A comparative analysis of conservative versus surgical treatment of Morton's neuroma

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.

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton's Neuroma: Short-term Results

BACKGROUND

Although the precise pathoetiology of Morton's neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma.

MATERIALS AND METHODS

Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton's neuroma and who then underwent isolated IML decompression without neuroma resection.

RESULTS

A total of 12 patients underwent isolated IML decompression for Morton's neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement.

CONCLUSION

Isolated IML release of chronically symptomatic Morton's neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation.

LEVEL OF EVIDENCE

Level IV: Case series.

Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases

Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.

Treatment of Morton's neuroma: A systematic review

BACKGROUND

The treatment of Morton's neuroma (MN) can be operative, conservative and infiltrative. Our aim was the evaluation of evidence on outcomes with different types of conservative, infiltrative and surgical treatment in patients affected by primary MN.

METHODS

The bibliographic search was conducted in MEDLINE, Cochrane Library, DARE. Only studies in English were collected. The last search was in August 2015. Case series and randomized controlled trials (RCTs) assessing patients' satisfaction or pain improvement at an average follow-up of at least 6 months after treatment of primary MN were included. Two reviewers selected the studies, evaluated their methodological quality, and retrieved data independently.

RESULTS

Of 283 titles found, only 29 met the inclusion criteria. Data showed better outcomes with operative treatment.

CONCLUSIONS

The evaluated case series and few RCTs showed better results with invasive treatment. More and better RCTs which evaluate risk-benefit ratio are required to confirm these results.

Morton's interdigital neuroma of the foot: A literature review

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.

Plantar approach for Morton's neuroma: An effective technique for primary excision

BACKGROUND

Morton's neuroma is a common cause of inter-metatarsal foot pain. Surgical excision is generally indicated when non-operative measures have been unsuccessful; various surgical techniques have been described in the literature for excision, with no consensus on the overall ideal surgical approach.

AIM

To assess patient outcomes and complications following plantar surgical approach to neurectomy in a consecutive series of patients.

METHOD

An analysis of consecutive patients undergoing excision of Morton's neuroma using a plantar approach by a single surgeon over a 12 month period. Pre- and post-operative AOFAS and VAS scores were completed during outpatient visits.

RESULTS

20 patients were included in the study, with pre-operative confirmation of a soft tissue mass on ultrasound scan. All patients demonstrated improvement in their post-operative functional scores; 2 patients (10%) did not have full resolution of their symptoms post-operatively. Mean AOFAS scores improved from 39 to 80 post-operatively and VAS from 40 to 92. No patients had wound complications or scar pain.

CONCLUSION

Neurectomy performed via a plantar approach provides good exposure, adequate soft tissue healing, with rapid resolution of pain and return to normal activities post-operatively.

Cost-effectiveness of steroid (methylprednisolone) injections versus anaesthetic alone for the treatment of Morton's neuroma: economic evaluation alongside a randomised controlled trial (MortISE trial)

BACKGROUND

Morton's neuroma is a common foot condition affecting health-related quality of life. Though its management frequently includes steroid injections, evidence of cost-effectiveness is sparse. So, we aimed to evaluate whether steroid injection is cost-effective in treating Morton's neuroma compared with anaesthetic injection alone.

METHODS

We undertook incremental cost-effectiveness and cost-utility analyses from the perspective of the National Health Service, alongside a patient-blinded pragmatic randomised trial in hospital-based orthopaedic outpatient clinics in Edinburgh, UK. Of the original randomised sample of 131 participants with Morton's neuroma (including 67 controls), economic analysis focused on 109 (including 55 controls). Both groups received injections guided by ultrasound. We estimated the incremental cost per point improvement in the area under the curve of the Foot Health Thermometer (FHT-AUC) until three months after injection. We also conducted cost-utility analyses using European Quality of life-5 Dimensions-3 Levels (EQ-5D-3L), enhanced by the Foot Health Thermometer (FHT), to estimate utility and thus quality-adjusted life years (QALYs).

RESULTS

The unit cost of an ultrasound-guided steroid injection was £149. Over the three months of follow-up, the mean cost of National Health Service resources was £280 for intervention participants and £202 for control participants - a difference of £79 [bootstrapped 95% confidence interval (CI): £18 to £152]. The corresponding estimated incremental cost-effectiveness ratio was £32 per point improvement in the FHT-AUC (bootstrapped 95% CI: £7 to £100). If decision makers value improvement of one point at £100 (the upper limit of this CI), there is 97.5% probability that steroid injection is cost-effective. As EQ-5D-3L seems unresponsive to changes in foot health, we based secondary cost-utility analysis on the FHT-enhanced EQ-5D. This estimated the corresponding incremental cost-effectiveness ratio as £6,400 per QALY. Over the recommended UK threshold, ranging from £20,000 to £30,000 per QALY, there is 80%-85% probability that steroid injection is cost-effective.

