London Sheffield 020 3976 4871
Phone Icon

Stump Neuroma Treatment – Persistent Pain After Morton’s Neuroma Surgery

Stump neuroma: your questions answered

Three short videos from Robin Weaver on stump neuromas: what they are, how they are treated, and how cryosurgery works.

This video series is general patient information. It is not a diagnosis, and it cannot replace an individual assessment of your foot.

This content is blocked because it requires marketing cookies.

Stump neuroma · part 1

What Is a Stump Neuroma, and Why Does It Form?

What a stump neuroma is, why it forms after Morton's neuroma excision surgery, how often it becomes painful, and why it does not settle on its own.

  • What a stump neuroma is. Traditional Morton's neuroma excision surgery (neurectomy) involves cutting and removing a section of the nerve. Where the nerve is cut, the two remaining nerve endings become disorganised, change shape, and form a tangled nerve ending known as a stump neuroma.
  • Formed in every case, painful in some. Every cut nerve forms a stump neuroma, so the rate of formation is 100%. That is not the same as the rate of pain. Approximately 30% to 40% of neurectomy patients end up with a painful stump neuroma.
  • Variable onset after surgery. Symptoms can develop rapidly after the original operation, or emerge years later.
  • It does not resolve spontaneously. Without targeted treatment a symptomatic stump neuroma does not rectify itself, and the symptoms become chronic and persistent.
Read the full transcript

Hi, I'm Robin. It's the last day of my holiday, and I just thought I would take this opportunity to talk to you about stump neuromas — about what they are, why they're such a problem, and what we can do to actually help you and to treat them for you.

So, stump neuromas: what are they? They are a collection of tangled nerve endings that occur at the site of where the neuroma was previously removed from. Morton's neuroma excision surgery is called a neurectomy, and a neurectomy involves cutting the nerve. Where the nerve was cut and taken out, that leaves two remnants of the nerve, and at those terminal endings, the nerve fibres become disorganised, change shape, and become what's known as a stump.

If you look at the frequency of stump neuromas, the answer is a bit more nuanced than you would expect. The frequency of a stump neuroma is actually 100%. If you take a nerve and you cut it, 100% of cut nerves form stump neuromas. But that doesn't mean that 100% of people that have neurectomies actually have painful stump neuromas. It's about 30% to 40% of people that have neurectomies that end up with painful stump neuromas.

Stump neuromas can occur years later, but sometimes that can be quite quickly afterwards. Without treatment, the stump neuroma doesn't rectify itself, and the symptoms just become chronic and persistent.

This content is blocked because it requires marketing cookies.

Stump neuroma · part 2

Treatment Options, and What Our Own Study Found

Why conventional options serve stump neuroma patients poorly, how ultrasound-guided cryosurgery differs, and the six-month outcomes from our own consecutive patient series.

  • The conventional options are limited. Patients with post-surgical stump neuromas are poorly served by existing options. Revision surgery carries unpredictable results, while neuropathic medications (gabapentin, pregabalin, amitriptyline, duloxetine) can cause side effects, dependency concerns, and difficulty coming off them.
  • Ultrasound-guided cryosurgery as a minimally invasive alternative. Cryosurgery targets the painful nerve stump percutaneously under ultrasound guidance, without further surgical cutting.
  • Our own six-month outcomes. In a consecutive cohort of 9 to 10 stump neuroma patients followed up at six months, average Visual Analogue Scale pain scores reduced from 7 out of 10 before treatment to 2 out of 10 afterwards. Approximately half the patients became completely pain-free, all patients recorded lower pain scores (with one non-responder moving from 8 out of 10 to 7), and no patients were made worse, with no complications.
  • Consistent with the published literature. These findings align with independent published series reporting substantial pain reduction in refractory neuromas: von Falck, Örgel et al., CVIR 2022, and Friedman, Richman & Adler, J Ultrasound Med 2012. Both are small observational series; there are no randomised comparative trials in this area to date.
Read the full transcript

Stump neuroma patients are actually really quite badly served by the range of existing options. The options that they have are either more surgery — with unpredictable results and probably more of the same in terms of results — or management with drugs, such as gabapentin, pregabalin, amitriptyline, and duloxetine. These drugs can be very helpful for nerve pain, but a lot of patients don't want to be dependent on drugs, and some of these drugs do have side effects and can be quite difficult to come off.

