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Foot & Ankle International Oct 2020Morton's neuroma is a frequent cause of metatarsalgia. Operative treatment is indicated if nonoperative management has failed. The objective of the present study was to...
BACKGROUND
Morton's neuroma is a frequent cause of metatarsalgia. Operative treatment is indicated if nonoperative management has failed. The objective of the present study was to describe a technique of Morton's neuroma excision by a minimally invasive commissural approach and evaluate the long-term outcome and complications.
METHODS
A retrospective study of 108 patients with Morton's neuroma treated surgically with a commissural approach between September 1990 and December 2010 was performed. The surgical technique is described. Clinical outcomes and complications were evaluated. The average follow-up was 121 months. Eleven patients were men and 97 women. The average age was 49.4 years; 56.8% neuromas were at the third space and 43.2% at the second space. Six patients presented 2 neuromas in the same foot, and 9 patients had bilateral neuroma.
RESULTS
The visual analog scale (VAS) average pain score was 5.4 points preoperatively and 0.2 points at the final follow-up. The author found a significant difference between the VAS scores preoperatively and postoperatively ( < .01). Excellent and good satisfaction outcomes were achieved in 93.6%. The postoperative complication incidence was 3%.
CONCLUSION
The author believes a minimally invasive commissural approach has advantages over a dorsal or plantar incision. It is a simple and reproducible technique, with satisfactory outcomes, low complication rates, and a quick return to usual activities.
LEVEL OF EVIDENCE
Level IV, retrospective case series.
Topics: Adult; Female; Humans; Male; Metatarsalgia; Middle Aged; Morton Neuroma; Neuroma; Pain Measurement; Retrospective Studies
PubMed: 32674597
DOI: 10.1177/1071100720936599 -
Journal of Ultrasound Mar 2024Ultrasound guidance is particularly useful for percutaneous injections in the diagnosis and management of painful conditions of the ankle and foot. The injectates used...
Ultrasound guidance is particularly useful for percutaneous injections in the diagnosis and management of painful conditions of the ankle and foot. The injectates used include steroids and local anesthetics, such as lidocaine, mepivacaine, bupivacaine, ropivacaine, and platelet-rich plasma. Osteoarthritis is the main indication for joint injections. Joints amenable to being injected include the tibiotalar, subtalar, midtarsal, and metatarsophalangeal joints. Tendon injections mainly involve the Achilles, peroneus, extensors, and tibialis tendons, while plantar fascia injections are useful for treating plantar fasciitis and plantar fibromatosis. Forefoot injections include joint arthritis, intermetatarsal bursitis, and Morton neuroma. The standardized approaches and doses reviewed in this paper are based on the authors' experience and can lead to high success in symptomatic relief for various conditions. These injections can be curative or serve as a guide to identify the source of pain when surgery or other therapeutic options are planned.
Topics: Humans; Ankle; Lower Extremity; Ankle Joint; Achilles Tendon; Pain; Ultrasonography, Interventional
PubMed: 37518823
DOI: 10.1007/s40477-023-00808-1 -
European Radiology Dec 2022This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up.
METHODS
This is an evaluator-blinded randomised trial in which 33 patients with MN were injected by an experienced orthopaedic surgeon based on anatomical landmarks (blind injection, group 1) and 38 patients were injected by an experienced musculoskeletal radiologist under US guidance (group 2). Patients were assessed using the visual analogue scale and the Manchester Foot Pain and Disability index (MFPDI). Injections consisted of 1 ml of 2% mepivacaine and 40 mg triamcinolone acetonide in each web space with MN. Up to 4 injections were allowed during the first 3 months of follow-up. Follow-up was performed by phone calls and/or scheduled consultations at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1, 2 and 3 years. Statistical analysis was performed using unpaired Student's t tests.
RESULTS
No differences in age or clinical measures were found at presentation between group 1 (VAS, 8.5 ± 0.2; MFPDI, 40.9 ± 1.1) and group 2 (VAS, 8.4 ± 0.2; MFPDI, 39.8 ± 1.2). Improvement in VAS was superior in group 2 up to 3 years of follow-up (p < 0.05). Improvement in MFPDI was superior in group 2 from 45 days to 2 years of follow-up (p < 0.05). Satisfaction with the treatment was higher in group 2 (87%) versus group 1 (59.1%) at 3 years of follow-up.
