaging assistance.
Physical Examination and Clinical Tests
Palpation along the medial border of the great toe: Tenderness or a palpable lump may be identified, which may be reproduced on direct palpation over the nerve where the patient is asked to describe any reproduction of the symptoms. This clinical test is reliable. Footwear history is very relevant, and patients should bring their most used shoes.
Tuning fork (Tinel’s sign): Tingling may occur with tapping over the nerve.
Role of Ultrasound and Other Imaging
Ultrasound will help demonstrate the nerve swelling, and exclude any other soft tissue lesions. The skilful musculoskeletal sonographer will locate the affected nerve segment, and will even be able to direct a diagnostic or therapeutic injection to the lesion. MRI can show changes around the nerve, however the ultrasound provides a far more accessible and real time imaging technique.
Nerve conduction studies are used at times, but are not always conclusive for this nerve.
Treatment Options and Self-Care Strategies
The majority of Joplins Neuroma cases are not refractory to conservative treatment, particularly early in the course.
Non-Surgical Management and Lifestyle Changes
The most effective initial intervention for Joplin’s has been reported as switching to wide, lowheeled shoes with a forefoot toe box. Padding along the medial toe may help to decrease pressure to the nerve in activity. Custom orthotics may offload the medial forefoot in patients with biomechanical issues such as over-pronation.
Anti-inflammatory medication may help during an acute exacerbation. Injections of corticosteroids around the nerve have been successful in decreasing inflammation and alleviating symptoms. Alcohol sclerosing injections have been used in Morton’s neuroma, and appear to be effective in some cases of Joplin’s, progressively fibrosis the tissue over several interventions.
When Surgery Is Considered
Surgery is considered when conservative treatment has been tried consistently for a few months and there has not been enough pain relief. Often the operation involves releasing the tissue surrounding the nerve to decompress it, but in more advanced cases the whole affected segment of nerve may have to be removed (resection). This operation results in permanent numbness along the inner great toe however most people can live with this as the chronic pain they suffered from is relieved.
There is a period of protected weight bearing after the operation and a gradual return to normal footwear. Recovery from surgical treatment of this nerve condition typically involves gradual rehabilitation and careful monitoring of symptoms to ensure optimal healing outcomes.