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Matthews BG, Thomson CE, Harding MP, McKinley JC, Ware RS. Treatments for Morton's neuroma. Cochrane Database Syst Rev 2024; 2:CD014687. [PMID: 38334217 PMCID: PMC10853972 DOI: 10.1002/14651858.cd014687.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
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.
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Affiliation(s)
- Barry G Matthews
- Faculty of Health, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, Australia
| | - Colin E Thomson
- Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh and St John's Hospital Livingston, Edinburgh, UK
| | | | - John C McKinley
- Royal Infirmary of Edinburgh and Royal Hospital for Sick Children, Edinburgh, UK
| | - Robert S Ware
- School of Medicine and Dentistry, Griffith University, Brisbane, Australia
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Chen L, Qing A, Zhu T, Yang P, Ye L. Effect and safety of extracorporeal shockwave therapy for postherpetic neuralgia: A randomized single-blind clinical study. Front Neurol 2022; 13:948024. [PMID: 36226089 PMCID: PMC9548589 DOI: 10.3389/fneur.2022.948024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the efficacy and safety of extracorporeal shockwave therapy (ESWT) for postherpetic neuralgia. Design Randomized single-blind clinical study. Patients Patients with postherpetic neuralgia. Methods Patients were randomly divided into the control group and the ESWT group. The control group received conventional treatment while the ESWT group received conventional treatment and ESWT. The primary outcome is pain degree as assessed by the numeric rating scale (NRS), and secondary outcomes include brief pain inventory (BPI), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Pittsburgh Sleep Quality Index (PSQI). Data were collected at baseline and at weeks 1, 4, and 12. Linear mixed-effects models were applied to repeated measurement data. Results The scores on the NRS, BPI, SAS, SDS, and PSQI decreased over time in both groups. The NRS and SDS scores of the ESWT group were statistically lower than the control group. There was no time × group interaction in the mixed model analysis. Baseline age was correlated with NRS scores and BPI scores, and invasive treatment was related to PSQI scores, with no interaction effect for baseline confounders observed. No adverse events were observed during the process of this trial. Conclusion Extracorporeal shockwave therapy combined with conventional treatment could relieve pain and improve the psychological state in patients with postherpetic neuralgia without serious adverse effects.
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Affiliation(s)
- Lu Chen
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu, China
| | - Ailing Qing
- Department of Anesthesiology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Pingliang Yang
- Department of Anesthesiology, The First Affiliated Hospital of Chengdu Medical College, Xindu, China
- *Correspondence: Pingliang Yang
| | - Ling Ye
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu, China
- Ling Ye
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Nazim B Tengku Yusof T, Seow D, Vig KS. Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc 2022; 112:18-191. [PMID: 34878537 DOI: 10.7547/18-191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
| | - Dexter Seow
- †Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Khushdeep S Vig
- ‡Department of Orthopedic Surgery, Albany Medical Center, Albana, NY
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Matthews BG, Thomson CE, McKinley JC, Harding MP, Ware RS. Treatments for Morton's neuroma. Hippokratia 2021. [DOI: 10.1002/14651858.cd014687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Barry G Matthews
- Faculty of Health, School of Clinical Sciences; Queensland University of Technology (QUT); Brisbane Australia
| | - Colin E Thomson
- Department of Trauma & Orthopaedics; The Royal Infirmary of Edinburgh and St John’s Hospital Livingston; Edinburgh UK
| | - John C McKinley
- Royal Infirmary of Edinburgh and Royal Hospital for Sick Children; Edinburgh UK
| | | | - Robert S Ware
- Menzies Health Institute Queensland; Griffith University; Brisbane Australia
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Lu VM, Puffer RC, Everson MC, Gilder HE, Burks SS, Spinner RJ. Treating Morton's neuroma by injection, neurolysis, or neurectomy: a systematic review and meta-analysis of pain and satisfaction outcomes. Acta Neurochir (Wien) 2021; 163:531-43. [PMID: 32056015 DOI: 10.1007/s00701-020-04241-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Individual evidence suggests that multiple modalities can be used to treat entrapment pathology by Morton's neuroma, including injection, neurolysis, and neurectomy. However, their impacts on patient pain and satisfaction have yet to be fully defined or elucidated. Correspondingly, our aim was to pool systematically identified metadata and substantiate the impact of these different modalities in treating Morton's neuroma with respect to these outcomes. METHODS Searches of 7 electronic databases from inception to October 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. The incidences of outcomes were extracted and pooled by random-effects meta-analysis of proportions. RESULTS A total of 35 articles satisfied all criteria, reporting a total of 2998 patients with Morton's neuroma managed by one of the three modalities. Incidence of complete pain relief after injection (43%; 95% CI, 23-64%) was significantly lower than neurolysis (68%; 95% CI, 51-84%) and neurectomy (74%; 95% CI, 66-82%) (P = 0.02). Incidence of complete satisfaction after injection (35%; 95% CI, 21-50%) was significantly lower than neurolysis (63%; 95% CI, 50-74%) and neurectomy (57%; 95% CI, 47-67%) (P < 0.01). The need to proceed to further surgery was significantly greater following injection (15%; 95% CI, 9-23%) versus neurolysis (2%; 95% CI, 0-4%) or neurectomy (5%; 95% CI, 3-7%) (P < 0.01). Incidence of procedural complications did not differ between modalities (P = 0.30). CONCLUSIONS Although all interventions demonstrated favorable procedural complication incidences, surgical interventions by either neurolysis or neurectomy appear to trend towards greater incidences of complete pain relief and complete patient satisfaction outcomes compared to injection treatment. The optimal decision-making algorithm for treatment for Morton's neuroma should incorporate these findings to better form and meet the expectations of patients.
