Effectiveness of customized insoles in patients with Morton's neuroma: a randomized, controlled, double-blind clinical trial

The comparison of postoperative outcomes in Morton's neuroma excision between plantar versus dorsal approach: A systematic review and meta-analysis

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.

Treatments for Morton's neuroma

BACKGROUND

Morton's neuroma (MN) is a painful neuropathy resulting from a benign enlargement of the common plantar digital nerve that occurs commonly in the third webspace and, less often, in the second webspace of the foot. Symptoms include burning or shooting pain in the webspace that extends to the toes, or the sensation of walking on a pebble. These impact on weight-bearing activities and quality of life.

OBJECTIVES

To assess the benefits and harms of interventions for MN.

SEARCH METHODS

On 11 July 2022, we searched CENTRAL, CINAHL Plus EBSCOhost, ClinicalTrials.gov, Cochrane Neuromuscular Specialised Register, Embase Ovid, MEDLINE Ovid, and WHO ICTRP. We checked the bibliographies of identified randomised trials and systematic reviews and contacted trial authors as needed.

SELECTION CRITERIA

We included all randomised, parallel-group trials (RCTs) of any intervention compared with placebo, control, or another intervention for MN. We included trials where allocation occurred at the level of the individual or the foot (clustered data). We included trials that confirmed MN through symptoms, a clinical test, and an ultrasound scan (USS) or magnetic resonance imaging (MRI).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We assessed bias using Cochrane's risk of bias 2 tool (RoB 2) and assessed the certainty of the evidence using the GRADE framework.

MAIN RESULTS

We included six RCTs involving 373 participants with MN. We judged risk of bias as having 'some concerns' across most outcomes. No studies had a low risk of bias across all domains. Post-intervention time points reported were: three months to less than 12 months from baseline (nonsurgical outcomes), and 12 months or longer from baseline (surgical outcomes). The primary outcome was pain, and secondary outcomes were function, satisfaction or health-related quality of life (HRQoL), and adverse events (AE). Nonsurgical treatments Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA) Two RCTs compared CS+LA versus LA. At three to six months: • CS+LA may result in little to no difference in pain (mean difference (MD) -6.31 mm, 95% confidence interval (CI) -14.23 to 1.61; P = 0.12, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Assessed via a pain visual analogue scale (VAS; 0 to 100 mm); a lower score indicated less pain.) • CS+LA may result in little to no difference in function when compared with LA (standardised mean difference (SMD) -0.30, 95% CI -0.61 to 0.02; P = 0.06, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Function was measured using: the American Orthopaedic Foot and Ankle Society Lesser Toe Metatarsophalangeal-lnterphalangeal Scale (AOFAS; 0 to 100 points) - we transformed the scale so that a lower score indicated improved function - and the Manchester Foot Pain and Disability Schedule (MFPDS; 0 to 100 points), where a lower score indicated improved function.) • CS+LA probably results in little to no difference in HRQoL when compared to LA (MD 0.07, 95% CI -0.03 to 0.17; P = 0.19; 1 study, 122 participants; moderate-certainty evidence), and CS+LA may not increase satisfaction (risk ratio (RR) 1.08, 95% CI 0.63 to 1.85; P = 0.78; 1 study, 35 participants; low-certainty evidence). (Assessed using the EuroQol five dimension instrument (EQ-5D; 0-1 point); a higher score indicated improved HRQoL.) • The evidence is very uncertain about the effects of CS+LA on AE when compared with LA (RR 9.84, 95% CI 1.28 to 75.56; P = 0.03, I2 = 0%; 2 studies, 157 participants; very low-certainty evidence). Adverse events for CS+LA included mild skin atrophy (3.9%), hypopigmentation of the skin (3.9%) and plantar fat pad atrophy (2.6%); no adverse events were observed with LA. Ultrasound-guided (UG) CS+LA versus non-ultrasound-guided (NUG) CS+LA Two RCTs compared UG CS+LA versus NUG CS+LA. At six months: • UG CS+LA probably reduces pain when compared with NUG CS+LA (MD -15.01 mm, 95% CI -27.88 to -2.14; P = 0.02, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). (Assessed with a pain VAS.) • UG CS+LA probably increases function when compared with NUG CS+LA (SMD -0.47, 95% CI -0.84 to -0.10; P = 0.01, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). We do not know of any established minimum clinical important difference (MCID) for the scales that assessed function, specifically, the MFPDS and the Manchester-Oxford Foot Questionnaire (MOXFQ; 0 to 100 points; a lower score indicated improved function.) • UG CS+LA may increase satisfaction compared with NUG CS+LA (risk ratio (RR) 1.71, 95% CI 1.19 to 2.44; P = 0.003, I2 = 15%; 2 studies, 114 feet; low-certainty evidence). • HRQoL was not measured. • UG CS+LA may result in little to no difference in AE when compared with NUG CS+LA (RR 0.42, 95% CI 0.12 to 1.39; P = 0.15, I2 = 0%; 2 studies, 116 feet; low-certainty evidence). AE included depigmentation or fat atrophy for UG CS+LA (4.9%) and NUG CS+LA (12.7%). Surgical treatments Plantar incision neurectomy (PN) versus dorsal incision neurectomy (DN) One study compared PN versus DN. At 34 months (mean; range 28 to 42 months), PN may result in little to no difference for satisfaction (RR 1.06, 95% CI 0.87 to 1.28; P = 0.58; 1 study, 73 participants; low-certainty evidence), or for AE (RR 0.95, 95% CI 0.32 to 2.85; P = 0.93; 1 study, 75 participants; low-certainty evidence) compared with DN. AE for PN included hypertrophic scaring (11.4%), foreign body reaction (2.9%); AE for DN included missed nerve (2.5%), artery resected (2.5%), wound infection (2.5%), postoperative dehiscence (2.5%), deep vein thrombosis (2.5%) and reoperation with plantar incision due to intolerable pain (5%). The data reported for pain and function were not suitable for analysis. HRQoL was not measured.

