Mortons Neuroma Report Same Foot Again?
J Clin Orthop Trauma. 2020 May-Jun; 11(iii): 406–409.
Morton'due south neuroma – Current concepts review
Received 2020 Feb 27; Revised 2020 Mar 25; Accepted 2020 Mar 26.
Abstract
Morton's neuroma is a common pathology affecting the forefoot. It is non a true neuroma just is fibrosis of the nerve. This is caused secondary to pressure or repetitive irritation leading to thickness of the digital nerve, located in the 3rd or 2d intermetatarsal infinite. The treatment options are: orthotics, steroid injections and surgical excision normally performed through dorsal arroyo. Careful clinical examination, patient choice, pre-operative counselling and surgical technique are the cardinal to success in the management of this condition.
Keywords: Morton'due south neuroma human foot forefoot hurting digital nerve
ane. Introduction
Morton's neuroma was outset described in the literature in 1876 by an American surgeon, Thomas George Morton. It is a mutual pathology affecting the forefoot. It is not a true neuroma but is fibrosis of the digital nervus. This is acquired secondary to pressure or repetitive irritation leading to thickness of the nerve, located in the 2nd or 3rd intermetatarsal space. The 3rd intermetatarsal infinite is virtually commonly affected. Histologically the neuroma has neural oedema, demyelination (axonal injury) and perineural fibrosis.1 , 2 , 3 , 4 This degenerate tissue therefore causes localised pain and discomfort mainly on weight bearing. Current literature suggests that the use of pointed heeled shoes may exist a causative cistron because this increase in pressure over the forefoot can atomic number 82 to neuronal injury.one
2. Presentation
The classical description of a Morton'southward neuroma is paraesthesia within the affected digital nerve, accompanied past forefoot pain and is more commonly seen in females. 17% of patients depict some trauma to the foot resulting in symptoms.five The about common characteristic of the pain is burning in nature. Altered sensations and feeling a "pebble in the shoe" is reported by more 50% of patients. The pain is often exacerbated past walking, use of tight or heeled shoes and is reported by runners due to the increased weight bearing through the forefoot.5 , 6 Resting the foot or removing the shoe improves pain in most cases peculiarly early in the onset of this condition. In chronic cases the pain could be constant. Dark pain and residuum pain is reported by about 25% of patients.5
3. Examination
Clinically, in that location are no visual cues to the presence of a neuroma. Whatever deformity of the foot peculiarly hallux valgus tin can lead to overcrowding of the toes and increased pressure level on the lesser toes, and is therefore an of import predisposing factor. Plantar callosities around metatarsal heads are suggestive of transfer metatarsalgia, synovitis, subluxation or dislocation of metatarso-phalangeal articulation of 2nd or 3rd toes. The other differential diagnoses include: plantar plate tear, Freiberg's affliction, stress response or stress fracture of metatarsals. It has been reported that clinical assessment by experienced clinician has upward to 98% accuracy as compared to an ultrasound (USS) examination.5
The nigh sensitive clinical tests for the diagnosis of Morton'due south neuroma are the thumb alphabetize finger squeeze test, Mulder'south click test and human foot clasp test in that lodge. Thumb alphabetize finger test is performed by applying pressure level in the intermetatarsal space. Pollex is placed on the dorsal aspect whereas index finger is kept on the plantar aspect. Positive examination results in pain in presence of Morton'southward neuroma. It is important to make sure that the pressure is exerted in the intermetatarsal space and not in the metatarsophalangeal joint itself. Splaying of toes is a good indication that the test has been performed appropriately.
Mulder's click exam is performed past dorsiflexing the foot and squeezing the metatarsals. An audible click is suggestive of presence of Morton's neuroma. This test does not specify which intermetatarsal space which is affected. It is dependent on size of the neuroma and is usually positive in Morton's neuroma measuring 1 cm or more.five
4. Function of imaging
A baseline weight begetting radiograph volition aid in the exclusion of other causes of forefoot pain and give an overview of the osteology. USS and Magnetic Resonance imaging (MRI) are comparable modalities for diagnosing Morton's neuroma.2 , seven , eight An experienced musculoskeletal radiologist can arm-twist a neuroma with a sensitivity of 95% with USS (Fig. 1). However, if there is whatsoever doubtfulness of the diagnosis, an MRI scan is the gold standard investigation to identify a neuroma, which can most easily exist seen on T1 axial slice (Fig. two).eight , 9
Ultrasound scan showing Morton'southward Neuroma (bold arrow).
