-
Journal of the American Podiatric... 2022Extracorporeal shockwave therapy (ESWT) was first introduced into clinical practice in 1982 and has been a beneficial inclusion to the noninvasive treatment option of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Extracorporeal shockwave therapy (ESWT) was first introduced into clinical practice in 1982 and has been a beneficial inclusion to the noninvasive treatment option of numerous orthopaedic pathologies. However, clinical evidence of the use of ESWT for various foot and ankle disorders has been limited with a consensus on its efficacy yet available. Therefore, the purpose of this study is to systematically review the literature, to provide a critical evaluation and meta-analysis for the use of ESWT in foot and ankle disorders.
METHODS
The PubMed and Embase databases were systematically reviewed and clinical studies that reported ESWT use for various foot and ankle disorders included.
RESULTS
A total of 24 clinical studies that included 12 randomized controlled trials and 12 case series were identified. Analysis of the evidence has indicated that ESWT can help manage plantar fasciitis, calcaneal spur, Achilles tendinopathy and Morton's neuroma. Meta-analysis of the change in pre- to post-VAS overall scores for plantar fasciitis significantly favored ESWT compared to placebo/conservative treatment with a MD -3.10 (95% CI, -4.36 to -1.83; I2 = 68%; P < 0.00001).
CONCLUSIONS
The current evidence has suggested that ESWT can provide symptomatic benefit to plantar fasciitis treatment, with minimal and unremarkable side effects. Overall, ESWT has been demonstrated to be a safe treatment option with a favorable complication profile. Further well-designed studies of ESWT for the treatment of calcaneal spurs, Achilles tendinopathy and Morton's neuroma are warranted to more soundly and safely support its current use. Future studies are suggested to investigate the optimization of ESWT treatment protocols.
Topics: Achilles Tendon; Ankle; Extracorporeal Shockwave Therapy; Fasciitis, Plantar; Heel Spur; Humans; Morton Neuroma; Tendinopathy; Treatment Outcome
PubMed: 34878537
DOI: 10.7547/18-191 -
Journal of Foot and Ankle Research Dec 2021The aim of this retrospective study was to examine if a correlation between Morton's Neuroma (MN) and an increased interphalangeal angle (IPA) or intermetatarsal angle...
BACKGROUND
The aim of this retrospective study was to examine if a correlation between Morton's Neuroma (MN) and an increased interphalangeal angle (IPA) or intermetatarsal angle (IMA) can be found in preoperative weightbearing dorsal-plantar X-rays of the foot.
METHODS
Forty-five patients with forty-nine MN in the interspaces 2/3 or 3/4 and 49 controls were recruited for this study. Every MN was matched with an asymptomatic control without history of metatarsalgia. The diagnosis was made by clinical examination, magnetic resonance imaging (MRI) and positive histopathology after operative resection. IMA 1/5, 2/3, 2/4, 2/5, 3/4 and IPA 2/3, 3/4 were measured for both groups.
RESULTS
The IPA 3/4 was significantly enlarged by 2.8 degrees (p < 0.001) with Area under the curve (AUC) 0.75 (p < 0.001), sensitivity of 73% and specificity of 67% in feet with MN compared to controls. The IMA 3/4 was significantly enlarged by 1 degree (p < 0.048) with AUC 0.64 (p < 0.031), sensitivity of 71% and specificity of 43% in feet with MN compared to controls. No difference between IMA 2/4, 2/5, 1/5 or correlation between IPA or IMA and the size of the MN in the MRI was found.
CONCLUSION
The results confirm the clinical observation of an increased IPA in patients with MN. An increased IPA should therefore be considered in the diagnosis of MN.
Topics: Case-Control Studies; Humans; Metatarsalgia; Morton Neuroma; Radiography; Retrospective Studies
PubMed: 34863257
DOI: 10.1186/s13047-021-00502-7 -
Foot & Ankle Specialist Feb 2022Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be...
