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Seminars in Musculoskeletal Radiology Jun 2023Lesser (or central) metatarsalgia is defined as pain in the forefoot under or around the lesser metatarsals and their respective metatarsophalangeal joints. Two common... (Review)
Review
Lesser (or central) metatarsalgia is defined as pain in the forefoot under or around the lesser metatarsals and their respective metatarsophalangeal joints. Two common causes of central metatarsalgia are Morton's neuroma (MN) and plantar plate (PP) injury. Because both clinical and imaging features overlap, establishing the correct differential diagnosis may be challenging. Imaging has a pivotal role in the detection and characterization of metatarsalgia. Different radiologic modalities are available to assess the common causes of forefoot pain, so the strengths and weakness of these imaging tools should be kept in mind. It is crucial to be aware of the pitfalls that can be encountered in daily clinical practice when dealing with these disorders. This review describes two main causes of lesser metatarsalgia, MN and PP injury, and their differential diagnoses.
Topics: Humans; Diagnosis, Differential; Metatarsalgia; Foot
PubMed: 37230133
DOI: 10.1055/s-0043-1764388 -
Radiology Case Reports Jul 2023A 51-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with pain and a typical history of Morton's neuroma. Examination...
A 51-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with pain and a typical history of Morton's neuroma. Examination revealed a palpable swelling over the right foot in the third intermetatarsal space. Following failed conservative management, the patient underwent excision of the neuroma. Histology revealed of necrotizing granulomas with peripheral palisading and no evidence of features specific to a neuroma. This has rarely been described previously and supports the concept of rheumatoid synovitis and nodules producing symptoms mimicking Morton's neuroma/metatarsalgia. 4.
PubMed: 37214324
DOI: 10.1016/j.radcr.2023.04.001 -
Seminars in Musculoskeletal Radiology Dec 2022A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided...
A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided intervention, the joints, soft tissues, and osseous structures may be accessible using various percutaneous techniques as a potential alternative therapeutic tool, avoiding the need for surgery with its associated risks and morbidity. This article discusses the potential range of image-guided interventional treatments. Injections, aspiration, biopsies, cryoablation, and radiofrequency ablation are described. Newer novel treatments are also covered. Finally, the common pathologies of Morton's neuroma, Achilles tendinopathy, and plantar fasciitis are addressed.
Topics: Humans; Ankle; Achilles Tendon; Tendinopathy; Ankle Joint; Ultrasonography, Interventional
PubMed: 36791742
DOI: 10.1055/s-0042-1760120 -
Seminars in Musculoskeletal Radiology Dec 2022Magnetic resonance imaging (MRI) is a robust method used for both preoperative and postoperative evaluation of Morton's neuroma and other neural lesions. MRI is used to...
Magnetic resonance imaging (MRI) is a robust method used for both preoperative and postoperative evaluation of Morton's neuroma and other neural lesions. MRI is used to confirm the diagnosis and for precise localization, estimation of outcome, and differential diagnoses. The differential diagnoses include mechanically induced plantar plate ruptures with associated Morton's neuroma-like tumors in the intermetatarsal/interdigital spaces; mechanical fibrosis cushion formations and pseudo bursae in the plantar foot adipose tissue; rheumatologic affections, such as rheumatoid nodules, gouty nodules, and intermetatarsal bursitis; and lastly the tenosynovial giant cell tumor (formerly called pigmented villonodular synovitis). In the postoperative evaluation after resection of Morton's neuroma, the same differential diagnoses must be considered as in the preoperative evaluation. Similarly, a high prevalence (up to 25%) of asymptomatic Morton's neuroma-like findings in the intermetatarsal and interdigital spaces should be kept in mind when interpreting postoperative recurrent forefoot pain after Morton's neuroma resection.
Topics: Humans; Morton Neuroma; Neuroma; Foot; Foot Diseases; Peripheral Nervous System Neoplasms
PubMed: 36791739
DOI: 10.1055/s-0042-1760212 -
Journal of Hand Surgery Global Online Jan 2023Painful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that...
PURPOSE
Painful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that reduce pain, no type has been universally accepted.
METHODS
We performed a retrospective cohort study by administering follow-up surveys to all surgical patients treated in our department for lower-extremity neuroma from September 1, 2015, to October 22, 2021, that could be contacted, excluding those with Morton neuroma. In addition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) questionnaire, survey questions covered the time to pain reduction, use of physical or occupational therapy, and characteristics of the pain. When available, previously collected preoperative and postoperative PROMIS PI data were used for patients who could not be contacted for the telephone survey. Paired-sample nonparametric testing was used to compare preoperative and postoperative PROMIS PI scores.
