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European Radiology Feb 2022Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound...
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 VI, foot and ankle.
OBJECTIVES
Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.
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 foot and ankle in order 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 that was shared with all panel members for final approval.
RESULTS
A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.
CONCLUSION
According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.
KEY POINTS
• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.
Topics: Achilles Tendon; Ankle; Consensus; Humans; Musculoskeletal System; Radiology; Tendinopathy
PubMed: 34432122
DOI: 10.1007/s00330-021-08125-z -
Skeletal Radiology Mar 2022To assess the value of the divergence of toes on conventional radiographs of the foot for diagnosing Morton's neuroma.
OBJECTIVES
To assess the value of the divergence of toes on conventional radiographs of the foot for diagnosing Morton's neuroma.
METHODS
This retrospective case-control study was approved by the local ethics committee. In 100 patients with MRI-proven Morton's neuroma 2/3 or 3/4 (study group) and 100 patients without (control group), conventional weight-bearing dorso-plantar view radiographs were evaluated for the subjective presence of interphalangeal divergence, called the Vulcan salute sign or V-sign, by two blinded, independent musculoskeletal radiologists. Interphalangeal angles (2/3 and 3/4) and intermetatarsal angle I/V were measured. The t test and chi-squared test were used to compare the groups. Diagnostic performance was calculated. Interobserver reliability was assessed using κ statistics and intraclass correlation coefficient (ICC).
RESULTS
The difference between the groups was significant (P < 0.05) regarding the presence of the V-sign, which was found in 30 of 100 patients with Morton neuroma and in 3 of 100 control patients, with a sensitivity of 30% and a specificity of 97%. The differences between interphalangeal angles were significant (P < 0.05) between the groups. The interphalangeal angle 2/3 mean values were 7.9° (± 4.8) for the study group vs 5.4° (± 2.6) for the controls; the 3/4 angle values were 6.5° (± 3.8) and 3.4° (± 2.5), respectively. There was no significant difference between the groups in the intermetatarsal angle I/V. Interobserver agreement was substantial for the V-sign, with a κ value of 0.78. The ICC was excellent concerning angle measurements, with all values ≥ 0.94.
CONCLUSION
The Vulcan salute sign on conventional radiographs is specific for Morton's neuroma.
Topics: Case-Control Studies; Humans; Morton Neuroma; Neuroma; Radiography; Reproducibility of Results; Retrospective Studies
PubMed: 34263343
DOI: 10.1007/s00256-021-03851-3 -
Journal of Ultrasonography Jun 2021Morton's neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular...
Morton's neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular degeneration, and deregulation of sympathetic innervation. Patients usually present with burning or sharp metatarsalgia at the dorsal or plantar aspect of the foot. The management of Morton's neuroma starts with conservative measures, usually with limited efficacy, including orthotics and anti-inflammatory medication. When conservative treatment fails, a series of minimally invasive ultrasound-guided procedures can be employed as second-line treatments prior to surgery. Such procedures include infiltration of the area with a corticosteroid and local anesthetic, chemical neurolysis with alcohol or radiofrequency thermal neurolysis. Ultrasound aids in the accurate diagnosis of Morton's neuroma and guides the aforementioned treatment, so that significant and potentially long-lasting pain reduction can be achieved. In cases of initial treatment failure, the procedure can be repeated, usually leading to the complete remission of symptoms. Current data shows that minimally invasive treatments can significantly reduce the need for subsequent surgery in patients with persistent Morton's neuroma unresponsive to conservative measures. The purpose of this review is to present current data on the application of ultrasound for the diagnosis and treatment of Morton's neuroma, with emphasis on the outcomes of ultrasound-guided treatments.
