Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma.

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Plantar and dorsal approaches for excision of morton's neuroma: a comparison study.

BACKGROUND: Morton's neuroma is a painful enlargement of the plantar digital nerve between the metatarsal heads that causes pain of the forefoot. Several approaches have been used to treat Morton's neuroma, each of them having distinct advantages and disadvantages. OBJECTIVES: The purpose of this study was to investigate and compare the clinical outcomes of neurectomy in the treatment of Morton's neuroma through plantar and dorsal approaches. MATERIALS AND METHODS: A total of 20 patients with a mean age of 48.5 ± 13.0 years (range: 19-66 years) who underwent excision of a Morton's neuroma that did not respond to conservative treatment were retrospectively analysed from June 2014 to June 2021. All the neurectomies were performed using a plantar or dorsal approach. Outcomes were evaluated using visual analogue scale (VAS) scores, American Orthopedic Foot and Ankle Society (AOFAS) scores, the Foot and Ankle Ability Measure (FAAM), and complications. The appearance index (AI) was also used to assess the influence of foot appearance on the quality of life after surgery. RESULTS: Eight patients underwent neurectomy by the dorsal approach, and 12 patients underwent neurectomy by the plantar approach. The average follow-up time was 28.9 ± 12.9 months (range: 15-72 months). No statistically significant difference was found between the dorsal and plantar approach groups with respect to postoperative pain measured by the VAS score. The postoperative AOFAS scores and FAAM outcomes were not significantly different between the groups. The complications reported in the dorsal approach group were significantly less than those of the plantar group, mainly discomfort in wearing shoes. The AI of the plantar group and the dorsal group were significantly different. CONCLUSION: The excision of the Morton's neuroma by both the dorsal and plantar approach resulted in satisfactory outcomes. However, the foot appearance after surgery by the plantar approach had less influence on the quality of life than that using the dorsal approach. Our recommendation is that surgeons should choose the approach they are most familiar with and with which they are most confident in performing. In addition, the plantar approach is recommended if the patient needs a better appearance.

Long-term comparison between blind and ultrasound-guided corticoid injections in Morton neuroma.

OBJECTIVES: This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up. METHODS: This is an evaluator-blinded randomised trial in which 33 patients with MN were injected by an experienced orthopaedic surgeon based on anatomical landmarks (blind injection, group 1) and 38 patients were injected by an experienced musculoskeletal radiologist under US guidance (group 2). Patients were assessed using the visual analogue scale and the Manchester Foot Pain and Disability index (MFPDI). Injections consisted of 1 ml of 2% mepivacaine and 40 mg triamcinolone acetonide in each web space with MN. Up to 4 injections were allowed during the first 3 months of follow-up. Follow-up was performed by phone calls and/or scheduled consultations at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1, 2 and 3 years. Statistical analysis was performed using unpaired Student's t tests. RESULTS: No differences in age or clinical measures were found at presentation between group 1 (VAS, 8.5 ± 0.2; MFPDI, 40.9 ± 1.1) and group 2 (VAS, 8.4 ± 0.2; MFPDI, 39.8 ± 1.2). Improvement in VAS was superior in group 2 up to 3 years of follow-up (p < 0.05). Improvement in MFPDI was superior in group 2 from 45 days to 2 years of follow-up (p < 0.05). Satisfaction with the treatment was higher in group 2 (87%) versus group 1 (59.1%) at 3 years of follow-up. CONCLUSION: Ultrasound-guided injections lead to a greater percentage of long-term improvement than blind injections in MN. KEY POINTS: • Ultrasound-guided corticosteroid injections in Morton neuroma provide long-term pain relief in more than 75% of patients. • Ultrasound-guided injections in Morton neuroma led to greater long-term pain relief and less disability than blind injections up to 3 years of follow-up. • The presence of an ipsilateral neuroma is associated with worse long-term disability score.

Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton's neuroma and correlation with intraoperative anatomical variations.

BACKGROUND: Morton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT). OBJECTIVES: This retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve. MATERIAL AND METHODS: The study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016. RESULTS: The mean pre-operative Giannini score of 13 (0-30) improved to 61 (20-80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin's criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome. CONCLUSION: Dividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible. LEVEL OF EVIDENCE: Level IV - Case Control Retrospective study.

Ultrasound-Guided Injection Treatments Versus Surgical Neurectomy for Morton Neuroma: A Cost-Effectiveness Analysis.