RESULTS
Initial query in the medical record by Current Procedural Terminology codes yielded 1,812 patients for chart review, of whom 33 were eligible to call. In total, 9 (27%) patients completed both preoperative and postoperative PROMIS PIs: 6 (18.2%) completed full telephone surveys and 3 (9.1%) had preoperative and postoperative PROMIS PI data in the chart review but could not be contacted for the full telephone survey. Four of the 6 telephone-survey respondents reported pain reduction within 12 months of their surgery. Wilcoxon signed-rank testing demonstrated a moderate but nonstatistically significant reduction in PROMIS PI scores, with a median difference of -4.85 ( = .1; 95% CI -12 to 1.2).
CONCLUSIONS
There were notable improvements in our cohort, but larger studies are needed to determine whether surgical treatment of lower-extremity neuroma results in a clinically important and significant difference in PROMIS PI scores, as well as to discern the advantages each treatment.
TYPE OF STUDY/LEVEL OF EVIDENCE
Therapeutic IV.
PubMed: 36704377
DOI: 10.1016/j.jhsg.2022.03.005 -
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 and Ankle Surgery : Official... Feb 2023The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be...
BACKGROUND
The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both. The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure.
METHODS
A retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery.
RESULTS
Twenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001).
CONCLUSION
Medial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients.
LEVEL OF EVIDENCE
Level IV, retrospective case series.
Topics: Humans; Retrospective Studies; Metatarsal Bones; Foot Diseases; Foot Deformities; Metatarsophalangeal Joint; Pain; Toes; Osteotomy; Contracture; Treatment Outcome
PubMed: 36646596
DOI: 10.1016/j.fas.2023.01.001 -
Journal of Clinical Medicine Oct 2022The therapeutic algorithm for symptomatic Morton's syndrome is not standardized as several managements have been proposed. Ultrasound-guided alcohol injection (USGAI) is...
The therapeutic algorithm for symptomatic Morton's syndrome is not standardized as several managements have been proposed. Ultrasound-guided alcohol injection (USGAI) is one of the non-operative procedures described. This report presents the case of digital ischemia that occurred after alcoholization for the treatment of Morton's syndrome. This complication is described for the first time in the scientific literature, and it should not only be added to the list of sequalae of USGAI, but more importantly, it should also be explained to the patient when this alternative treatment to traditional surgery is proposed.
PubMed: 36362491
DOI: 10.3390/jcm11216263 -
BMC Musculoskeletal Disorders Oct 2022Morton's neuroma is a painful enlargement of the plantar digital nerve between the metatarsal heads that causes pain of the forefoot. Several approaches have been used...
BACKGROUND
Morton's neuroma is a painful enlargement of the plantar digital nerve between the metatarsal heads that causes pain of the forefoot. Several approaches have been used to treat Morton's neuroma, each of them having distinct advantages and disadvantages.
OBJECTIVES
The purpose of this study was to investigate and compare the clinical outcomes of neurectomy in the treatment of Morton's neuroma through plantar and dorsal approaches.
MATERIALS AND METHODS
A total of 20 patients with a mean age of 48.5 ± 13.0 years (range: 19-66 years) who underwent excision of a Morton's neuroma that did not respond to conservative treatment were retrospectively analysed from June 2014 to June 2021. All the neurectomies were performed using a plantar or dorsal approach. Outcomes were evaluated using visual analogue scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, the Foot and Ankle Ability Measure (FAAM), and complications. The appearance index (AI) was also used to assess the influence of foot appearance on the quality of life after surgery.
RESULTS
Eight patients underwent neurectomy by the dorsal approach, and 12 patients underwent neurectomy by the plantar approach. The average follow-up time was 28.9 ± 12.9 months (range: 15-72 months). No statistically significant difference was found between the dorsal and plantar approach groups with respect to postoperative pain measured by the VAS score. The postoperative AOFAS scores and FAAM outcomes were not significantly different between the groups. The complications reported in the dorsal approach group were significantly less than those of the plantar group, mainly discomfort in wearing shoes. The AI of the plantar group and the dorsal group were significantly different.
CONCLUSION
The excision of the Morton's neuroma by both the dorsal and plantar approach resulted in satisfactory outcomes. However, the foot appearance after surgery by the plantar approach had less influence on the quality of life than that using the dorsal approach. Our recommendation is that surgeons should choose the approach they are most familiar with and with which they are most confident in performing. In addition, the plantar approach is recommended if the patient needs a better appearance.
Topics: Adult; Humans; Metatarsal Bones; Middle Aged; Morton Neuroma; Pain, Postoperative; Quality of Life; Retrospective Studies
PubMed: 36203146
DOI: 10.1186/s12891-022-05858-w