What can be done about stump neuromas other than drugs and more surgery? Well, this is where cryosurgery comes into its own. It's minimally invasive, and it does seem to have a really positive effect on patients with stump neuromas.

Recently, we conducted a study within our clinic looking at patients that had stump neuromas. We took a group of 9 or 10 consecutive patients that had cryosurgery with us and followed those patients up. What we found was that their level of pain was approximately 7 out of 10 before their treatment — so their average pre-treatment Visual Analogue Score (VAS) was 7 out of 10. When we followed those patients up at 6 months after treatment, we found that that average score had reduced from 7 out of 10 down to 2 out of 10.

Approximately half the patients that had the treatment were pain-free, and all the patients actually had lower pain scores. There is a slight caveat to that: one patient out of the 10 didn't respond as well as everybody else. That one patient's pain score decreased from an 8 out of 10 to a 7, so it's arguable that that one patient was a non-responder. No patients were made worse, and there weren't any complications with that group of patients that I can think of.

Our findings were actually in keeping with other published evidence regarding the efficacy of cryosurgery for stump neuromas. I'm not actually aware of any other treatment that is as effective as cryosurgery for stump neuromas. So cryosurgery for stump neuroma patients, I think, is an excellent alternative.

This content is blocked because it requires marketing cookies.

Stump neuroma · part 3

How Cryosurgery Works, and Outcomes After Years of Pain

The mechanism behind cryosurgery for stump neuroma — nerve remodelling, scar remodelling and reduced inflammation — and what it can achieve for people who have been in pain for years.

  • Neural remodelling (Wallerian degeneration). Freezing the nerve stump causes a localised, temporary breakdown of the disorganised nerve endings, known as Wallerian degeneration, allowing the nerve to regenerate in a more sympathetic, less pain-sensitive manner.
  • Internal scar remodelling. Post-surgical stump neuromas form internal hypertrophic scar tissue. Intralesional cryosurgery is a recognised treatment for remodelling hypertrophic and keloid scars — Har-Shai, Amar & Sabo, Plast Reconstr Surg 2003, reported a mean 51% reduction in scar volume after a single session, with histology showing more organised collagen architecture — softening internal scarring around the nerve.
  • Resolution of co-existing bursitis. Patients with stump neuromas frequently have a secondary inflamed fluid-filled bursa sitting next to the nerve stump; cryosurgery dampens local inflammation so the co-existing bursitis improves simultaneously.
  • Meaningful salvage even after years of chronic pain. In our clinical cohort the average duration of symptoms prior to cryosurgery was 6 years, ranging from 2 to 19 years, including a patient with 9 to 10 years of severe pain whose VAS score reduced from 9 out of 10 down to 0 at six months.
Read the full transcript

How does it work? Cryosurgery does seem to have a remodelling effect. First of all, it remodels the nerve, so it causes a localised, temporary breakdown of the nerve. This breakdown is referred to as Wallerian degeneration. Very quickly after the nerve has been frozen, you get a breakdown of the nerve, and the nerve regenerates. When it regenerates in stump neuroma patients, it seems to regenerate in a more sympathetic manner that's less prone to becoming painful. So it helps remodel the nerve.

Secondly, cryosurgery is a recognised treatment for treating scarring. Hypertrophic scars and keloid scars in the past have been treated with cryosurgery quite successfully, and there's a large element of that with stump neuromas: you see these hypertrophic scars that form internally. So the cryosurgery works by remodelling that scar tissue.

Also, as I've talked about in the past, it dampens down all the inflammation that you see in and around the nerve. Frequently, patients with stump neuromas have co-existing bursitis, where there's an inflamed sac of fluid that sits next to the stump neuroma. Simultaneously, that improves as well, which only helps the situation.