AUTHORS' CONCLUSIONS

Although there are many interventions for MN, few have been assessed in RCTs. There is low-certainty evidence that CS+LA may result in little to no difference in pain or function, and moderate-certainty evidence that UG CS+LA probably reduces pain and increases function for people with MN. Future trials should improve methodology to increase certainty of the evidence, and use optimal sample sizes to decrease imprecision.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

Assessing the Subjective Effectiveness of Sensorimotor Insoles (SMIs) in Reducing Pain: A Descriptive Multicenter Pilot Study

This pilot study aimed to investigate the use of sensorimotor insoles in pain reduction, different orthopedic indications, and the wearing duration effects on the development of pain. Three hundred and forty patients were asked about their pain perception using a visual analog scale (VAS) in a pre-post analysis. Three main intervention durations were defined: VAS_post: up to 3 months, 3 to 6 months, and more than 6 months. The results show significant differences for the within-subject factor "time of measurement", as well as for the between-subject factor indication (p < 0.001) and worn duration (p < 0.001). No interaction was found between indication and time of measurements (model A) or between worn duration and time of measurements (model B). The results of this pilot study must be cautiously and critically interpreted, but may support the hypothesis that sensorimotor insoles could be a helpful tool for subjective pain reduction. The missing control group and the lack of confounding variables such as methodological weaknesses, natural healing processes, and complementary therapies must be taken into account. Based on these experiences and findings, a RCT and systematic review will follow.

Forefoot Injuries in Athletes: Integration of the Movement System

Despite the prevalence of forefoot related problems in athletes, there are few comprehensive summaries on examination and intervention strategies for those with forefoot related symptoms. While many factors may contribute to pathology and injury, the presence of abnormal foot alignment can negatively affect lower extremity biomechanics and be associated with injuries. Physical therapists may use the characteristics associated abnormal pronation or abnormal supination to describe the movement system disorder and serve as a guide for evaluating and managing athletes with forefoot pathologies. Athletes with an abnormal pronation movement system diagnosis typically demonstrate foot hypermobility, have decreased strength of the tibialis posterior muscle, and present with a medially rotated lower extremity position. Athletes with abnormal supination movement system diagnosis typically demonstrate foot hypomobility, decreased strength of the fibularis muscles, and a laterally rotated lower extremity position. Interventions of manual therapy, taping, strengthening exercises, and neuromuscular reeducation can be directed at the identified impairments and abnormal movements. The purpose of this clinical commentary is to integrate a movement system approach in pathoanatomical, evaluation, and intervention considerations for athletes with common forefoot pathologies, including stress fractures, metatarsalgia, neuroma, turf toe, and sesamoiditis. By applying a prioritized, objective problem list and movement system diagnosis, emphasis is shifted from a pathoanatomical diagnosis-based treatment plan to a more impairment and movement focused treatment.

LEVEL OF EVIDENCE

5.

Anatomic basis for a new ultrasound-guided, mini-invasive technique for release of the deep transverse metatarsal ligament

Introduction

Morton's neuroma is an entrapment neuropathy of the third common plantar digital nerve, caused by the deep transverse metatarsal ligament (DTML). Minimally invasive or percutaneous surgery is a very common procedure, but surgical effectivity of this technique remains controversial. The goal of our study was to prove the effectiveness and safety of a new ultrasound‐guided technique for DTML‐release in a cadaver model.

Materials, Methods, and Results

The DTML was visualized in 10 fresh frozen donated body to science‐feet (eight male and two females, five left and five right) using an US device (GE Logic R7; 13 MHz linear probe, Madrid, Spain). Consecutively, minimally invasive ultrasound‐guided surgery was performed. Exclusion criteria of the donated bodies to science were previous history of forefoot surgery and space occupying mass lesions. The complete release of the ligament was achieved in all specimens without damage of any important anatomical structures as proven by anatomical dissection.

Conclusions

The results of this study indicate that our novel approach of an ultrasound‐guided release of the DTML is safer and more effective compared to blind techniques. The DTML could reliably be visualized and securely cut through a dorsal, minimally invasive surgical incision of only 2 mm.

The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art

Civinini Morton’s Syndrome (CMS), better known as Morton’s Neuroma, is a benign enlargement that typically affects the third common digital branch of the plantar nerve. It is a common cause of metatarsalgia leading to debilitating pain. It prefers the female gender, with a female to male ratio of 5:1 and an average age of 50 years at time of surgery. Precise aetiology remains under debate, with four etiopathogenetic theories often cited in the literature. Clinical symptoms, physical exam and instrumental evidence are important in assessing and grading the disease. Biomechanics seem to play an important role, especially regarding the usefulness of correct footwear. The first approach in the early stages of this condition usually begins with shoe modifications and orthotics, designed to limit the nerve compression. In order to prevent or delay the development of CMS, shoes should be sufficiently long, comfortable, broad toe-boxed, should bear a flat heel and a sufficiently thick external sole which should not be excessively flexible. Most authors suggested that an insole with medial arch support and a retrocapital bar or pad, just proximal to the metatarsal heads, displaces the pressure sites and can be beneficial to relieve the pain from the pinched nerve. A threshold period of 4.5 months appears to emerge from the results of the analysed studies, indicating that, beyond this period and in neuromas larger than 5-6 mm, orthotics and/or shoes modifications do not seem to give convincing results, proving to be more a palliation for the clinical condition to allow an acceptable life with pain rather than a real treatment. (www.actabiomedica.it)