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2.
Foot Ankle Int ; 41(12): 1474-1479, 2020 Dec.
Article in English | MEDLINE | ID: mdl-32856473

ABSTRACT

BACKGROUND: Morton's neuroma (MN) is often a diagnostic dilemma lacking a gold standard set of diagnostic criteria. Advanced imaging of MN is evolving including ultrasonography. The current study aimed to analyze the relationship between ultrasonographic findings and symptoms, clinical data, and operative findings in a subgroup of patients. METHODS: We evaluated physical examination, ultrasonographic findings, symptoms, and in a subgroup, the operative findings for Morton's neuroma. We analyzed the symptoms, the findings on physical examination, and ultrasonography data and performed a statistical correlation between them. A total of 175 patients were seen for suspected Morton's neuroma during the last 7 years. RESULTS: Neuropathic pain of the toes was reported in 63% of patients. Presence of ultrasonographic findings suggesting Morton's neuroma was observed in 77% of cases. A mild significant relationship between neuropathic pain and positive ultrasonographic findings was observed. We found a strong correlation between ultrasonographic and clinical evaluation, but more than half with clinical negative Morton's neuroma had positive findings at ultrasonography. In the subgroup of operatively treated patients (n = 44) surgery confirmed Morton's neuroma in all patients who had positive ultrasonography findings. CONCLUSIONS: The current study suggests that the association of ultrasonographic evaluation and clinical evaluation can be very useful for the management of Morton's neuroma. Our study could help with the development of a multiperspective approach in the diagnosis of Morton's neuroma. LEVEL OF EVIDENCE: Level II, prospective cohort survey study.


Subject(s)
Morton Neuroma/diagnostic imaging , Morton Neuroma/physiopathology , Neuralgia/diagnostic imaging , Neuralgia/physiopathology , Adolescent , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Humans , Male , Middle Aged , Morton Neuroma/surgery , Neuralgia/surgery , Physical Examination , Prospective Studies , Surveys and Questionnaires , Ultrasonography , Young Adult
3.
Acta Biomed ; 91(4-S): 60-68, 2020 05 30.
Article in English | MEDLINE | ID: mdl-32555077

ABSTRACT

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.


Subject(s)
Conservative Treatment/methods , Morton Neuroma/therapy , Orthotic Devices , Shoes , Equipment Design , Humans , Morton Neuroma/diagnosis , Morton Neuroma/physiopathology , Syndrome , Treatment Outcome
4.
J Man Manip Ther ; 28(1): 60-67, 2020 02.
Article in English | MEDLINE | ID: mdl-31177965

ABSTRACT

Objectives: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and utility of physical therapy (PT) is unknown. Mechanical Diagnosis and Therapy (MDT) is a classification system utilizing direction-specific treatment for orthopedic conditions based on mechanical and symptomatic response to repeated end range movements. The purpose of this case series is to describe the management of three patients with a medical diagnosis of MN using the MDT classification system.Methods: Three female patients aged 54-75 years with unilateral plantar forefoot pain for 6 weeks to 8 years were referred by a podiatrist following positive clinically accepted diagnostic criteria for MN including radiological imaging and provocation testing. Patients were evaluated and treated utilizing MDT assessment and treatment principles. The intervention consisted of repeated movements matched to the patient's directional preference at either the lumbar spine (1 patient) or distal extremity (2 patients).Results: Immediate and one-year outcomes were excellent, demonstrating rapid and lasting improvement. Following discharge, the patients have been asymptomatic or able to self-manage without seeking additional medical intervention for this condition. Total visit frequency per patient averaged 2-3 visits total across 8-16 days.Discussion: Responses to repeated end range movements testing allowed for classification and prescription of exercise to rapidly improve symptoms and function in three patients referred to PT services with medically diagnosed MN. This series provides preliminary evidence that MDT may be effective in classifying and treating patients with MN.