If you're one of those patients that think all is lost and that you've got no hope for the future, that isn't the case at all. Cryosurgery offers an excellent means of salvaging the situation. And that's actually what cryosurgery is referred to: it's referred to as a salvage treatment for such patients. It can be really meaningful.

Amongst that group of patients that I told you about, the average duration of symptoms was 6 years. Some patients had only been struggling for as little as 2 years, and one patient had had issues for 19 years. These patients with stump neuromas frequently think that they've actually got no hope, and life will just continue as they are, taking medications, et cetera. But that isn't the case — cryosurgery can offer a very meaningful resolution to this problem.

I can think of one patient in the group: he had had a lot of pain, and his pre-treatment pain score was a 9 out of 10. He had had symptoms for about 9 or 10 years prior to his cryosurgery. He went from a 9 out of 10 down to a 0 at 6 months. So you can imagine, that was life-changing, and they're the kind of results that can be achieved — not for everybody, I wish it could — but if it doesn't totally get rid of the pain, it's likely to improve it quite significantly for you.

References

Stump Neuroma Audio Overview

Listen to a clear, easy-to-understand overview of stump neuroma, including causes, symptoms, and how it can be treated.

At The Barn Clinic we see many patients whose forefoot pain has returned, or never fully resolved, after surgery to remove a Morton’s neuroma. In a proportion of these cases the cause is a stump neuroma — a new, painful tangle of nerve tissue that forms at the cut end of the nerve. It is a frustrating problem, often overlooked, and one we treat with minimally invasive, ultrasound-guided cryosurgery.

When Morton’s Neuroma Surgery Doesn’t Settle the Pain

Surgery to remove a Morton’s neuroma — a neurectomy — relieves symptoms for many people, but not for everyone. A meaningful minority are left with forefoot pain that persists or returns. To complicate matters, neuroma-like tissue is a common finding on imaging of the operated interspace in both painful and pain-free feet after surgery (Espinosa et al., 2010), so post-surgical forefoot pain is easily misattributed. Where that tissue has genuinely become painful, a stump neuroma is the usual explanation.

What Is a Stump Neuroma?

When a nerve is divided during a neurectomy, the cut end does not simply disappear. It attempts to regrow, and the fibres bunch into a disorganised knot — a stump neuroma — at the severed end. In effect every cut nerve forms one; the real question is whether it becomes painful. A significant share of patients who undergo a neurectomy go on to develop a painful stump. It can surface within months of the operation or years later, and once established it does not settle on its own.

Why a Stump Neuroma Can Hurt More Than the Original

A stump neuroma frequently sits within dense surgical scar, tethered in place and exposed to pressure with every step. For some patients the pain is worse than the Morton’s neuroma that led to the original surgery — sharply localised, and carrying the burning, electric, hypersensitive quality that is so characteristic of nerve pain.

Symptoms of a Stump Neuroma

  • burning, shooting or electric pain at the site of previous surgery
  • a tender, sometimes palpable spot that is sensitive to direct pressure
  • pain reproduced by tapping over the scar (a positive Tinel’s sign)
  • numbness or altered sensation in the toes supplied by the nerve
  • pain that has persisted, or returned, since the neurectomy

Diagnosis

Clinical assessment. The consultation begins with a careful history of the original surgery and the pain that followed, and a hands-on examination — including tapping over the scar to reproduce the symptoms.

Dynamic ultrasound. High-resolution ultrasound, performed in clinic and in real time by the treating specialist, can show the stump within the scar tissue and help distinguish it from a recurrence or an inflamed bursa. Scanning the forefoot under load adds to the picture.

The Existing Options — and Their Limits

Patients with a stump neuroma are often poorly served by the choices in front of them. Further surgery means operating back into scarred tissue, with unpredictable results and the real risk of forming yet another stump. Nerve-pain medications — gabapentin, pregabalin, amitriptyline, duloxetine — can take the edge off, but many patients would rather not depend on them, and some are hard to tolerate or to come off. Alcohol (sclerosing) injections and radiofrequency are sometimes offered, but both work by deliberately damaging the nerve.

