Efficacy of corticosteroid injection versus size of plantar interdigital neuroma

Infiltrative Treatment of Morton's Neuroma: A Systematic Review

BACKGROUND

Morton's neuroma (MN) is one of the most frequent neurological pathologies in feet, affecting approximately 4% of the general population. The treatment of MN can be surgical, conservative, and infiltrative, with different substances used in the injections for MN, as steroids, sclerosing solutions, and others. This review aims to evaluate the efficacy of current infiltrative therapy for Morton's neuroma and, additionally, to define adverse effects of this therapy.

MATERIAL AND METHODS

A literature search was performed in PubMed, Embase, CINHAL, Epistemonikos, Web of Science (WOS), SPORTSDiscus and Cochrane Library. This search involved the application of all types of infiltrative treatment applicable to MN. The search was limited to original data describing clinical outcomes and pain using the Visual Analogue pain Scale (VAS) or the Johnson Satisfaction Scale, between February and June 2023.

RESULTS

Twelve manuscripts were selected (six randomized controlled trials and six longitudinal observational studies) involving 1,438 patients. Capsaicin was reported to produce a VAS score reduction of 51.8%. Corticosteroids also reported a high level of efficacy. Alcohol and Hyaluronic Acid injections are well tolerated, but the effects of their application need further research. There were no serious adverse events.

CONCLUSIONS

Corticosteroids, sclerosant injections, hyaluronic acid and capsaicin have been shown to be effective in reducing the pain related to MN.

Differential Diagnosis of Metatarsalgia

Lesser (or central) metatarsalgia is defined as pain in the forefoot under or around the lesser metatarsals and their respective metatarsophalangeal joints. Two common causes of central metatarsalgia are Morton's neuroma (MN) and plantar plate (PP) injury. Because both clinical and imaging features overlap, establishing the correct differential diagnosis may be challenging. Imaging has a pivotal role in the detection and characterization of metatarsalgia. Different radiologic modalities are available to assess the common causes of forefoot pain, so the strengths and weakness of these imaging tools should be kept in mind. It is crucial to be aware of the pitfalls that can be encountered in daily clinical practice when dealing with these disorders. This review describes two main causes of lesser metatarsalgia, MN and PP injury, and their differential diagnoses.

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.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

Efficacy of a Single Corticosteroid Injection for Morton's Neuroma in Adults: A Systematic Review

BACKGROUND

Morton's neuroma is a common condition that routinely presents in podiatric practice. The aim of this study was to systematically synthesize the evidence relating to the effectiveness of a corticosteroid injection for Morton's neuroma.

METHODS

Studies with a publication date of 1960 or later were eligible, and searches were performed within the Turning Research Into Practice database; the Cochrane Central Register of Controlled Trials; the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register; MEDLINE (Ovid); PubMed; Embase; Cumulative Index to Nursing and Allied Health Literature; and the gray literature. Study selection criteria included randomized and nonrandomized controlled trials where a single corticosteroid injection for Morton's neuroma pain was investigated. The primary outcome was Morton's neuroma pain as measured by any standard validated pain scale.

RESULTS

Ten studies involving 695 participants were included. The quality of the studies was considered low and subject to bias. Of the included studies, five compared corticosteroid injection to usual care, one compared corticosteroid injection to local anesthetic alone, one compared ultrasound-guided to non-ultrasound-guided injections, three compared corticosteroid injections to surgery, one compared small to large neuromas, six assessed patient satisfaction, four measured adverse events, one studied return to work, and one examined failure of the corticosteroid injection to improve pain. Overall, these studies identified a moderate short- to medium-term benefit of corticosteroid injections on the primary outcome of pain and a low adverse event rate.

CONCLUSIONS

A single corticosteroid injection appears to have a beneficial short- to medium-term effect on Morton's neuroma pain. It appears superior to usual care, but its superiority to local anaesthetic alone is questionable, and it is inferior to surgical excision. A very low adverse event rate was noted throughout the studies, indicating the intervention is safe when used for Morton's neuroma. However, the quality of the evidence is low, and these findings may change with further research.

Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review

Backgroud

This review aimed to evaluate the effects of corticosteroid injections on Morton's neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework.

Methods

Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton's neuroma. Data search, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). guidelines, and clinical outcomes were evaluated using various outcome measures.

Results

With 3–12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfaction scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain.

Conclusions

Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton's interdigital neuroma although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.

Medium-Term Results of Corticosteroid Injections for Morton's Neuroma

BACKGROUND

The objective of this study was to evaluate the medium-term results of corticosteroid injections for Morton's neuroma.

METHODS

This was a prospective follow-up study of a previous randomized controlled trial (RCT). Forty-five neuromas in 36 patients were injected with a single corticosteroid injection either with or without ultrasound guidance. As the results of the RCT showed no difference in outcomes between techniques, the data were pooled for the purpose of this study. Questionnaires were sent out and responses were collected via mail or telephone interview. Results were available in 42 out of 45 neuromas. There was a sex split of 68% female/32% male with a mean age of 62.6 years (SD, 12 years).

RESULTS

At mean follow-up of 4.8 years (SD, 0.91 years), the original corticosteroid injection remained effective in 36% (n = 16) of the patients. In these cases, the visual analog scale (VAS) pain score (P < .001) and Manchester-Oxford Foot Questionnaire Index (MOxFQ Index) (P = .001) remained significantly better than preintervention scores. The remaining cases underwent either a further injection or surgery. Fifty-five percent of the 11 neuromas that received a second injection continued to be asymptomatic in the medium term. Overall, 44% (n = 20) of the initial cohort underwent surgical excision by the medium-term follow-up. The VAS score, MOxFQ Index, and satisfaction scale score across all groups were not significantly different.