CONCLUSION
Ultrasound-guided injections lead to a greater percentage of long-term improvement than blind injections in MN.
KEY POINTS
• Ultrasound-guided corticosteroid injections in Morton neuroma provide long-term pain relief in more than 75% of patients. • Ultrasound-guided injections in Morton neuroma led to greater long-term pain relief and less disability than blind injections up to 3 years of follow-up. • The presence of an ipsilateral neuroma is associated with worse long-term disability score.
Topics: Humans; Morton Neuroma; Mepivacaine; Adrenal Cortex Hormones; Neuroma; Pain; Ultrasonography, Interventional; Treatment Outcome
PubMed: 35726101
DOI: 10.1007/s00330-022-08932-y -
Diagnostics (Basel, Switzerland) Jan 2023Intermetatarsal bursitis (IMB) is an inflammation of the intermetatarsal bursas. The condition causes forefoot pain with symptoms similar to those of Morton's neuroma... (Review)
Review
Intermetatarsal bursitis (IMB) is an inflammation of the intermetatarsal bursas. The condition causes forefoot pain with symptoms similar to those of Morton's neuroma (MN). Some studies suggest that IMB is a contributing factor to the development of MN, while others describe the condition as a differential diagnosis. Among patients with rheumatic diseases, IMB is frequent, but the scope is yet to be understood. The aim of this paper was to investigate the diagnostic considerations of IMB and its role in metatarsalgia by a systematic review approach. We identified studies about IMB by searching the electronic databases Pubmed, Embase, Cochrane Library, and Web of Science in September 2022. Of 1362 titles, 28 met the inclusion criteria. They were subdivided according to topic: anatomical studies ( = 3), studies of patients with metatarsalgia ( = 10), and studies of patients with rheumatic diseases ( = 15). We conclude that IMB should be considered a cause of pain in patients with metatarsalgia and patients with rheumatic diseases. For patients presenting with spreading toes/V-sign, IMB should be a diagnostic consideration. Future diagnostic studies about MN should take care to apply a protocol that is able to differ IMB from MN, to achieve a better understanding of their respective role in forefoot pain.
PubMed: 36673020
DOI: 10.3390/diagnostics13020211 -
Foot & Ankle International Feb 2021Morton's neuroma is associated with chronic pain and disability. There is a paucity of literature regarding patient-related outcome measures (PROMs) in patients managed...
BACKGROUND
Morton's neuroma is associated with chronic pain and disability. There is a paucity of literature regarding patient-related outcome measures (PROMs) in patients managed nonoperatively. We sought to investigate nonoperative and operative management of Morton's neuroma using PROMs in patients with follow-up to 1 year.
METHODS
We conducted a prospective observational study and collected data on all patients with a new diagnosis of Morton's neuroma treated from February 2016 until April 2018. Primary outcome measures were the Manchester-Oxford Foot Questionnaire (MOXFQ) for pain, EuroQoL (EQ) time trade-off (TTO), and EQ visual analog scale (VAS) taken preoperatively and at 52 weeks postoperatively. Forty-four patients were treated nonoperatively and 94 patients were treated operatively.
RESULTS
Pretreatment and 52-week scores were 55.7 and 43.10 (nonoperative) and 63.7 and 40.1 (operative) for MOXFQ (pain), 0.72 and 0.82 (nonoperative) and 0.68 and 0.82 (operative) for EQ-TTO, and 71.5 and 76.2 (nonoperative) and 73.1 and 68.7 (operative) for EQ-VAS. There was a statistically significant improvement in MOXFQ (pain) in nonoperative ( = .02) and operative groups ( < .001). There was a statistically significant improvement in EQ-TTO in the operative group only ( = .01).
CONCLUSION
This is the largest study investigating outcomes to 12 months of both nonoperative and operatively managed patients with Morton's neuroma. Both nonoperative and operative management lead to symptom improvement at 12 months.
LEVEL OF EVIDENCE
Level III, comparative study.