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Thomson L, Aujla RS, Divall P, Bhatia M. Non-surgical treatments for Morton's neuroma: A systematic review. Foot Ankle Surg 2020; 26:736-743. [PMID: 31718949 DOI: 10.1016/j.fas.2019.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/29/2019] [Accepted: 09/17/2019] [Indexed: 02/04/2023]
Abstract
TITLE Non-surgical treatment for Morton's neuroma: a systematic review. BACKGROUND Morton's neuroma (MN) is an entrapment degenerative neuropathy with a strong predilection for the 3rd interdigital web space. The objective of our study was to identify the most significant evidence produced for the non-operative treatment of Morton's neuroma and assess outcomes of these interventions. METHOD The electronic databases Medline, Ovid EMBASE, CINAHL and Cochrane CENTRAL from inception to October 2018 were searched. Two independent reviewers assessed the quality of the studies using the Modified Coleman Criteria. Statistics were combined across cohort studies to calculate pooled mean results, and improvements in outcomes. RESULTS Initial electronic and hand search identified 486 studies. After title and abstract review there were 38 that went on to full-text review. Finally, 22 studies were included in the final review. We identified 9 different non-operative treatment modalities; Corticosteroid injection, Alcohol injection, Extra-corporeal Shockwave therapy (ESWT), Radiofrequency Ablation (RFA), Cryoablation, Capsaicin injection, Botulinum toxin, Orthosis and YAG Laser Therapy. Corticosteroid showed a statistically significant reduction in mean VAS over all their studies (p < 0.01), with 50% success at 12 months. Alcohol showed promising short-term pain-relieving results only. Orthotics, Capsaicin injections, Cryoablation, Botulinum toxin, RFA and ESWT did show statistically significant improvements, but with limitation to their application. CONCLUSION Following review, the authors would recommend the use of corticosteroid injections to treat Morton's neuromas. The authors feel that radio-frequency ablation and cryoablation would benefit from further well designed randomised controlled trials.
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Affiliation(s)
- Lauren Thomson
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, LE1 5WW, United Kingdom.
| | - Randeep S Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, LE1 5WW, United Kingdom
| | - Pip Divall
- Clinical Librarian, University Hospitals of Leicester, Leicester, LE1 5WW, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, LE1 5WW, United Kingdom
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Pérez-Domínguez B, Casaña-Granell J. The effects of a combined physical therapy approach on Morton's Neuroma. An N-of-1 Case Report. Foot (Edinb) 2020; 44:101684. [PMID: 32713798 DOI: 10.1016/j.foot.2020.101684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is a lack of supporting evidence for conservative treatments involving Morton's Neuroma, which has often a clinical presentation with many associated complications such as functional impairment and chronic pain. This case study assessed the effects of a combined physical therapy treatment for Morton's Neuroma, an injury often referred for surgery. METHODS The patient suffered a long-standing Morton's Neuroma and received 6 combined physical therapy sessions that included soft-tissue massage, joint mobilization, strengthening therapeutic exercises and pain education. Values for pain with deep pressure, pain maladaptive beliefs and functionality were taken using clinical testing and questionnaires. RESULTS After the intervention was successfully completed, pain when applying deep pressure resolved. Functionality involving the toe-to-wall test showed an improvement in ankle dorsiflexion and better results were found in both the LEFS and FAAM questionnaires. Pain maladaptive beliefs, assessed with the Pain Catastrophizing Scale and the Pain Awareness Questionnaire also reflected an improvement. CONCLUSION A combined physical therapy approach shows encouraging results in the treatment of Morton's Neuroma.
