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Indian Journal of Orthopaedics Feb 2020Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This... (Review)
Review
BACKGROUND
Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.
MATERIALS AND METHODS
A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.
CONCLUSIONS
There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.
LEVEL OF EVIDENCE
Level V, meta-synthesis.
PubMed: 32211125
DOI: 10.1007/s43465-019-00015-3 -
Clinical Radiology Apr 2015To determine the accuracy of MRI versus ultrasound for Morton's neuroma. (Meta-Analysis)
Meta-Analysis Review
AIM
To determine the accuracy of MRI versus ultrasound for Morton's neuroma.
MATERIALS AND METHODS
A search was undertaken for clinical studies published in any language in PubMed up to the date of December 2013. Studies assessing the accuracy of the ultrasound or MRI for the diagnosis of Morton's neuroma were included. Data were pooled for meta-analysis. Study selection, data collection, and extraction were performed independently by two authors. Meta-disc 1.4 and Revman 5.2 software were applied for statistical analysis.
RESULTS
The study included 12 studies; 217 patients underwent MRI and 241 underwent ultrasound examinations. There appeared greater diagnostic accuracy for ultrasound than MRI for the diagnosis of Morton's neuroma (ultrasound sensitivity 90%, specificity 88%, positive likelihood ratio 2.77, negative likelihood ratio 0.16 versus MRI sensitivity 93%, specificity 68%, positive likelihood ratio 1.89, negative likelihood ratio 0.19).
CONCLUSIONS
The available evidence suggests that ultrasound can provide better accuracy for the diagnosis of Morton's neuroma than MRI.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Foot Diseases; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroma; Reproducibility of Results; Sensitivity and Specificity; Ultrasonography; Young Adult
PubMed: 25466436
DOI: 10.1016/j.crad.2014.10.017 -
Diagnostics (Basel, Switzerland) Jun 2022Morton's neuroma (MN) is a common condition in clinical practice. The compressive etiology is the most accepted, in which compression occurs in the tunnel formed by the...
UNLABELLED
Morton's neuroma (MN) is a common condition in clinical practice. The compressive etiology is the most accepted, in which compression occurs in the tunnel formed by the adjacent metatarsals, the deep transverse metatarsal ligament (DTML) and the plantar skin. Ultrasound (US) is a reliable method of study. The presence of insufficient space under the DTML may be related to the appearance of MN.
OBJECTIVES
To verify the relationship between MN and the space under the DTML between the metatarsal heads of the third (M3) and the fourth (M4) metatarsals using US.
METHODS
This is a cross-sectional epidemiological study. The research study using the ultrasound (US) technique was carried out on 200 feet belonging to 100 patients aged 18 to 65 of both sexes, with a control group formed by 62 patients and a study group formed by 38 patients diagnosed with MN.
RESULTS
The presence of MN and the factors associated with it were studied in 100 patients using ultrasound (US). The assessment and comparison with US of the space inferior to the DTML between M3 and M4 in control groups and patients with MN show that patients with MN have a smaller size in the variable "h" (height or distance DTML-plantar skin), in the variable "b" (base or intermetatarsal distance M3 and M4) and in the variable "s" (surface of the parallelogram "h" × "b"). The predictors of MN are a decrease in dimension "b" and an increase in weight. Sitting in an office chair and the use of a bicycle, due to equinus, have an influence on the space below the DTML, reducing it and promoting the appearance of MN.
CONCLUSIONS
The two US measurements ("h" and "b") in the space below the DTML are smaller in patients with MN than in the asymptomatic group. A shorter distance between M3 and M4, and an increase in BMI are predictors of MN.
PubMed: 35741177
DOI: 10.3390/diagnostics12061367 -
Clinics in Podiatric Medicine and... Jan 2021Morton's neuroma is a common painful pathology that occurs in the plantar forefoot. Many treatment options exist and surgical management is used after conservative... (Review)
Review
Morton's neuroma is a common painful pathology that occurs in the plantar forefoot. Many treatment options exist and surgical management is used after conservative treatment options fail. While within the literature, there is a high success rate with primary neurectomy procedures, the risk of recurrence of symptoms or "stump neuromas" remains difficult to treat and can lead to debilitating pain. This article expands on a previously published article to discuss an update on a nerve sparing, microneurosurgical, procedure for the management of Morton's neuromas.
Topics: Foot; Foot Diseases; Humans; Morton Neuroma; Neuroma; Pain
PubMed: 35101239
DOI: 10.1016/j.cpm.2021.07.002 -
Foot and Ankle Surgery : Official... Jun 2022The effectiveness of operative treatments other than neurectomy for Morton's neuroma remains debatable despite several reported studies. This review aimed to evaluate...
BACKGROUND
The effectiveness of operative treatments other than neurectomy for Morton's neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton's neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies.
METHODS
Several electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton's neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type.