Topics: Foot; Humans; Morton Neuroma; Outcome Assessment, Health Care; Pain Measurement; Postoperative Period; Prospective Studies; Retrospective Studies; Surveys and Questionnaires; Treatment Outcome; Visual Analog Scale
PubMed: 33019802
DOI: 10.1177/1071100720961069 -
International Orthopaedics Dec 2022The optimal treatment of symptomatic Morton's neuroma remains unclear; conservative methods are sometimes ineffective and neurectomy has significant rates of patient...
Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML): a case series with minimum two-year follow-up.
BACKGROUND
The optimal treatment of symptomatic Morton's neuroma remains unclear; conservative methods are sometimes ineffective and neurectomy has significant rates of patient dissatisfaction. The aim of this study was to evaluate the outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML) in patients with Morton's neuroma.
METHODS
Between January 2018 and November 2019, 27 patients (29 feet) diagnosed with Morton's neuroma after clinical and radiological evaluation underwent DMMO and percutaneous DTML release. The primary clinical outcomes were pain (VAS) and function (AOFAS score). Secondary outcomes included patient satisfaction, complications, and radiographic outcomes. Patients were followed up for a minimum of two years.
RESULTS
The median age of the participants was 66 years (range 48-79) and the follow-up time was 28 months (24-47). There was a decrease of 5.7 points in the VAS for pain (p < .001) and an increase of 19.9 in AOFAS (p < .001) after the surgical procedure. There was one case of superficial infection and one patient required resection of the neuroma (neurectomy). The majority of patients (89.7%) were satisfied and considered the procedure outcome as excellent or good.
CONCLUSION
Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy and percutaneous release of the deep transverse metatarsal ligament showed significant improvement in pain and function with a low incidence of complications and a high rate of personal satisfaction.
Topics: Humans; Child, Preschool; Child; Metatarsal Bones; Morton Neuroma; Follow-Up Studies; Osteotomy; Pain; Ligaments
PubMed: 36031662
DOI: 10.1007/s00264-022-05557-0 -
Foot & Ankle International Sep 2019Recent studies have demonstrated that clinical diagnosis of Morton's neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have...
BACKGROUND
Recent studies have demonstrated that clinical diagnosis of Morton's neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have questioned the cost-effectiveness of intraoperative histopathology of excised specimens. The purpose of this study was to determine the utility of both preoperative imaging and intraoperative histology in the treatment of Morton's neuroma in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes.
METHODS
A retrospective review was performed on all patients who underwent operative resection suspected Morton's neuroma with 4 fellowship-trained foot and ankle surgeons between 2007 and 2017. Procedures were excluded from the study if the pathology report was not available for review. Diagnoses were made either by clinical examination and/or by the results of preoperative imaging. All pathology reports were reviewed to determine the final diagnosis, considered the "gold standard." Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton's neuroma. Two hundred eighty-seven procedures in 269 patients with 313 clinically suspected neuromas met inclusion criteria.
RESULTS
Of the 313 suspected neuromas, 309 (98.7%) were confirmed Morton's neuromas on histopathologic examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179 (57.2%) suspected neuromas, with magnetic resonance imaging (MRI) and ultrasonography used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 using both. The total estimated cost of histopathologic analysis for the cohort was $143 667, and the estimated combined cost of preoperative imaging and intraoperative histopathology in our cohort totaled $278 567.
CONCLUSION
Our study found that the diagnosis of Morton's neuroma could be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis.
LEVEL OF EVIDENCE
Level IV, retrospective case series.
Topics: Adult; Humans; Magnetic Resonance Imaging; Morton Neuroma; Pain Measurement; Retrospective Studies; Ultrasonography; Young Adult
PubMed: 31142153
DOI: 10.1177/1071100719851121 -
Diagnostics (Basel, Switzerland) Sep 2021Among the tools useful for the management of neuropathic pain, ultrasound presents several advantages, shown by the literature. We assessed the scientific production... (Review)
Review
Among the tools useful for the management of neuropathic pain, ultrasound presents several advantages, shown by the literature. We assessed the scientific production about neuropathic pain and ultrasound from different points of view: general topics, journal categories, geographical origin and lexical analysis. We searched papers on PubMed using the Medical Subject Headings "neuropathic pain" AND "ultrasound". We collected data about the journals where the papers were published, the country of the affiliation of the first author. For the lexical analysis, we evaluated the presence of selected words in the papers, and we built a graph representing the connections among words and papers. The papers were focused on the use of ultrasound as a diagnostic tool and guide for the therapy, assessing its application in different diseases such as Morton's neuroma and piriformis syndrome. The most represented journal category was anesthesia while the most common country the United States of America. The lexical analysis confirmed the importance of ultrasound for diagnosis of specific disease and treatment of pain. The described approaches provide a multiperspective evaluation of the literature and may support the interpretation of the information contained by the papers.