Subject(s)
Morton Neuroma/classification , Morton Neuroma/physiopathology , Morton Neuroma/therapy , Physical Therapy Modalities , Aged , Female , Gait/physiology , Humans , Middle Aged , Pain Measurement , Range of Motion, Articular/physiology , Walk Test
5.
Foot Ankle Int ; 39(7): 829-835, 2018 07.
Article in English | MEDLINE | ID: mdl-29641258

ABSTRACT

BACKGROUND: The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot width, foot length, coefficient of spreading, and arch index between subjects with Morton's neuroma (MN) and control subjects. METHODS: Dynamic peak plantar pressure, contact time, pressure-time integral, and geometric data were extracted using the EMED-X platform in 52 subjects with MN and 31 control subjects. Differences in peak pressure, contact time, pressure-time integral, and geometric data between participants with and those without MN were determined using independent-samples t tests. There were no significant differences in age, weight, height, and body mass index between patients with MN and control subjects. RESULTS: There were no significant differences in the peak pressures of all masked areas and pressure-time integrals under metatarsal 2 to 4 heads between patients with MN and control subjects. In addition, no significant differences were observed between patients with MN and control subjects in geometric measurements of forefoot length, width, coefficient of spreading, foot progression angle, and arch index. CONCLUSION: No relationship was found in this study between peak pressure, contact time, and pressure-time integral under the metatarsal heads, forefoot width, foot length, coefficient of spreading, and foot progression angle in a symptomatic MN group compared with a control group. The need to perform osteotomies to treat MN not associated with other lesser metatarsal phalangeal joint pathologies is questionable. LEVEL OF EVIDENCE: Level III, Case-Control Study.


Subject(s)
Metatarsus/anatomy & histology , Metatarsus/physiology , Morton Neuroma/physiopathology , Adult , Case-Control Studies , Female , Humans , Male , Metatarsus/physiopathology , Middle Aged , Morton Neuroma/pathology , Pressure
6.
Foot Ankle Int ; 38(9): 944-951, 2017 Sep.
Article in English | MEDLINE | ID: mdl-28617064

ABSTRACT

BACKGROUND: The effectiveness of corticosteroid injection for the treatment of Morton's neuroma is unclear. In addition, most of the studies related to it are case-control or retrospective case series. The purpose of this study was to compare the effectiveness between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) for the treatment of Morton's neuroma. METHODS: Forty-one patients with a diagnosis of Morton's neuroma were randomized to receive 3 injections of either a corticosteroid plus a local anesthetic or a local anesthetic alone. The patients and the researcher who collected data were blinded to the treatment groups. The visual analog scale for pain and the American Orthopaedic Foot & Ankle Score (metatarsophalangeal/interphalangeal score) were obtained at baseline, after each injection, and at 3 and 6 months after the last injection. RESULTS: There were no significant between-group differences in terms of pain and function improvement at 3 and 6 months after treatment completion in comparison with baseline values. At the end of the study, 17 (48.5%) patients requested surgical excision of the neuroma: 7 (44%) in the experimental group and 10 (53%) in the control group ( P = 1.0). CONCLUSION: The injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and function improvement in patients with Morton's neuroma. LEVEL OF EVIDENCE: Level I, randomized controlled trial.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , Morton Neuroma/surgery , Neuroma/surgery , Peripheral Nervous System Neoplasms/drug therapy , Adrenal Cortex Hormones/pharmacology , Humans , Morton Neuroma/physiopathology , Orthopedics , Prospective Studies , Randomized Controlled Trials as Topic , Retrospective Studies
7.
Foot Ankle Int ; 38(3): 310-317, 2017 Mar.
Article in English | MEDLINE | ID: mdl-27837053

ABSTRACT

BACKGROUND: The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton's neuroma (MN). METHODS: Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author's private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years. RESULTS: When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location. CONCLUSION: We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence. LEVEL OF EVIDENCE: Level III, case control study.


Subject(s)
Hallux Valgus/surgery , Metatarsal Bones/surgery , Morton Neuroma/surgery , Radiography/methods , Weight-Bearing/physiology , Case-Control Studies , Foot , Hallux Valgus/physiopathology , Humans , Morton Neuroma/physiopathology , Reproducibility of Results
8.
J Foot Ankle Res ; 9: 46, 2016.
Article in English | MEDLINE | ID: mdl-27980684

ABSTRACT

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.


