One of the most challenging issues people experience after amputation is pain. And one of the main causes of post-amputation pain which occurs even after the limb has completely healed, are the presence of Neuromas.
What is a Neuroma?
A neuroma is a clump of nerves that form together under the skin of your residual limb after amputation. Neuromas are formed when the nerves attempt to regenerate as part of the healing process, by retracting and forming into a bundle. Along with fibrous repair tissue, they form a tumor, normally non-malignant, which becomes a visible bump under your residual limb’s skin. Since nerves are the parts of our body in charge of transmitting sensations, neuromas can be extremely sensitive to touch, especially when pressed against a foreign object, like your prosthesis.
What are the Symptoms?
A neuroma usually presents as a growth that can be tender to the touch, found under the skin of your residual limb. The pain commonly presents as a shooting sensation whenever the residual limb presses against the prosthesis while walking. Occasionally, neuroma pain occurs even without internal or external stimulation.
Different individuals have varying experiences with neuromas. Some don’t even discover that they have it, as they feel no pain at all. Depending on its size or where the neuroma is located, some are asymptomatic, especially when the severed nerves are located at a point far back under the muscle where it is not subject to a lot of pressure or manipulation. Some experience mild pain. The larger it is and the closer the neuroma is to the areas that often come in contact with external objects (i.e. your residual limb and prosthetic socket), the more severe the pain can be, oftentimes enough to keep a person from wearing his or her prosthesis, or performing even the simplest tasks.
How is it diagnosed?
Problematic neuromas in amputees may sometimes be difficult to detect because pain may be associated with other possible causes, such as infections succeeding amputation, and phantom limb syndrome, among others.
Painful neuromas are diagnosed through a Tinel test. During this test, the doctor taps on the area where he or she suspects the neuroma is located. The presence of a problematic neuroma results in a shooting pain as the area is tapped.
There are various recommended treatment options for neuromas, categorized as Non-medication, Medication or Surgical. If you are suffering from neuroma pain, your medical team may choose one or more of the following approaches:
Ultrasound. This treatment involves the use of heat generated by sound waves, focusing on the affected limb, and is said to decrease inflammation and swelling by increasing blood flow. A study published in the Physiotherapy Journal by F. Uygur showed that ultrasound therapy resulted not only in immediate relief from pain, but also in improvements in gait among amputees.
Applying various manual techniques on the residual limb is a therapeutic treatment which lessens pain by increasing blood flow, reducing swelling, and alleviating stress and anxiety. It is also said to help your limb develop tolerance to touch and pressure.
This type of therapy is administered regularly, typically through a hand-held machine applied directly on your limb, creating a mild shaking movement that contracts the muscles. The vibration has a numbing effect on the muscles, minimizing pain. In a study conducted by SM Berger, a Consultant Anaesthetist at the North West Regional Pain Relief Center of Hope Hospital, Safford, a big number of amputees who participated found moderate to good degree of pain relief through vibration therapy.
This approach may seem counterintuitive at the onset, but percussion therapy, when done correctly, is a technique that desensitizes your residual limb, providing immediate, if not long lasting, relief from neuroma pain. Finger tapping is a common physical therapy technique among amputees with residual limb pain that is easy enough to self-administer.
This involves the insertion of needles in various points of the body, which is said to cause it to release hormones called endorphins. Endorphins have analgesic effects on the body, creating a positive sensation and reducing our perception of pain. A number of studies have found that acupuncture helps relieve chronic pain. It is also said to change how blood pressure and body temperature responds to pain.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS is one of the most common methods of pain relief that uses electricity. The mild electrical currents produced by electrodes are used to relieve neuroma pain as well as a host of other conditions, such as arthritis, other post-surgical pain, and even incontinence. The electrodes are applied either internally or externally, and, in the case of neuroma, at the exact area where there is pain.
Modifying the prosthesis socket, in many cases, just adjusting the shape of the prosthesis socket does wonders to alleviate the pain. Adjusting the prosthesis can minimize the neuroma from rubbing against the socket. Having a well-fitting foot can prevent not only neuroma pain, but also other limb pain associated with amputation.
Patients may undergo one or more of the above mentioned non-medication treatments, in tandem with local analgesics and steroids, as non-invasive options to treat neuroma pain. However, if the pain persists, doctors may prescribe surgery.
During surgery, the surgeon may cut the nerve far back under the muscle of the affected limb where it will be subject to less physical contact. However, with this technique, there’s a tendency for the neuroma to grow back.
A new, promising approach called Targeted Muscle Reinnervation (TMR), involves applying nerve transfers. It is performed primarily to improve control of a upper limb prosthesis. However, studies showed that TMR may also provide long lasting relief from neuroma pain. More studies are needed to determine the long-term effectiveness of this approach.
There is no single perfect treatment guaranteed to cure neuroma or the pain associated with it. Until now, medical research is still trying to find more definitive ways to prevent and provide lasting relief from this occurrence.
As with other conditions, it is important to recognize that not every amputee’s journey towards finding the right treatment is the same. Listen to your body, observe, communicate how you feel, and work closely with your medical team to determine what treatment, or combination of treatments, is best for you. With your vigilance, the support of your doctors, Prosthetist, and the right treatment, there is hope in finding lasting relief from neuroma pain.