PubMed: 34574046
DOI: 10.3390/diagnostics11091705 -
The Journal of Manual & Manipulative... Feb 2020: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and...
: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and utility of physical therapy (PT) is unknown. Mechanical Diagnosis and Therapy (MDT) is a classification system utilizing direction-specific treatment for orthopedic conditions based on mechanical and symptomatic response to repeated end range movements. The purpose of this case series is to describe the management of three patients with a medical diagnosis of MN using the MDT classification system.: Three female patients aged 54-75 years with unilateral plantar forefoot pain for 6 weeks to 8 years were referred by a podiatrist following positive clinically accepted diagnostic criteria for MN including radiological imaging and provocation testing. Patients were evaluated and treated utilizing MDT assessment and treatment principles. The intervention consisted of repeated movements matched to the patient's directional preference at either the lumbar spine (1 patient) or distal extremity (2 patients).: Immediate and one-year outcomes were excellent, demonstrating rapid and lasting improvement. Following discharge, the patients have been asymptomatic or able to self-manage without seeking additional medical intervention for this condition. Total visit frequency per patient averaged 2-3 visits total across 8-16 days.: Responses to repeated end range movements testing allowed for classification and prescription of exercise to rapidly improve symptoms and function in three patients referred to PT services with medically diagnosed MN. This series provides preliminary evidence that MDT may be effective in classifying and treating patients with MN.
Topics: Aged; Female; Gait; Humans; Middle Aged; Morton Neuroma; Pain Measurement; Physical Therapy Modalities; Range of Motion, Articular; Walk Test
PubMed: 31177965
DOI: 10.1080/10669817.2019.1611044 -
Foot and Ankle Surgery : Official... Jun 2024Current literature lacks comprehensive information comparing the clinical outcomes of plantar and dorsal approaches for Civinini-Morton syndrome, also known as Morton's... (Review)
Review
BACKGROUND
Current literature lacks comprehensive information comparing the clinical outcomes of plantar and dorsal approaches for Civinini-Morton syndrome, also known as Morton's neuroma. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of neurectomy for Morton's neuroma, focusing on the differences between the plantar and dorsal approach.
METHODS
Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included postoperative sensory loss, scar tenderness, reoperation, histopathology, complications, pain score, patient satisfaction, functional scores, and time to weight bearing.
RESULTS
Total eight studies were included in this study. In aggregate, 237 neuromas underwent excision using the plantar approach, while 312 neuromas were treated via the dorsal approach. A significantly higher rate of postoperative reduced sensory was found in the dorsal group: 48.5 % (64/132) Vs. 62.0 % (80/129) with the relative ratio (RR) of 0.79 (95 % CI, 0.64-0.97). A significantly higher rate of postoperative scar tenderness was noted in the plantar group: 16.7 % (32/192) Vs. 6.2 % (14/225) with the RR of 2.27 (95 % CI, 1.28-4.04). Regarding the histopathology, 99.3 % (143/144) and 97.1 % (134/138) accuracy rate was confirmed in the plantar approach and dorsal approach, respectively, with the RR of 1.02 (95 % CI, 0.98-1.07). Overall reoperations and complications were not different between groups at 5.3 % (10/189) and 8.8 % (19/216) in the plantar group versus 6.1 % and 12.0 % (35/291) in dorsal group.
CONCLUSIONS
We recommend detailed discussions with patients prior to surgery to weigh the advantages and disadvantages of each approach.
PubMed: 38880729
DOI: 10.1016/j.fas.2024.05.018