BACKGROUND. Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. OBJECTIVE. The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas when conservative management has failed. METHODS. An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three selective injection strategies in which one or more ultrasound-guided injection therapies was tried first before surgery for patients who did not respond to treatment. The three selective injection strategies were selective steroid injection, selective alcohol injection, and selective steroid/alcohol injection in which both steroid injections and alcohol sclerosing injections were trialed successively before surgical neurectomy. The direct-to-surgery approach was compared with the three different selective injection strategies and with a no-treatment strategy in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuroma in whom conservative management had failed. Model parameters, including treatment costs, effectiveness, complication rates, and health utility states, were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality-adjusted life year (QALY) with a time horizon of 3 years. A societal cost perspective was adopted with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses for key model parameters were performed. RESULTS. For the base input values, the steroid/alcohol selective injection strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401.61/QALY compared with no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective injection strategy became most cost-effective. CONCLUSION. A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared with proceeding directly to surgical neurectomy. CLINICAL IMPACT. Ultrasound-guided injection therapies are indicated as first-line treatment of patients with symptomatic Morton neuromas when conservative management fails.

The Vulcan salute sign: a non-sensitive but specific sign for Morton's neuroma on radiographs.

OBJECTIVES: To assess the value of the divergence of toes on conventional radiographs of the foot for diagnosing Morton's neuroma. METHODS: This retrospective case-control study was approved by the local ethics committee. In 100 patients with MRI-proven Morton's neuroma 2/3 or 3/4 (study group) and 100 patients without (control group), conventional weight-bearing dorso-plantar view radiographs were evaluated for the subjective presence of interphalangeal divergence, called the Vulcan salute sign or V-sign, by two blinded, independent musculoskeletal radiologists. Interphalangeal angles (2/3 and 3/4) and intermetatarsal angle I/V were measured. The t test and chi-squared test were used to compare the groups. Diagnostic performance was calculated. Interobserver reliability was assessed using κ statistics and intraclass correlation coefficient (ICC). RESULTS: The difference between the groups was significant (P < 0.05) regarding the presence of the V-sign, which was found in 30 of 100 patients with Morton neuroma and in 3 of 100 control patients, with a sensitivity of 30% and a specificity of 97%. The differences between interphalangeal angles were significant (P < 0.05) between the groups. The interphalangeal angle 2/3 mean values were 7.9° (± 4.8) for the study group vs 5.4° (± 2.6) for the controls; the 3/4 angle values were 6.5° (± 3.8) and 3.4° (± 2.5), respectively. There was no significant difference between the groups in the intermetatarsal angle I/V. Interobserver agreement was substantial for the V-sign, with a κ value of 0.78. The ICC was excellent concerning angle measurements, with all values ≥ 0.94. CONCLUSION: The Vulcan salute sign on conventional radiographs is specific for Morton's neuroma.

Presurgical Perspective and Postsurgical Evaluation of Morton's Neuroma and Other Nerve Lesions.

Magnetic resonance imaging (MRI) is a robust method used for both preoperative and postoperative evaluation of Morton's neuroma and other neural lesions. MRI is used to confirm the diagnosis and for precise localization, estimation of outcome, and differential diagnoses. The differential diagnoses include mechanically induced plantar plate ruptures with associated Morton's neuroma-like tumors in the intermetatarsal/interdigital spaces; mechanical fibrosis cushion formations and pseudo bursae in the plantar foot adipose tissue; rheumatologic affections, such as rheumatoid nodules, gouty nodules, and intermetatarsal bursitis; and lastly the tenosynovial giant cell tumor (formerly called pigmented villonodular synovitis). In the postoperative evaluation after resection of Morton's neuroma, the same differential diagnoses must be considered as in the preoperative evaluation. Similarly, a high prevalence (up to 25%) of asymptomatic Morton's neuroma-like findings in the intermetatarsal and interdigital spaces should be kept in mind when interpreting postoperative recurrent forefoot pain after Morton's neuroma resection.

The interphalangeal angle as a novel radiological measurement tool for Morton's neuroma - a matched case-control study.