RESULTS
After reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy.
CONCLUSION
Whether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable.
LEVEL OF EVIDENCE
Level III, systematic review.
Topics: Denervation; Foot; Foot Diseases; Humans; Morton Neuroma; Neuroma; Osteotomy
PubMed: 34736848
DOI: 10.1016/j.fas.2021.10.011 -
Foot & Ankle International Jul 2018The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot...
BACKGROUND
The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot width, foot length, coefficient of spreading, and arch index between subjects with Morton's neuroma (MN) and control subjects.
METHODS
Dynamic peak plantar pressure, contact time, pressure-time integral, and geometric data were extracted using the EMED-X platform in 52 subjects with MN and 31 control subjects. Differences in peak pressure, contact time, pressure-time integral, and geometric data between participants with and those without MN were determined using independent-samples t tests. There were no significant differences in age, weight, height, and body mass index between patients with MN and control subjects.
RESULTS
There were no significant differences in the peak pressures of all masked areas and pressure-time integrals under metatarsal 2 to 4 heads between patients with MN and control subjects. In addition, no significant differences were observed between patients with MN and control subjects in geometric measurements of forefoot length, width, coefficient of spreading, foot progression angle, and arch index.
CONCLUSION
No relationship was found in this study between peak pressure, contact time, and pressure-time integral under the metatarsal heads, forefoot width, foot length, coefficient of spreading, and foot progression angle in a symptomatic MN group compared with a control group. The need to perform osteotomies to treat MN not associated with other lesser metatarsal phalangeal joint pathologies is questionable.
LEVEL OF EVIDENCE
Level III, Case-Control Study.
Topics: Adult; Case-Control Studies; Female; Humans; Male; Metatarsus; Middle Aged; Morton Neuroma; Pressure
PubMed: 29641258
DOI: 10.1177/1071100718766553 -
The Journal of Foot and Ankle Surgery :... 2023This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic...
This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.
Topics: Humans; Retrospective Studies; Neuroma; Morton Neuroma; Radiography; Physical Examination; Foot Diseases
PubMed: 37353000
DOI: 10.1053/j.jfas.2023.06.002 -
Foot & Ankle International Jan 2015Ultrasonography-guided alcohol injection (USGAI) of Morton's neuroma represents an alternative to operative treatment. Nonetheless, the literature only reports few small...
BACKGROUND
Ultrasonography-guided alcohol injection (USGAI) of Morton's neuroma represents an alternative to operative treatment. Nonetheless, the literature only reports few small studies evaluating the effectiveness of the treatment. The aim of the present retrospective study was to assess the effectiveness of USGAI to treat Morton's neuroma in 508 patients at 2 medical centers.
METHODS
Between January 2001 and January 2012, 508 patients with 540 Morton's neuroma had USGAI for Morton's neuroma. Only second and third web-space neuromas were included in this study.
RESULTS
A mean number of 3.0 (range, 1 to 4) injections were performed for each neuroma. Mean local inflammatory reaction was 0.7 (range, 0 to 2). There were no other local or systemic complications. The overall mean pre-USGAI VAS score was 8.7 (range, 6 to 10), while the post-USGAI VAS score at 1 year was 3.6 (range, 0 to 9). The delta VAS between the pre- and post-USGAI was statistically significant (P < .0001). At 1-year follow-up 74.5% of patients were satisfied with the procedure.
CONCLUSION
USGAI produced encouraging results in over 500 patients affected by Morton's neuroma. The procedure proved to be safe in all patients.
LEVEL OF EVIDENCE
Level IV, retrospective case series.
Topics: Ablation Techniques; Adult; Aged; Aged, 80 and over; Ethanol; Female; Humans; Injections, Intralesional; Male; Metatarsalgia; Middle Aged; Nerve Compression Syndromes; Neuroma; Pain Measurement; Retrospective Studies; Surgery, Computer-Assisted; Ultrasonography
PubMed: 25367249
DOI: 10.1177/1071100714551386 -
Ultrasonography (Seoul, Korea) Apr 2022Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot,...
Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot, dynamic capability of US, and the ability to perform direct real-time evaluations of the pain site are also strong advantages of US as a modality for examining the foot. Moreover, knowing the possible pain sources to investigate when a patient has a specific site of pain will enhance the diagnostic quality of US, and will help radiologists to perform US efficiently and effectively. The purpose of this article is to review the common etiologies of metatarsalgia including Morton's neuroma, plantar plate injury, synovitis, tenosynovitis, bursitis, and metatarsal fractures, and to discuss their US features.
PubMed: 34879474
DOI: 10.14366/usg.21193 -
Pain and Therapy Jun 2020This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot... (Review)
Review
PURPOSE OF REVIEW
This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.
RECENT FINDINGS
Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton's neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress-platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration. Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.
PubMed: 32107725
DOI: 10.1007/s40122-020-00157-5