PubMed: 34258038
DOI: 10.15557/JoU.2021.0022 -
Journal of Plastic, Reconstructive &... Oct 2021
Topics: Anatomy, Regional; Cadaver; Dissection; Forefoot, Human; Humans; Morton Neuroma; Nerve Transfer; Tibial Nerve
PubMed: 34175257
DOI: 10.1016/j.bjps.2021.05.053 -
Polish Journal of Radiology 2021Morton's neuroma-bursal complex (MNBC) is a common cause of metatarsalgia which is usually investigated with ultrasound. Patients presenting with metatarsalgia may also...
PURPOSE
Morton's neuroma-bursal complex (MNBC) is a common cause of metatarsalgia which is usually investigated with ultrasound. Patients presenting with metatarsalgia may also have computed tomography (CT) as part of their investigation to look for alternative causes such as stress fracture. Although CT is considered to be of most use in assessing the bones in this scenario, the soft tissues can also be reviewed. This study analyses whether MNBC can reliably be detected on CT in patients presenting with metatarsalgia.
MATERIAL AND METHODS
43 cases were identified on the Radiology Information System where both CT and ultrasound had been undertaken to assess for metatarsalgia. Two blinded consultant musculoskeletal radiologists retrospectively reviewed the CTs to determine the presence or absence of MNBC and this was compared to the ultrasound reports.
RESULTS
There was a mean sensitivity of 45.5% and mean specificity of 62.5%. Mean accuracy was 52.3% and Youden's index was 0.080. There was fair agreement between the two reviewers with Cohen's κ of 0.62.
CONCLUSIONS
Sensitivity and specificity of CT for MNBC are poor. CT should not be used as an isolated modality to make a definite diagnosis regarding the presence or absence of a MNBC.
PubMed: 34136050
DOI: 10.5114/pjr.2021.106692 -
Clinics in Orthopedic Surgery Jun 2021This review aimed to evaluate the effects of corticosteroid injections on Morton's neuroma using an algorithmic approach to assess the methodological quality of reported...
BACKGROUD
This review aimed to evaluate the effects of corticosteroid injections on Morton's neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework.
METHODS
Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton's neuroma. Data search, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). guidelines, and clinical outcomes were evaluated using various outcome measures.
RESULTS
With 3-12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfaction scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain.
CONCLUSIONS
Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton's interdigital neuroma although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.
Topics: Adrenal Cortex Hormones; Disability Evaluation; Humans; Injections, Intralesional; Morton Neuroma; Pain Measurement; Patient Satisfaction; Surveys and Questionnaires
PubMed: 34094019
DOI: 10.4055/cios20256 -
JBJS Case Connector May 2021A 65-year-old man presented with plantar foot pain associated with a mass in the first webspace. A Morton neuroma was considered the probable diagnosis. Despite...
CASE
A 65-year-old man presented with plantar foot pain associated with a mass in the first webspace. A Morton neuroma was considered the probable diagnosis. Despite nonoperative treatment the pain continued. Surgical excision was performed, and histology was interpreted as a schwannoma. Symptoms resolved after surgery.
CONCLUSION
Schwannoma of the foot is a rare condition, and to the best of our knowledge, this is the first case reported in the first webspace. Definitive treatment and diagnosis is surgical excision. Surgeons should consider schwannomas in the differential diagnosis of plantar foot pain because this can be misdiagnosed as a Morton neuroma.
Topics: Aged; Diagnosis, Differential; Foot; Humans; Male; Neurilemmoma
PubMed: 34014845
DOI: 10.2106/JBJS.CC.20.01010 -
Foot (Edinburgh, Scotland) Jun 2021"Morton's Neuroma" is a frequent cause of chronic forefoot pain. It can affect general population, including athletes, and can lead to progressive foot pain and...
BACKGROUND
"Morton's Neuroma" is a frequent cause of chronic forefoot pain. It can affect general population, including athletes, and can lead to progressive foot pain and discomfort for daily life activities and sports.
HYPOTHESIS/PURPOSE
Our objective is to evaluate the long-term results in a series of 85 feet, operatively treated with minimally invasive interdigital approach for neurectomy.