BACKGROUND
Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be explored as an option for the prevention of recurrence of Morton's neuroma. The purpose of the present investigation was to determine the consistency of the relevant foot neurovascular and muscle anatomy and to demonstrate the feasibility of TMR as an option for Morton's neuroma.
METHODS
The anatomy of 5 fresh-tissue donor cadaver feet was studied, including the course and location of the medial and lateral plantar nerves (MPNs and LPNs), motor branches to abductor hallucis (AH) and flexor digitorum brevis (FDB), as well as the course of sensory plantar digital nerves. Measurements for the locations of the muscular and sensory branches were taken relative to landmarks including the navicular tuberosity (NT), AH, FDB, and the third metatarsophalangeal joint (third MTPJ).
RESULTS
The mean number of nerve branches to FDB identified was 2. These branch points occurred at an average of 8.6 cm down the MPN or LPN, 9.0 cm from the third MTPJ, 3.0 cm distal to AH distal edge, and 4.8 cm from the NT. The mean number of nerves to AH was 2.2. These branch points occurred at an average of 6.3 cm down the MPN, 11.9 cm from the third MTPJ, 0.8 cm from the AH distal edge, and 3.8 cm from the NT.
CONCLUSIONS
Recurrent interdigital neuroma, painful scar, and neuropathic pain are common complications of operative management for Morton's neuroma. Targeted muscle reinnervation is a technique that has demonstrated efficacy for the prevention and treatment of neuroma, neuropathic pain, and phantom limb pain in amputees. Herein, we have described the neuromuscular anatomy for the application of TMR for the management of Morton's neuroma. Target muscles, including the AH and FDB, have consistent innervation patterns in the foot, and consequently, TMR represents a viable option to consider for the management of recalcitrant Morton's neuroma.
LEVELS OF EVIDENCE
V.
Topics: Feasibility Studies; Foot; Foot Diseases; Humans; Morton Neuroma; Muscles; Neuroma
PubMed: 34854338
DOI: 10.1177/19386400211002702 -
The Journal of Foot and Ankle Surgery :... 2022Longitudinal plantar approaches are generally considered at risk for wound healing problems. Thus, we wanted to investigate long-term outcomes after a primary Morton's...
Longitudinal plantar approaches are generally considered at risk for wound healing problems. Thus, we wanted to investigate long-term outcomes after a primary Morton's neuroma excision through a longitudinal plantar approach. A retrospective study of patients with primary neuroma excision was conducted. Twenty-four patients (28 feet) were evaluated at a mean 9-year follow-up (range, 6-14) by a single trained examiner using a specific postoperative evaluation protocol, including AOFAS Forefoot subjective and objective scores. Good-to-excellent outcomes were reported in 25 (89.3%) cases. A hypertrophic scar formation and keratosis occurred in only 2 cases (7.1%). All the patients, with a single exception, achieved full weightbearing with a postoperative shoe from the first day after the operation. A longitudinal plantar approach can lead to long-term, good-to-excellent outcomes with no case of recurrence or reoperation. Accurate wound closure and immediate weightbearing with a postoperative shoe can minimize the rate of complications. This approach should be considered for primary resection of Morton's neuromas.
PubMed: 34782249
DOI: 10.1053/j.jfas.2021.10.010 -
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 -
European Radiology Mar 2022To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma)...
Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.
OBJECTIVES
To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications.
METHODS
We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper.
RESULTS
Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia.
CONCLUSION
Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures.
KEY POINTS
• Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.
Topics: Anesthetics, Local; Consensus; Humans; Lower Extremity; Musculoskeletal System; Radiography; Radiology; Ultrasonography, Interventional
PubMed: 34581843
DOI: 10.1007/s00330-021-08283-0 -
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 Foot and Ankle Surgery :... 2022The optimal treatment strategy for the presentation of multiple Morton's neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. We aimed...