BACKGROUND: The aim of this retrospective study was to examine if a correlation between Morton's Neuroma (MN) and an increased interphalangeal angle (IPA) or intermetatarsal angle (IMA) can be found in preoperative weightbearing dorsal-plantar X-rays of the foot. METHODS: Forty-five patients with forty-nine MN in the interspaces 2/3 or 3/4 and 49 controls were recruited for this study. Every MN was matched with an asymptomatic control without history of metatarsalgia. The diagnosis was made by clinical examination, magnetic resonance imaging (MRI) and positive histopathology after operative resection. IMA 1/5, 2/3, 2/4, 2/5, 3/4 and IPA 2/3, 3/4 were measured for both groups. RESULTS: The IPA 3/4 was significantly enlarged by 2.8 degrees (p < 0.001) with Area under the curve (AUC) 0.75 (p < 0.001), sensitivity of 73% and specificity of 67% in feet with MN compared to controls. The IMA 3/4 was significantly enlarged by 1 degree (p < 0.048) with AUC 0.64 (p < 0.031), sensitivity of 71% and specificity of 43% in feet with MN compared to controls. No difference between IMA 2/4, 2/5, 1/5 or correlation between IPA or IMA and the size of the MN in the MRI was found. CONCLUSION: The results confirm the clinical observation of an increased IPA in patients with MN. An increased IPA should therefore be considered in the diagnosis of MN.

An Updated Nerve Sparing Surgical Technique for Addressing Morton's Neuroma.

Morton's neuroma is a common painful pathology that occurs in the plantar forefoot. Many treatment options exist and surgical management is used after conservative treatment options fail. While within the literature, there is a high success rate with primary neurectomy procedures, the risk of recurrence of symptoms or "stump neuromas" remains difficult to treat and can lead to debilitating pain. This article expands on a previously published article to discuss an update on a nerve sparing, microneurosurgical, procedure for the management of Morton's neuromas.

Morton's neuroma: review of anatomy, pathomechanism, and imaging.

Morton's neuroma is a commonly encountered cause of forefoot pain, which may limit weight-bearing activities and footwear choices. Although the aetiology and pathomechanism of this condition is controversial, the histological endpoint is well established as benign perineural fibrosis of a common plantar digital nerve, typically within the third intermetatarsal space. The diagnosis of Morton's neuroma is mainly based on characteristic symptoms and clinical findings, but may be confirmed by ultrasonography. Although ultrasound is a highly accurate diagnostic tool for Morton's neuroma, it is subject to interoperator variability due to differences in technique and level of experience. In this paper, the authors review the anatomy of the common plantar digital nerves and surrounding structures in the forefoot, which are deemed relevant to the understanding of Morton's neuroma, especially from a sonographic point of view. Several theories of the pathomechanism of Morton's neuroma are briefly discussed. The main purpose of this article is to illustrate the ultrasound techniques for evaluating Morton's neuroma and performing ultrasound-guided corticosteroid injections.

Sex Correlation to the Prevalence of Pedal Neuromas in Various Interspaces: A Retrospective Study.

BACKGROUND: Morton's neuromas are abnormalities of the common digital nerve branch located between the lesser metatarsal heads. Historically, interdigital (Morton's) neuromas have been characterized as being most common in the third interspace and in females. The principal investigator observed Morton's neuromas commonly in the second and third interspaces in both sexes. To our knowledge, no literature exists to evaluate Morton's neuroma location with a focus on each sex independently. The present study evaluates Morton's neuroma interspace location and whether there is a variation by sex. METHODS: In this retrospective study, 582 deidentified magnetic resonance imaging reports with a diagnosis code for Morton's neuroma were evaluated for patients scanned from January 2, 2015, through April 19, 2016. Incomplete records and those with radiologist findings inconsistent with Morton's neuroma were eliminated. For the remaining 379 patients, data were collected on sex, laterality, history of trauma, plantar plate tear, age, and interspace location. Special focus was given to second and third interspace Morton's neuromas. Data were evaluated using the Pearson χ2 and independent-samples Mann-Whitney U tests, with P < .05 indicating statistical significance. RESULTS: No statistically significant distribution between sex and second and third interspace Morton's neuromas was noted. Right vs left foot, age, and history of trauma did not vary statistically significantly between sexes. There was a statistically significant difference between the presence of plantar plate tears between sexes. Male patients with Morton's neuromas were found to have a higher rate of plantar plate tears (P = .01). CONCLUSIONS: This study found that there were no statistically significant differences between sexes and Morton's neuromas location, laterality, or age.

Relationship Between Sensory Symptoms, Mulder's Sign, and Dynamic Ultrasonographic Findings in Morton's Neuroma.

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.

Ultrasound-guided radiofrequency ablation for treatment of Morton's neuroma: initial experience.