CONCLUSIONS

Steroid injections are effective and cost-effective in relieving foot pain measured by the FHT for three months. However, cost-utility analysis was initially inconclusive because the EQ-5D-3L is less responsive than the FHT to changes in foot health. By using the FHT to enhance the EQ-5D, we inferred that injections yield good value in cost per QALY.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13668166.

The diagnosis and management of Morton's neuroma: a literature review

Morton's neuroma is a common condition mainly affecting middle aged women, and there are many proposed etiological theories involving chronic repetitive trauma, ischemia, entrapment, and intermetatarsal bursitis. Incorrect terminology suggests that the underlying pathological process is a nerve tumor, although histological examination reveals the presence of inflammatory tissue-that is, perineural fibrosis. The common digital nerve and its branches in the third planter webspace are most commonly affected. Diagnosis is usually made through history taking and clinical examination but may be aided by ultrasonography and magnetic resonance imaging. Current nonoperative treatment strategies include shoe-wear modifications, custom made orthoses, and injections of local anesthetic agents, sclerosing agents, and steroids. Operative management options primarily involve either nerve decompression or neurectomy. We have reviewed the published literature to evaluate the outcomes of the available diagnostic modalities and treatment options and present an algorithm for clinical practice.

Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial

BACKGROUND

Morton neuroma is a common cause of neuralgia affecting the web spaces of the toes. Corticosteroid injections are commonly administered as a first-line therapy, but the evidence for their effectiveness is weak. Our primary research aim was to determine whether corticosteroid injection is an effective treatment for Morton neuroma compared with an anesthetic injection as a placebo control.

METHODS

We performed a pragmatic, patient-blinded randomized trial set within hospital orthopaedic outpatient clinics in Edinburgh, United Kingdom. One hundred and thirty-one participants with Morton neuroma (mean age, fifty-three years; 111 [85%] female) were randomized to receive either corticosteroid and anesthetic (1 mL methylprednisolone [40 mg] and 1 mL 2% lignocaine) or anesthetic alone (2 mL 1% lignocaine). An ultrasonographic image was obtained before treatment, and injections were performed with the needle placed under ultrasonographic guidance. The primary outcome was the difference in patient global assessment of foot health between the two groups at three months after injection. This was measured with use of a 100-unit visual analog scale (VAS) anchored by "best imaginable health state" and "worst imaginable health state."

RESULTS

Compared with the control group, global assessment of foot health in the corticosteroid group was significantly better at three months (mean difference, 14.1 scale points [95% confidence interval, 5.5 to 22.8 points]; p = 0.002). The difference between the groups was also significant at one month. Significant and nonsignificant improvements associated with the corticosteroid injection were observed for measures of pain, function, and patient global assessment of general health at one and three months after injection. The size of the neuroma as determined by ultrasonography did not significantly influence the treatment effect.

CONCLUSIONS

Corticosteroid injections for Morton neuroma can be of symptomatic benefit for at least three months.

Efficacy of corticosteroid injection versus size of plantar interdigital neuroma

BACKGROUND

The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroid injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of the neuroma.

METHODS

Forty-three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroid injection was given using 40 mg of methylprednisolone along with 1% lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups on the basis of the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5 mm or less and group 2 patients had neuromas larger than 5 mm. A visual analog scale (VAS) for pain (scale 0 to 10), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Johnson satisfaction scale were used to assess patients before injection and then at 6 weeks, 6 months, and 12 months following the injection. Thirty-nine patients had confirmed neuromas. Group 1 (lesion ≤ 5 mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and group 2 (lesion >5 mm) had 22 patients (mean age, 33 years) (8 males, 14 females).

RESULTS

VAS scores, AOFAS scores, and Johnson scale improved significantly in both groups at 6 weeks (p < .0001). At 6 months postinjection, this improvement remained significant only in group 1 with all scores (p < . 001). At 12 months, there was no difference between both groups and outcome scores nearly approached preinjection scores. At the final review, two patients in group 1 and four patients in group 2 had severe recurrent symptoms and therefore underwent surgical excision of the neuroma after they rejected the offer for a repeat injection (p = 0.6).

CONCLUSION

A single ultrasound-guided corticosteroid injection resulted in generally short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection appears to be more significant and long-lasting for lesions smaller than 5 mm.

Surgical approaches to the forefoot for common sports-related pathologies: a review of the literature and cadaveric dissection

This article reviews the published literature regarding the surgical approaches to pathologies encountered within the forefoot, including arthroscopic and open techniques, and their treatment. We have demonstrated these surgical approaches with cadavers, to identify the key anatomical landmarks and safe zones for these surgical techniques, to prevent the complications associated with their treatment.