STUDY DESIGN
Case series.
METHOD
83 patients (85 feet) were treated between January 2003 and December 2019. The AOFAS score and VAS scale were used to evaluate the patients pre and postoperatively. Results were analyzed using the JASP software.
RESULTS
Mean age was 50.58 years (range 23-77). Eleven (11) were men, and seventy-four (74) women, with two bilateral cases. Mean follow up was 49 months. Our series was evaluated with AOFAS and VAS scores, both showing statistically significant improvement posterior to the operative procedure.
CONCLUSIONS
A series of 85 feet operatively treated for Morton's neuroma with minimally invasive interdigital approach for neurectomy is presented. Long term results were similar to other published series with different approaches, with the advantage of minimal incision, minimum soft tissue dissection and no need to release intermetatarsal ligament, immediate weightbearing and quick return to daily activities and sports. It is concluded that minimally invasive neurectomy with interdigital approach is a safe procedure for Morton's neuroma treatment with similar results that other operative procedures.
LEVEL EVIDENCE
Level IV.
Topics: Adult; Aged; Denervation; Female; Foot Diseases; Humans; Male; Middle Aged; Morton Neuroma; Neuroma; Pain Measurement; Retrospective Studies; Young Adult
PubMed: 33945999
DOI: 10.1016/j.foot.2021.101808 -
La Radiologia Medica Jul 2021No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim...
PURPOSE
No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses.
METHODS
Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes.
RESULTS
Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters.
CONCLUSION
Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.
Topics: Adult; Aged; Equipment Design; Female; Follow-Up Studies; Foot Orthoses; Forefoot, Human; Humans; Male; Metatarsalgia; Middle Aged; Retrospective Studies; Ultrasonography
PubMed: 33881714
DOI: 10.1007/s11547-021-01354-8 -
Zeitschrift Fur Rheumatologie Apr 2022The goal was to assess public interest in a wide range of musculoskeletal symptoms and disorders during the coronavirus disease 2019 (COVID-19) pandemic.
OBJECTIVE
The goal was to assess public interest in a wide range of musculoskeletal symptoms and disorders during the coronavirus disease 2019 (COVID-19) pandemic.
METHODS
We searched Google Trends for 118 search queries within the United States. We compared two timeframes of 2020 (March 15-July 4 and July 5-October 31) to similar timeframes over the four prior years (2016-2019).
RESULTS
In the early pandemic, March 15-July 4, a statistically significant decrease in relative search volume of the majority of queries (60%) was detected, with a significant increase in only 2 queries (i.e. myalgia and toe swelling). In the phase July through October, a statistically significant decrease was detected in only 22% of search queries; there was no difference for 60% of search queries between 2020 and 2016-2019 suggesting a return to their prior levels for most of search queries. Interestingly, the search volume of 18% of search queries (i.e. fatigue, joint pain, muscle pain, myalgia, spondylosis, radiculopathy, myelopathy, neck pain, neck strain, lower back strain, sciatica, shoulder pain, frozen shoulder, elbow pain, lateral epicondylitis, wrist pain, carpal tunnel, hand pain, finger pain, trigger finger, and Morton's neuroma) was significantly increased compared with the four prior years.
CONCLUSION
Public interest focused on COVID-19 and sought online information for COVID-19 symptoms in the early pandemic. In the period July through October, there was an upward trend in musculoskeletal symptoms and some colloquial terms/well-known musculoskeletal conditions coupled with a downward trend in general musculoskeletal disorder terms and certain specific diagnoses. This information may help rheumatologists understand public interest in musculoskeletal symptoms and disorders and address the needs of patients to mitigate the negative impact of the pandemic on outcomes.
Topics: COVID-19; Humans; Infodemiology; Musculoskeletal Diseases; Pandemics; Search Engine; United States
PubMed: 33779835
DOI: 10.1007/s00393-021-00989-2