AIM: To assess the efficacy and safety of ultrasound-guided radiofrequency ablation (RFA) for treatment of symptomatic Morton's neuroma. MATERIALS AND METHODS: Patients with symptomatic Morton's neuroma of the foot were referred for treatment with RFA, prior to consideration for surgery. All neuromas were proven by ultrasound imaging and had a trial of conservative management including orthotic support and/or steroid injections. Ultrasound-guided RFA was performed as an outpatient procedure under local anaesthetic. Patients were followed up at 8 weeks and 8 months. Outcomes were assessed with a visual analogue scale (VAS) score, Manchester-Oxford Foot and Ankle Questionnaire, overall patient satisfaction, and complications. RESULTS: Twenty-two neuromas were treated with RFA under ultrasound guidance. The VAS score at 8 weeks was significantly lower than the VAS score pre-procedure (p<0.001, Wilcoxon signed ranks test) and the VAS score at 8 months was significantly lower than the VAS score at 8 weeks (p=0.008, Wilcoxon signed ranks test). At 8 months, 89% of treated patients were satisfied with the procedure outcome. No significant adverse effects were recorded. CONCLUSION: Ultrasound-guided RFA is safe, with excellent initial results in treatment of symptomatic Morton's neuroma. Further studies on long-term outcomes and comparison to other management options will be required to establish its role in management of symptomatic Morton's neuroma.

Value of Preoperative Imaging and Intraoperative Histopathology in Morton's Neuroma.

BACKGROUND: Recent studies have demonstrated that clinical diagnosis of Morton's neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have questioned the cost-effectiveness of intraoperative histopathology of excised specimens. The purpose of this study was to determine the utility of both preoperative imaging and intraoperative histology in the treatment of Morton's neuroma in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes. METHODS: A retrospective review was performed on all patients who underwent operative resection suspected Morton's neuroma with 4 fellowship-trained foot and ankle surgeons between 2007 and 2017. Procedures were excluded from the study if the pathology report was not available for review. Diagnoses were made either by clinical examination and/or by the results of preoperative imaging. All pathology reports were reviewed to determine the final diagnosis, considered the "gold standard." Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton's neuroma. Two hundred eighty-seven procedures in 269 patients with 313 clinically suspected neuromas met inclusion criteria. RESULTS: Of the 313 suspected neuromas, 309 (98.7%) were confirmed Morton's neuromas on histopathologic examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179 (57.2%) suspected neuromas, with magnetic resonance imaging (MRI) and ultrasonography used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 using both. The total estimated cost of histopathologic analysis for the cohort was $143 667, and the estimated combined cost of preoperative imaging and intraoperative histopathology in our cohort totaled $278 567. CONCLUSION: Our study found that the diagnosis of Morton's neuroma could be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Intra- and Interobserver Reliability of Size Measurement of Morton Neuromas on Sonography.

OBJECTIVES: Sonography is often used for analysis of Morton neuromas, but the measurement reliability is unknown. The aim of this study was to determine the intra- and interobserver reliability and precision of sonographic measurement of Morton neuromas. METHODS: Three observers with different levels of sonography experience (observer A, expert; observer B, intermediate; observer C, beginner) performed repeated measurements of the size of Morton's neuroma in 20 patients. Intraclass correlation coefficient and limit of agreement were used to evaluate reliability and measurement precision. RESULTS: The intraclass correlation coefficient for intraobserver reliability was 0.80, 0.71, and 0.43 (limit of agreement, 20%, 18%, and 47%) in observers A, B, and C, respectively. The intraclass correlation coefficient for interobserver reliability was 0.72, 0.38, and 0.38 (limit of agreement, 25%, 36%, and 35%) between observers A/B, A/C, and B/C, respectively. CONCLUSIONS: The intra- and interobserver reliability values for sonographic measurement of Morton neuroma size were dependent on observer experience. Experienced observers had higher reliability, while observers who were less familiar with sonography showed moderate to low reliability.

Short term comparison between blind and ultrasound guided injection in morton neuroma.