Subject(s)
Equinus Deformity/complications , Foot/physiopathology , Morton Neuroma/etiology , Adult , Aged , Ankle Joint/physiopathology , Anthropometry/methods , Body Mass Index , Case-Control Studies , Equinus Deformity/physiopathology , Female , Humans , Male , Middle Aged , Morton Neuroma/physiopathology , Posture/physiology , Range of Motion, Articular/physiology , Young Adult
9.
Bone Joint J ; 98-B(10): 1376-1381, 2016 Oct.
Article in English | MEDLINE | ID: mdl-27694592

ABSTRACT

AIMS: This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma. PATIENTS AND METHODS: Between May 2006 and April 2013, we prospectively studied 99 consecutive patients (111 feet) who were to undergo excision of a Morton's neuroma. There were 78 women and 21 men with a mean age at the time of surgery of 56 years (22 to 78). Patients completed the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF-12) and a supplementary patient satisfaction survey three months pre-operatively and six months post-operatively. RESULTS: Statistically significant differences were found between the mean pre- and post-operative MOXFQ and the physical component of the SF-12 scores (p = 0.00081 and p = 0.00092 respectively). Most patients reported their overall satisfaction as excellent (n = 49, 49.5%) or good (n = 29, 29.3%), but ten patients were dissatisfied, reporting poor (n = 8, 8.1%) or very poor (n = 2, 2.0%) results. Only 63 patients (63%) were pain-free at follow-up: in eight patients (8.1%), the MOXFQ score worsened. There was no statistically significant difference in outcome between surgery on single or multiple sites. However, the MOXFQ scores were significantly worse after revision surgery (p = 0.004). CONCLUSIONS: The patient-reported outcomes after resection of a symptomatic Morton's neuroma are acceptable but may not be as good as earlier studies suggest. Surgery at several sites can be undertaken safely but caution should be exercised when considering revision surgery. Cite this article: Bone Joint J 2016;98-B:1376-81.


Subject(s)
Foot/surgery , Morton Neuroma/surgery , Orthopedic Procedures/methods , Patient Satisfaction , Adult , Aged , Female , Follow-Up Studies , Foot/physiopathology , Humans , Male , Middle Aged , Morton Neuroma/physiopathology , Postoperative Period , Prospective Studies , Range of Motion, Articular , Surveys and Questionnaires , Treatment Outcome , Young Adult
10.
Adv Clin Exp Med ; 25(2): 295-302, 2016.
Article in English | MEDLINE | ID: mdl-27627563

ABSTRACT

BACKGROUND: Morton's neuroma, a painful enlargement of the plantar digital nerve between the metatarsal heads, is a common cause of metatarsalgia. The etiology and treatment are still a controversial matter. OBJECTIVES: The objective of this study was to evaluate the long-term follow-up results of neurectomy through a dorsal approach and to identify prognostic factors that can affect the final outcome. MATERIAL AND METHODS: The study included 41 patients who were treated for Morton's neuroma. Their average age was 44 years (range: 25-69 years). The average follow-up time was 7.4 years (range: 5-12 years). Surgery was performed through a dorsal approach. The clinical evaluations, visual analog scale (VAS) scores and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed. RESULTS: The mean preoperative AOFAS score was 39.4 ± 7.84 and the mean postoperative AOFAS score was 83.4 ± 12.1. The mean preoperative VAS scale was 7.04 ± 1.4 and the mean postoperative VAS scale was 1.4 ± 0.8. There were 31 patients (76%) with very good results in the subjective and objective patient assessments; six (15%) had good results; one (2%) had satisfactory results and three (7%) had poor results. Statistically significant differences in the results between single and multiple neuromas were found, depending on the size of the neuromas and the duration of the symptoms. There were no statistically significant differences depending on the time between surgery and assessment, on steroid injections before operation or on the duration of preoperative conservative treatment. CONCLUSIONS: Despite the development of less invasive techniques and very good outcomes in a short period of time, long-term results have shown that neurectomy is still useful in the treatment of Morton's neuroma. The results of the study show that the outcome does not change during the postoperative follow-up period. The best results were achieved in the case of single neuromas larger than 3 mm that were resected within 12 months of the onset of symptoms.


Subject(s)
Morton Neuroma/surgery , Neurosurgical Procedures/methods , Tibial Nerve/surgery , Adult , Aged , Female , Humans , Male , Middle Aged , Morton Neuroma/diagnosis , Morton Neuroma/physiopathology , Neurologic Examination , Neurosurgical Procedures/adverse effects , Pain Measurement , Recovery of Function , Tibial Nerve/physiopathology , Time Factors , Treatment Outcome
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