MRI browse showing Morton's Neuroma (bold pointer).
five. Size
The presence of a neuroma will not automatically crusade the patient to experience the symptoms of a Morton'southward neuroma. Bencardino reviewed 57 patients and noted that a 3rd of the patients radiologically had a neuroma but were asymptomatic. The mean diameter was 4.1 mm in the asymptomatic group compared to five.iii mm in the symptomatic group.10 The diagnosis of Morton's neuroma is relevant simply when the transverse bore on an MRI scan is 5 mm or more and tin be correlated to clinical findings.11 Sharp et el reviewed 29 cases and found no correlation between size and severity of symptoms.8 A prospective randomised controlled trial demonstrated no statistically significant departure in the mean size of neuromas that responded to handling with steroid injections (11 mm), compared to those that did not (12.5 mm). Authors of the study also noted that the size of the neuroma was non significantly different in patients who had a recurrence of symptoms as compared to those who continued to be hurting gratis at 12 months.12 Makki noted that the effect of steroid injection was sustained if the lesion was smaller than 5 mm.13 The literature therefore suggests that size of the lesion does non e'er correlate with symptom severity, and although smaller neuromas volition reply to steroid injections better than larger ones, patient reported outcome volition improve for both with the injections.
6. Management
The management of neuroma can be separate into not-operative measures or surgical management. The treatment algorithm, more often than not involves non-operative measures including injection therapy and if these methods fail to improve symptoms, surgical excision is the next choice.fourteen
Patient education is very important and the utilise of wide toebox shoes can be the simplest method of managing symptoms. However, patient compliance is an issue and can issue in failure to resolve symptoms.
7. Orthotics
The commonest form of handling (initially) is the Metatarsal Bar. This insole, made by orthotists spreads the heads of the metatarsals to salve pressure on the neuroma and thus improve symptoms. However, this does crave the patient to vesture broad toe box shoes and use the inserts and so a degree of compliance is required. There is no evidence to support the utilise of inversion or eversion insoles, with studies demonstrating no significant improvement in patient reported outcomes.15 , 16 Their use is therefore non recommended for the treatment of Morton'due south Neuroma.
8. Injection therapy
The utilize of therapeutic injections is very mutual in the management of Morton's neuroma, and multiple therapies accept been used. The injection can be guided past USS or done using a landmark technique. A randomised trial past Mahadevan et al did not show whatever statistical difference in patient outcomes later a steroid injection using USS or without.12 Santiago et al. noted that short term improvement in visual analogue scale (VAS) over three months in the grouping of patients having USS guided injections was improve but the issue was non sustained at half dozen months.17 In a randomised controlled study comparing insoles with steroid injections, Saygi et al. reported that orthotics on their own were not very helpful. Their results suggested that 82% of patients who received 2–iii steroid injections reported consummate satisfaction at 12 months.xviii
Corticosteroid is currently the mainstay of injection treatment for Morton's Neuroma. Outcomes for this modality evidence an improvement in multiple different patient reported outcome measures at 12 months.12 , 13 , eighteen , xix , 20 Although the mechanism of action is unclear as the neuroma is degenerate in nature, the agreement is that the steroid reduces the inflammation surrounding the neuroma and therefore reduces hurting and too local force per unit area effects. In a randomised controlled trial, information technology has been shown that corticosteroid injections are more effective than local anaesthetic alone.twenty At 1 year post-obit steroid injection, a third of patients crave surgical excision due to recurrence of pain.12 , 13 , 19 It has been shown that steroid injections are more effective if used within one twelvemonth of onset of symptoms.19
There are a number of studies looking into the employ of ethanol/booze injections into neuroma, which testify improvement in patient reported outcome measures at 12 months and reduction in neuroma size.21 , 22 , 23 , 24 , 25 , 26 , 27 This included one written report at v years by Gurdezi, which followed upward on the previous study past Hughes et al.22 , 27 Although the 12 month outcomes were promising with 84% patients reporting consummate resolution of symptoms, at 5 years this was the example in only 29% of patients. In add-on, a third of patients reported complications which include burning pain associated with alcohol injections which in some cases lasted for weeks.22 Moreover, subsequent surgery following alcohol injections tin can be difficult due to increased fibrosis and for these reasons we do not recommend alcohol injections for the treatment of Morton'due south neuroma.