OBJECTIVE: The aim of this work is to compare the effectiveness of blind and ultrasound-guided injection for Morton's neuroma (MN) to determine which is more appropriate as the initial procedure in conservative treatment. METHODS: This is an evaluator-blinded randomised trial. Of the 56 included patients, 27 were assigned to the blind group (A) and 29 to the ultrasound-guided group (B). Injection includes 1 ml of 2% mepivacaine and 40 mg of triamcinolone in each web space with MN. The included patients were assessed clinically by VAS score and the Manchester Foot Pain and Disability Score (MFPDS). The follow-up was performed at 15 days, 1 month, 45 days, 2 months, 3 months and 6 months after the initial injection. RESULTS: No differences in age or clinical measurements were found at presentation between group A and group B. At the follow-up, the ultrasound-guided group showed greater symptomatic relief at several stages of the follow-up: 45 days (VAS 3.0 ± 0.5 versus 5.5 ± 0.5, p = 0.001; MFPDS: 32.2 ± 1.8 versus 38.8 ± 2.0, p = 0.018), 2 months (VAS: 3.1 ± 0.5 versus 5.6 ± 0.5, p = 0.002; MFPDS: 31.5 ± 1.9 versus 38.5 ± 2.1, p = 0.020) and 3 months (VAS: 3.1 ± 0.4 versus 5.2 ± 0.6, p = 0.010; MFPDS: 31.2 ± 1.9 versus 37.7 ± 2.4, p = 0.047). CONCLUSION: Injection of MN under ultrasound guidance provides a statistically significant improvement at some stages of the follow-up (45 days, 2 and 3 months), compared with blind injection. KEY POINTS: • Ultrasound-guided steroid injections in Morton's neuroma provide short-term pain relief to over 60% of the patients. • Ultrasound-guided injections in Morton's neuroma lead to a higher percentage of short-term pain relief than blind injections. • Ultrasound-guided injections in Morton's neuroma lead to a lower percentage of skin side effects than blind injections.

Prediction of Clinical Prognosis according to Intermetatarsal Distance and Neuroma Size on Ultrasonography in Morton Neuroma: A Prospective Observational Study.

OBJECTIVES: This study aims to evaluate the clinical importance of intermetatarsal distance, size of neuroma, and proportion of neuroma in the intermetatarsal space in examinations of Morton neuroma using ultrasonography. METHODS: Clinical prognosis was observed prospectively after corticosteroid injections in 136 patients with Morton neuroma, and the results were compared with ultrasonographic parameters of intermetatarsal distance, size of neuroma, and proportion of neuroma in the intermetatarsal space. RESULTS: Twenty-one patients (15%) did not respond to corticosteroid injections and underwent surgical treatment for Morton neuroma. Logistic regression analysis and receiver operating characteristic curve analysis showed that the size of the neuroma was the sole predictor of failure of corticosteroid injections (P = .002). No other factors were significant for the prediction of clinical prognosis (P > .05). CONCLUSIONS: The size of the neuroma on ultrasonography is the sole predictor of corticosteroid injection failure, while intermetatarsal distance and proportion of neuroma in the intermetatarsal space are not significant when predicting clinical prognosis of Morton neuroma.

Mechanical Metatarsalgia as a Risk Factor for Relapse of Morton's Neuroma After Ultrasound-Guided Alcohol Injection.

Although many treatment modalities are available for Morton's neuroma, the injection of the neuroma with alcohol has gained popularity. However, recently, some investigators have observed a progressive deterioration in pain scores for patients initially pain free after the treatment. The purpose of the present retrospective comparative study was to determine whether mechanical metatarsalgia is related to symptom recurrence. We included 104 consecutive cases of ultrasound-guided alcohol injection for Morton's neuroma in 92 patients. Of these 104 cases, 51 were in group A (49%; Morton's neuroma) and 53 in group B (51%; Morton's neuroma associated with mechanical metatarsalgia). We evaluated each patient using a visual analog scale and American Orthopaedic Foot and Ankle Society forefoot scale, and Johnson satisfaction scale, with a mean follow-up period of 24 (range 12 to 39) months. Concomitant functional and mechanical disorders have been identified and treated with orthopedic inserts. The present study compared the clinical results and recurrence of symptoms in patients with isolated Morton's disease or Morton's disease associated with mechanical metatarsalgia. Of the 104 cases, the patients for 93 cases (89%) were completely satisfied or satisfied with minor reservations. No major complications developed. Symptoms recurred in 6 patients (6%), in whom neuroma was associated with mechanical disorders (p = .0269). Ultrasound-guided alcohol injection of Morton's neuroma is a relatively safe and well-tolerated treatment. Symptom recurrence is often associated with mechanical metatarsalgia. The treatment of the concomitant anatomical and functional disorders that target the genesis of the neuroma has an important role in the prevention of recurrence of this pathology.