The optimal treatment strategy for the presentation of multiple Morton's neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. We aimed to summarize and assess the efficacy of current treatment strategies. A systematic review, adhering to PRIMSA guidelines was performed. A computer base search was completed in PubMed, Embase, Cinahl, ISI Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A total of 253 articles were identified, with 7 articles being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, while 2 studies each describe simultaneous excision with 2 separate incisions and delayed excision respectively. There is no strong evidence favoring use of delayed excision or multiple incisions. Further high-quality research is required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.
Topics: Foot; Foot Diseases; Humans; Morton Neuroma; Neuroma
PubMed: 34526223
DOI: 10.1053/j.jfas.2021.08.003 -
AJR. American Journal of Roentgenology Feb 2022. Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. . The aim of this study was to determine... (Comparative Study)
Comparative Study
. Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. . The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas when conservative management has failed. . An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three selective injection strategies in which one or more ultrasound-guided injection therapies was tried first before surgery for patients who did not respond to treatment. The three selective injection strategies were selective steroid injection, selective alcohol injection, and selective steroid/alcohol injection in which both steroid injections and alcohol sclerosing injections were trialed successively before surgical neurectomy. The direct-to-surgery approach was compared with the three different selective injection strategies and with a no-treatment strategy in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuroma in whom conservative management had failed. Model parameters, including treatment costs, effectiveness, complication rates, and health utility states, were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality-adjusted life year (QALY) with a time horizon of 3 years. A societal cost perspective was adopted with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses for key model parameters were performed. . For the base input values, the steroid/alcohol selective injection strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401.61/QALY compared with no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective injection strategy became most cost-effective. . A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared with proceeding directly to surgical neurectomy. . Ultrasound-guided injection therapies are indicated as first-line treatment of patients with symptomatic Morton neuromas when conservative management fails.
Topics: Adrenal Cortex Hormones; Cost-Benefit Analysis; Denervation; Ethanol; Health Care Costs; Humans; Morton Neuroma; Treatment Outcome; Ultrasonography, Interventional
PubMed: 34523955
DOI: 10.2214/AJR.21.26419 -
Journal of the American Podiatric... Jul 2021Morton's neuroma is a common condition that routinely presents in podiatric practice. The aim of this study was to systematically synthesize the evidence relating to the...
BACKGROUND
Morton's neuroma is a common condition that routinely presents in podiatric practice. The aim of this study was to systematically synthesize the evidence relating to the effectiveness of a corticosteroid injection for Morton's neuroma.
METHODS
Studies with a publication date of 1960 or later were eligible, and searches were performed within the Turning Research Into Practice database; the Cochrane Central Register of Controlled Trials; the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register; MEDLINE (Ovid); PubMed; Embase; Cumulative Index to Nursing and Allied Health Literature; and the gray literature. Study selection criteria included randomized and nonrandomized controlled trials where a single corticosteroid injection for Morton's neuroma pain was investigated. The primary outcome was Morton's neuroma pain as measured by any standard validated pain scale.
RESULTS
Ten studies involving 695 participants were included. The quality of the studies was considered low and subject to bias. Of the included studies, five compared corticosteroid injection to usual care, one compared corticosteroid injection to local anesthetic alone, one compared ultrasound-guided to non-ultrasound-guided injections, three compared corticosteroid injections to surgery, one compared small to large neuromas, six assessed patient satisfaction, four measured adverse events, one studied return to work, and one examined failure of the corticosteroid injection to improve pain. Overall, these studies identified a moderate short- to medium-term benefit of corticosteroid injections on the primary outcome of pain and a low adverse event rate.
CONCLUSIONS
A single corticosteroid injection appears to have a beneficial short- to medium-term effect on Morton's neuroma pain. It appears superior to usual care, but its superiority to local anaesthetic alone is questionable, and it is inferior to surgical excision. A very low adverse event rate was noted throughout the studies, indicating the intervention is safe when used for Morton's neuroma. However, the quality of the evidence is low, and these findings may change with further research.
Topics: Adrenal Cortex Hormones; Adult; Humans; Injections; Morton Neuroma; Neuroma; Randomized Controlled Trials as Topic; Ultrasonography
PubMed: 34478534
DOI: 10.7547/20-151