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Chen L, Zhou R, Sun F, Weng Y, Ye L, Yang P. Efficacy and safety of the extracorporeal shockwave therapy in patients with postherpetic neuralgia: study protocol of a randomized controlled trial. Trials 2020; 21:630. [PMID: 32641142 PMCID: PMC7346340 DOI: 10.1186/s13063-020-04564-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/26/2020] [Indexed: 02/08/2023] Open
Abstract
Background Postherpetic neuralgia (PHN) is one of the most common types of chronic neuropathic pain, which seriously affects quality of the life because of pain severity and poor response to the currently available treatments. The main strategies for PHN management are medication and invasive interventional therapies; however, these approaches have many adverse effects, so it is important to find another effective and safe treatment for PHN. Methods A single-center, single-blind randomized clinical trial will evaluate 98 study participants randomized in a 1:1 ratio into control and experimental groups. The control group will receive conventional treatment including medication therapy and invasive interventional therapy. The experimental group will receive extracorporeal shockwave therapy (ESWT) in addition to conventional therapy. The primary outcome is pain intensity assessed on a visual analogue scale (VAS); the secondary outcomes are the following: quality of life assessed by the 36-Item Short-Form Health Survey (SF-36), psychological state for anxiety and depression measured by the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), and sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). Assessors blinded to the randomization will collect data during the intervention period at baseline and weeks 1, 4, and 12. The plasma levels of tumor necrosis factor-α and interleukin-6 will be assessed before and after ESWT to explore the biochemical mechanisms of ESWT in the treatment of PHN. Discussion This randomized controlled trial will evaluate the effectiveness and safety of ESWT in patients with PHN and thus will provide clinical evidence for its use in the management of PHN and explore the potential biochemical mechanisms of this treatment. Trial registration www.ChiCTR.org.cn, identifier: ChiCTR1900025828. Registered on 10 September 2019
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Affiliation(s)
- Lu Chen
- Department of Pain Management, West China Hospital, Sichuan University, Guoxuexiang No. 37, Chengdu, 610041, People's Republic of China
| | - Ruihao Zhou
- Department of Pain Management, West China Hospital, Sichuan University, Guoxuexiang No. 37, Chengdu, 610041, People's Republic of China
| | - Fuguo Sun
- Department of Pain Management, West China Hospital, Sichuan University, Guoxuexiang No. 37, Chengdu, 610041, People's Republic of China
| | - Yan Weng
- Department of Pain Management, West China Hospital, Sichuan University, Guoxuexiang No. 37, Chengdu, 610041, People's Republic of China
| | - Ling Ye
- Department of Pain Management, West China Hospital, Sichuan University, Guoxuexiang No. 37, Chengdu, 610041, People's Republic of China.
| | - Pingliang Yang
- Department of Anesthesiology, The First Affiliated Hospital of Chengdu Medical College, Xindu, 610500, Sichuan, People's Republic of China.
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Dang DY, Coughlin MJ. Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery. Indian J Orthop 2020; 54:3-13. [PMID: 32211125 PMCID: PMC7065734 DOI: 10.1007/s43465-019-00015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability. MATERIALS AND METHODS A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years. CONCLUSIONS There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems. LEVEL OF EVIDENCE Level V, meta-synthesis.
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Affiliation(s)
- Debbie Y. Dang
- Saint Alphonsus Medical Group, Department of Orthopaedic Surgery, Coughlin Foot and Ankle Clinic, 1075 North Curtis Road, Suite 300, Boise, ID 83706 USA
| | - Michael J. Coughlin
- Saint Alphonsus Medical Group, Department of Orthopaedic Surgery, Coughlin Foot and Ankle Clinic, 1075 North Curtis Road, Suite 300, Boise, ID 83706 USA
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Abstract
Morton's neuroma is a common pathology affecting the forefoot. It is not a true neuroma but is fibrosis of the nerve. This is caused secondary to pressure or repetitive irritation leading to thickness of the digital nerve, located in the third or second intermetatarsal space. The treatment options are: orthotics, steroid injections and surgical excision usually performed through dorsal approach. Careful clinical examination, patient selection, pre-operative counselling and surgical technique are the key to success in the management of this condition.