Radiofrequency ablation is some other treatment option which involves inserting a probe into the neuroma. The probe is so heated to between 85 and 90 °C. Although multiple studies report skillful patient reported outcomes, they have all been pocket-sized, retrospective in blueprint, with short term follow up. Radiofrequency ablation is non recommended as routine handling by National Plant of Clinical Excellence (NICE).28 , 29 , 30
Similarly, capsaicin, cryotherapy, Yttrium Aluminium Garnet (YAG) laser, actress-corporeal shockwave therapy and Botox injections have all been studied for the treatment of Morton's neuroma. However, all were small studies with short term follow up, and only weak evidence for their use and are therefore non recommended by the authors.31 , 32 , 33 , 34 , 35 , 36 , 37
9. Surgical excision
The neuroma tin be excised past two methods, either a dorsal or plantar approach. The dorsal approach allows the patient to weight behave immediately, with the plantar arroyo there is a run a risk of wound complications and scar sensitivity. Nonetheless, no studies have proven benefit over one or the other.15
The plantar approach is less commonly used and success following removal has a wide range from 51% to 85%.38 , 39 , 40 , 41 Wolfort et al. performed a prospective study on 17 neuroma through a plantar approach and achieved an fourscore% success with return to pre-surgical footwear.38
The dorsal approach, allows immediate weight begetting post-surgery and is better tolerated past patients. Coughlin et al. performed a review of dorsal surgical excision at 5.viii years in 82 patients, of which 85% reported splendid or proficient outcomes, with 65% remaining hurting free at 5.8 years.42 Womack had a 61% success in 232 patients. Dorsal arroyo is the authors preferred surgical technique (Fig. 3).15 , 42 , 43 , 44 , 45
Dorsal approach for Morton's Neuroma excision. Assuming arrow shows Morton's Neuroma.
10. Adjacent neuroma
Morton's neuroma in side by side intermetatarsal spaces is common with reported incidence as high as 28%.five , 46 Multiple studies have reported lower patient satisfaction with excision of adjacent interdigital space neuromas, although the reasoning behind this is uncertain.42 , 47 There is no clear consensus on whether both neuroma should be excised. Excision of both neuromas tin pb to increased complications related to wound healing and numbness. Some clinicians therefore resort to treating this by excising i of the neuromas and decompressing the adjacent intermetatarsal space. Others believe in sequential excision if required post-obit excision of the more symptomatic neuroma.
11. Failure following Morton'due south neuroma surgery
The failure rate following surgical excision has been reported as up to 30%. The main reasons for hurting following surgical excision are: incorrect diagnosis, neuroma in adjacent intermetatarsal infinite, incomplete resection, complex regional pain syndrome or recurrence of the Morton's neuroma also known as stump neuroma. Factors contributing to recurrence include formation of a new neuroma, adhesions and accessory branches of the digital fretfulness.43 , 48 There are a number of documented ways of preventing stump neuroma formation.49 , l , 51 Employ of steroid injection is the most commonly used modality for dealing with pain following surgical excision. The mechanism of activity is breakup of scar tissue and adhesions. Dellon and Mackinnon described a technique of implantation of the nerve stump inside the musculus. In threescore patients with 78 neuromas, 82% of their cohort had a adept to excellent results.52 Resection of the neuroma proximally with muscle implantation of the new stump can as well exist used. Overall the chances of success following revision surgery are much less satisfactory than primary excision.
12. Take home message
Morton's neuroma is a common crusade of forefoot pain. Most cases can initially be managed non surgically. Steroid injections are useful diagnostic and therapeutic non surgical treatment modality. Careful clinical exam, patient selection, pre-operative counselling and surgical technique are the central to success in the management of this condition.
Declaration of competing interest
None.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211826/
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