Cryosurgery for Stump Neuroma

This is where ultrasound-guided cryosurgery comes into its own. Carried out under local anaesthetic in the clinic, it uses real-time ultrasound to guide a fine cryoprobe precisely onto the stump. A controlled freeze interrupts the pain and acts on the abnormal nerve tissue and surrounding scar while preserving the nerve’s own protective sheath. It is minimally invasive, it avoids reopening the scarred surgical field, and it is often described as a salvage treatment — a way of rescuing a situation that has come to feel hopeless.

How Cryosurgery Affects the Nerve and diagram of nerve structure

Click image to enlarge for a clearer view.

How Cryosurgery Affects the Nerve

A carefully dosed freeze causes a controlled, temporary breakdown of the nerve (a process called Wallerian degeneration), after which it tends to regenerate in a more organised, less pain-prone form. Cryosurgery is also long established in the treatment of scar tissue, which helps remodel the dense scar a stump neuroma is usually embedded in, and it settles the surrounding inflammation. Unlike cutting, alcohol or heat-based ablation, it is designed to be nerve-sparing rather than destructive.

Our Outcomes

In a review of our own patients treated for a stump neuroma with cryosurgery, average pain scores fell from about 7 out of 10 before treatment to roughly 2 out of 10 at six months. Around half became completely pain-free, and every patient improved to some degree, with a single partial responder; no patient was made worse. These findings sit comfortably alongside the published evidence for cryosurgery of stump and peripheral neuromas (von Falck et al., 2022; Friedman et al., 2012).

When to Suspect a Stump Neuroma

If your forefoot pain has persisted or returned since Morton’s neuroma surgery — particularly if it is burning or electric in character, pinpointed to the scar, and set off by pressure — then a stump neuroma is well worth considering, and worth having properly assessed.

Specialist Assessment

If you are living with pain after Morton’s neuroma surgery, an accurate diagnosis is the essential first step. At The Barn Clinic in Sheffield and on Harley Street in London, your assessment includes dynamic, in-clinic ultrasound performed by the treating specialist, so the true cause of your pain is identified and the right treatment matched to it. Request a callback and a member of our team will be in touch.

References

  • Espinosa N, et al. Morton neuroma: MR imaging after resection — postoperative MR and histologic findings in asymptomatic and symptomatic intermetatarsal spaces. Radiology. 2010;255(3):850–6.
  • von Falck C, Örgel M, et al. Percutaneous image-guided cryoablation of painful post-amputation stump neuroma. Cardiovasc Intervent Radiol. 2022;45(2):223–7.
  • Friedman T, Richman D, Adler R. Sonographically guided cryoneurolysis for peripheral neuromas. J Ultrasound Med. 2012;31(12):2025–34.

FAQ – Stump Neuroma After Morton’s Neuroma Surgery

- Is a stump neuroma the same as my Morton’s neuroma coming back?

Not quite. A true recurrence is regrowth of neuroma tissue at the original site, whereas a stump neuroma forms at the cut end of the nerve after it was divided. They cause similar pain, so imaging is used to tell them apart.

+ How soon after surgery can a stump neuroma appear?

It varies widely — sometimes within a few months of the operation, sometimes years later.

+ Will it get better on its own?

No. Left untreated, the pain of a stump neuroma tends to become chronic and persistent.

+ Can cryosurgery be used if I’ve already had surgery?

Yes — and this is one of the situations it suits best. Because it is minimally invasive and doesn’t reopen the scarred surgical field, it is often used precisely as a salvage option after a neurectomy has failed to settle the pain.

+ Does cryosurgery involve more cutting?

No. It is a controlled freeze delivered through a fine probe under local anaesthetic, with no incision into the scar.

Case Study: Cryosurgery for a Long-Standing Stump Neuroma

One patient came to us having lived with severe pain for close to a decade after a neurectomy — scoring 9 out of 10, and largely resigned to managing it with medication. Six months after a single cryosurgery treatment, he was pain-free. Not every outcome is as complete, but it shows what can be possible even when the problem is long-standing.

View the case study
Request a callback
Leave your details with us and we’ll get back to you as soon as we can
Request a callback
Leave your details with us and we’ll get back to you as soon as we can