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Knobloch K, Ringeisen M, Hausdorf J, Gerdesmeyer L. Aspect of Reimbursement. Dtsch Arztebl Int 2019; 116:432. [PMID: 31423976 PMCID: PMC6706842 DOI: 10.3238/arztebl.2019.0431c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Karsten Knobloch
- *Präsident deutschsprachige internationale Gesellschaft für ESWT (DIGEST), Hannover, Germany
| | - Martin Ringeisen
- **Generalsekretär deutschsprachige internationale Gesellschaft für ESWT (DIGEST), Augsburg, Germany
| | - Jörg Hausdorf
- ***Leiter des AK Stoßwelle der DGOOC, München, Germany
| | - Ludger Gerdesmeyer
- ****Vorstand deutschsprachige internationale Gesellschaft für ESWT (DIGEST), Kiel, Germany
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Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. J Foot Ankle Res 2019; 12:12. [PMID: 30809275 PMCID: PMC6375221 DOI: 10.1186/s13047-019-0320-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/29/2019] [Indexed: 12/21/2022] Open
Abstract
Background Morton’s neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits footwear choices and weight bearing activities. This paper aims to review non-surgical interventions for MN, to evaluate the evidence base for the clinical management of MN. Methods Electronic biomedical databases (CINAHL, EMBASE, MEDLINE and Cochrane) were searched to January 2018 for studies evaluating the effectiveness of non-surgical interventions for Morton’s neuroma. Outcome measures of interest were treatment success rate (SR) (binary) and pain as measured using 100-point visual analogue scale (VAS) (continuous). Studies with and without control groups were included and were evaluated for methodological quality using the Downs and Black Quality Index. Results from randomised controlled trials (RCT) were compared between-groups, and case series were compared pre- versus post-treatment. Effect estimates are presented as odds ratios (OR) for binary data or mean differences (MD) for continuous data. Random effects models were used to pool effect estimates across studies where similar treatments were used. Heterogeneity was assessed using the I2 statistic. Results A total of 25 studies met the inclusion criteria, seven RCTs and 18 pre/post case series. Eight different interventions were identified, with corticosteroid or sclerosing injections being the most often reported (seven studies each). Results from a meta-analysis of two RCTs found corticosteroid injection decreased pain more than control on VAS (WMD: -5.3, 95%CI: -7.5 to − 3.2). Other RCTs reported efficacy of: manipulation/mobilisation versus control (MD: -15.3, 95%CI: -29.6 to − 1.0); extracorporeal shockwave therapy versus control (MD: -5.9, 95%CI: -21.9 to 10.1). Treatment success was assessed for extracorporeal shockwave therapy versus control (OR: 0.3, 95%CI: 0.0 to 7.1); and corticosteroid injection vs footwear/padding (OR: 6.0, 95%CI: 1.9 to 19.2). Sclerosing and Botox injections, radiofrequency ablation and cryoneurolysis have been investigated by case series studies, however these were of limited methodological quality. Conclusions Corticosteroid injections and manipulation/mobilisation are the two interventions with the strongest evidence for pain reduction, however high-quality evidence for a gold standard intervention was not found. Although the evidence base is expanding, further high quality RCTs are needed. Electronic supplementary material The online version of this article (10.1186/s13047-019-0320-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Barry G Matthews
- 1School of Clinical Sciences, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Sheree E Hurn
- 1School of Clinical Sciences, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia.,2Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Michael P Harding
- 3School of Health Sciences, University of South Australia, Adelaide, SA 5000 Australia
| | - Rachel A Henry
- Rachel Henry Podiatry, Clayfield, Brisbane, QLD 4011 Australia
| | - Robert S Ware
- 5Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111 Australia
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Di Caprio F, Meringolo R, Shehab Eddine M, Ponziani L. Morton's interdigital neuroma of the foot: A literature review. Foot Ankle Surg 2018; 24:92-98. [PMID: 29409221 DOI: 10.1016/j.fas.2017.01.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/15/2016] [Accepted: 01/27/2017] [Indexed: 02/04/2023]
Abstract
Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains little studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study may deal with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The present literature review crosses all key points, from diagnosis to surgical and nonoperative treatment, and recurrences. Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in those who want to delay or avoid surgery. Dorsal or plantar approaches were described for surgical treatment, both with strengths and weaknesses that will be scanned. Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse metatarsal ligament, too distal resection of common plantar digital nerve, an association of tarsal tunnel syndrome and incomplete removal. A deep knowledge of the causes and presentation of failures is needed to surgically face recurrences.
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Affiliation(s)
- Francesco Di Caprio
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy.
| | - Renato Meringolo
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
| | - Marwan Shehab Eddine
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
| | - Lorenzo Ponziani
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
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