Entrapment and compressive neuropathies

Entrapment and compressive neuropathies of the upper and lower extremities are frequently encountered disorders in the office. Certain clinical clues in the history and examination, along with electrodiagnostic testing and imaging studies, often suggest the correct diagnosis. Some of the more common neuropathies are discussed, along with suggestions regarding testing and treatment.

Treatment of recalcitrant intermetatarsal neuroma with 4% sclerosing alcohol injection: a pilot study

The purpose of this investigation was to conduct a prospective trial to assess the effectiveness of a 4% sclerosing alcohol injection in a small group of patients with intermetatarsal neuromas who had failed previous conservative therapies including corticosteroid injections. Six patients with 8 neuromas were followed for a mean 346 days. A weekly series of 3-9 injections containing 1 mL of the 4% alcohol sclerosing solution were given based on patient response to treatment. Pre- and posttreatment surveys consisting of both objective and subjective findings including a visual analog pain scale were collected. The average pretreatment visual analog pain rating was 7.5 +/- 1.14. The average posttreatment visual analog pain rating was 1.38 +/- 2.39 with an average reduction of 6.13. The average reported improvement in symptoms was 73%. Five of the 6 patients would recommend the treatment to a friend or family member. No complications were encountered. Two neuromas in 2 patients failed the sclerosing injection course: 1 ultimately responded to antiinflammatory use and the other underwent excision.

Interventions for the treatment of Morton's neuroma

BACKGROUND

Morton's neuroma is a common, paroxysmal neuralgia affecting the web spaces of the toes, typically the third. The pain is often so debilitating that patients become anxious about walking or even putting their foot to the ground. Insoles, corticosteroid injections, excision of the nerve, transposition of the nerve and neurolysis of the nerve are commonly used treatments. Their effectiveness is poorly understood.

OBJECTIVES

To examine the evidence from randomised controlled trials concerning the effectiveness of interventions in adults with Morton's neuroma.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group trials register (searched January 2003), MEDLINE (January 1966 to January Week 2 2003), EMBASE (January 1980 to February Week 2 2003), and CINAHL (January 1982 to February Week 1 2003).

SELECTION CRITERIA

Randomised or quasi-randomised (methods of allocating participants to an intervention which were not strictly random e.g. date of birth, hospital record, number alternation) controlled trials of interventions for Morton's neuroma were selected. Studies where participants were not randomised into intervention groups were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers selected trials for inclusion in the review, assessed their methodological quality and extracted data independently.

MAIN RESULTS

Three trials involving 121 people were included. There is, at most, a very limited indication that transposition of the transected plantar digital nerve may yield better results than standard resection of the nerve in the long term. There is no evidence to support the use of supinatory insoles. There are, at best, very limited indications to suggest that dorsal incisions for resection of the plantar digital nerve may result in less symptomatic post-operative scars when compared to plantar excision of the nerve.

REVIEWERS' CONCLUSIONS

There is insufficient evidence with which to assess the effectiveness of surgical and non-surgical interventions for Morton's neuroma. Well designed trials are needed to begin to establish an evidence base for the treatment of Morton's neuroma pain.

Entrapment and compressive neuropathies

Entrapment and compressive neuropathies of the upper and lower extremities are frequently encountered disorders in the office. Certain clinical clues in the history and examination, along with electrodiagnostic testing and imaging studies, often suggest the correct diagnosis. Some of the more common neuropathies are discussed, along with suggestions regarding testing and treatment.

Nerve entrapments of the lower leg, ankle and foot in sport

Exercise-related leg pain is a common and yet difficult management problem in sports medicine. There are many common causes of such symptoms including stress fractures and muscle compartment syndromes. There are also a number of less common but important conditions including popliteal artery entrapment and nerve entrapment syndromes. Even for an astute clinician, distinction between the different medical causes may be difficult given that many of their presenting features overlap. This review highlights the common clinical presentations and raises a regional approach to the diagnosis of the neurogenic symptoms. In part, this overlapping presentation of different pathological conditions may be due to a common aetiological basis of many of these conditions namely, fascial dysfunction. The same fascial restriction that predisposes to muscle compartment syndromes may also envelop the neurovascular structures within the leg resulting in either ischaemic or neurogenic symptoms. For many athletes with chronic exercise-related leg pain, combinations of such problems often coexist suggesting a more widespread fascial pathology. In our clinical experience, we often label such patients as 'fasciopaths'; however, the precise pathophysiological basis of this fascial problem remains to be elucidated. This review discusses the various nerve entrapment syndromes in the lower limb that may result in exercise-related leg pain in the sporting context. The anatomy, clinical presentation, investigation, medical management and surgical treatment are discussed at length for each of the syndromes. It is clear from clinical experience that the outcome of surgical management of such syndromes fares much better where a clear dermatomal pain distribution is present or where focal weakness and/or sensory symptoms appropriate for the nerve are present. In many situations, however, nonspecific leg pain or vague nonlocalising sensory symptoms are present and in such situations, alternative diagnoses must be considered and investigated appropriately. As mentioned above, many different pathologies may coexist in the lower limb and may be a source of confusion for the clinician or alternatively may be the reason for poor treatment outcomes.

Treatment of recurrent neuroma of the interdigital nerve by implantation of the proximal nerve into muscle in the arch of the foot

A prospective study was done to evaluate the results of treating recurrent "Morton's" neuroma by a technique that combined resecting the interdigital neuroma through a plantar approach and implantation of the proximal end of the nerve into an intrinsic muscle in the arch of the foot. As a part of this study, quantitative sensory testing was done for the medial plantar and medial calcaneal nerves. Seventeen recurrent interdigital neuromas were resected in 13 patients. Pain was identified on physical examination as being due to neuromas located in the first (one), second (six), third, (eight) and fourth (two) web spaces. Seven of the 13 patients were found to have, by quantitative sensory testing and physical examination, an associated tarsal tunnel syndrome responsible for symptoms related to numbness in the foot in addition to the pain of the recurrent neuroma. These patients had tarsal tunnel decompression at the time of the neuroma resection. At a mean follow-up time of 33.8 months (range 24-42 months), done by direct physician interview and examination, 80% of the patients had excellent relief of symptoms, returned to their regular job, and wore usual footwear. Twenty percent of the patients had good relief of symptoms, worked at a different job, and had to change their footwear. It is concluded that recurrent pain after a dorsal interdigital neurectomy can be treated successfully through a plantar approach with implantation of the proximal end of the nerve into an intrinsic muscle. This study also identified an association of tarsal tunnel syndrome in 54% of this series of patients with recurrent Morton's neuroma.

The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections

The cause of intermetatarsal neuromas or intermetatarsal neuritis is unclear; however, the most likely pathogenesis is either a mechanically induced degenerative neuropathy or entrapment of the intermetatarsal nerve as it passes under the transverse intermetatarsal ligament. Treatment of intermetatarsal neuromas includes the very simple method of changing shoe styles, more complex conservative treatments with functional orthotic devices, oral anti-inflammatory medications and cortisone injections, and surgical intervention. In this study, 100 adult patients with previously untreated intermetatarsal neuromas received three to seven injections of a 4% alcohol sclerosing solution every 5-10 days. No additional treatment was provided during the visits. The use of 4% alcohol sclerosing solution showed an 89% success rate. Of the 89 patients who were improved, 82 had complete resolution of symptoms. Eleven patients showed no improvement. The results of this prospective study indicate that the alcohol sclerosis treatment of intermetatarsal neuromas is a viable alternative to serial steroid injections or surgery for persistent symptoms.

Morton's Neuroma: Getting Patients Back on Track

Morton's neuroma, known also as intermetatarsal or interdigital neuroma, is a common foot injury that often curtails athletic activity. Nerve compression involving adjacent metatarsal heads and the transverse intermetatarsal ligament appears implicated in injury onset. Diagnosis is made clinically, and the condition typically causes initial symptoms of dull cramping or burning pain and more persistent sharp pain with nerve deterioration. Depending on injury severity, treatment is either conservative or surgical.

[Distal nerve compression of the leg. Clinical and electrophysiologic study]

Rare distal compressions of lower limb nerves include tarsal tunnel syndrome, entrapment of the first branch of the lateral plantar and medial calcaneal nerves, interdigital neuroma, compression of the deep peroneal nerve on the dorsum of the foot, entrapment of the superficial peroneal and sural nerves. Nerve conduction and electromyographic studies are essential to evaluate these peripheral nerve injuries in order to differentiate focal lower extremity nerve entrapments from ischemic mononeuropathies, lumbar radiculopathies or plexopathies, and generalized peripheral neuropathies. This review summarizes the clinical and electrophysiological findings for each of these rare entrapment syndromes and provides the necessary clues to obtain a correct differential diagnosis with other more common causes of foot and ankle pain and paresthesias.

Nonoperative treatment of plantar interdigital neuroma with a single corticosteroid injection

Patients who received a single corticosteroid injection for treatment of third webspace plantar interdigital neuroma were studied retrospectively. Forty-three patients (51 feet) were available for followup study (followup mean, 4 years; range, 2 to 6 years). Mean age of patients was 53 years. Pain initially was relieved in 36 patients (41 feet [80%]). Twenty-four feet (47%) ultimately required surgical excision, while most of the remaining 27 feet (53%), which had not been treated surgically, were the source of residual symptoms in patients. A single corticosteroid injection cannot be recommended as a cure for symptoms of third webspace neuroma, but it can be offered as a temporizing measure or as nonoperative treatment. A single corticosteroid injection does not preclude a successful surgical result.