CONCLUSION

Corticosteroid injections for Morton's neuroma remained effective in over a third of cases for up to almost 5 years. A positive outcome at 1 year following a corticosteroid injection was reasonably predictive of a prolonged effect from the injection.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Treating Morton's neuroma by injection, neurolysis, or neurectomy: a systematic review and meta-analysis of pain and satisfaction outcomes

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.

Non-surgical treatments for Morton's neuroma: A systematic review

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.

Five Centimeters Morton's Neuroma in a 46-Year-Old Woman Affected by Macrodactily

The present article described the case of a voluminous Morton's neuroma of the third intermetatarsal space in a patient affected by macrodactily. The case was unique because of its dimensions, the uncommon surgical approach which was needed for removal, the association with macrodactily of the fourth toe with Raynaud's phenomenon, and the postoperative defect in the intrinsic muscles. The patient was operated in February 2016 by transverse plantar approach. Twelve months after surgery, the patient complained for hypoesthesia on third and fourth toes with inability to actively spread the toes and enlargement in the second interdigital space. The dimensions of the lesions may be explained with the presence of macrodactily in the fourth toe with occasional Raynaud's phenomenon, which may have caused an abnormal arrangement of the nerve branches for the fourth interspace with related microtrauma. A plantar approach was highly recommended as the size of the lesion forced it to the plantar surface of the foot. The inability to actively spread the toes and the enlargement of the second interdigital space are likely to be related to a deficiency of the interosseous muscles, innervated by the deep branch of the lateral plantar nerve, which had probably been sacrificed because of the size of the lesion and the subversion of the surrounding anatomical relationships.

Morton's neuroma - Current concepts review

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.

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.

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.

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.

Role of imaging methods in diagnosis and treatment of Morton's neuroma

Among the many causes of forefoot pain, Morton's neuroma (MN) is often suspected, particularly in women, due to its high incidence. However, there remain controversies about its relationship with symptomatology and which diagnostic and treatment choices to choose. This article mainly focuses on the role of the various imaging methods and their abilities to support an accurate diagnosis of MN, ruling out other causes of forefoot pain, and as a way of providing targeted imaging-guided therapy for patients with MN.

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.

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.

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.

Three Cycles of Radiofrequency Ablation Are More Efficacious Than Two in the Management of Morton's Neuroma

BACKGROUND

Morton's neuroma is a common cause of forefoot pain. Outcomes of conservative therapy are mixed and many patients undergo operative intervention. Radiofrequency ablation has recently gained favor as a treatment option, although the optimal regime is unknown. This study investigates the effectiveness of 2 versus 3 cycles of radiofrequency ablation for the treatment of Morton's neuroma.

METHODS

We surveyed a cohort of patients with Morton's neuroma who had progressed to radiofrequency ablation after failed conservative treatment. Patients received either 2 or 3 cycles of radiofrequency ablation by a single surgeon. We assessed patients based on their change in numerical pain rating scale, symptom improvement, complications, and progression to surgical excision through a series of telephone interviews. Outcomes between the 2 treatment arms were compared by parametric tests.

RESULTS

Twenty-eight patients were included in the study. Eighteen patients with 21 neuromas received 2 cycles and 10 patients with 11 neuromas received 3 cycles. Mean time of follow-up was 12.9 months. Overall, 88% of patients were either very or moderately satisfied with their outcome. In patients who received 2 cycles mean numerical pain scores decreased from 7.9 ± 1.1 to 3.4 ± 2.4 postprocedure. Three patients progressed to operative excision. In patients who received 3 cycles, numerical pain scores decreased from 8.0 ± 1.0 to 1.5 ± 2.0 postprocedure. One patient progressed to operative excision. Patients who received 3 cycles had reduced medium-term pain postoperatively compared with 2 cycles (3.4 ± 2.4 vs 1.5 ± 2.0, P = .011).

CONCLUSION

Radiofrequency ablation provides a high rate of patient satisfaction in the treatment of Morton's neuroma with few side effects. It appears that 3 cycles may be superior to 2 cycles but a randomized controlled trial will be required to confirm these results.

LEVELS OF EVIDENCE

Intervention, Level III: Comparative study without concurrent controls.

Risk factors and the associated cutoff values for failure of corticosteroid injection in treatment of Morton's neuroma

BACKGROUND

Understanding the risk factors that predict the prognosis of Morton's neuroma after corticosteroid injection would help clinicians determine the appropriate treatment protocol. However, the cut-off values for the risk factors are unknown. The aim of this study was to identify the risk factors and cut-off values that predict failure of corticosteroid injection in treatment of Morton's neuroma.

METHOD

Among 201 patients who had corticosteroid injection for Morton's neuroma, 40 underwent further treatment after injections. Injection was performed with ultrasound guidance following ultrasound confirmation of the diagnosis. We compared demographic information, size of the neuroma, and other comorbidities between the patients who did and did not undergo further treatment after injection in order to determine the risk factors of failure. Receiver operating characteristic (ROC) curves were constructed to determine optimal cutoff values for each risk factor.

RESULTS

Stepwise logistic regression analysis showed that larger neuromas (p < 0.001) and younger patients (p = 0.026) predicted the failure of corticosteroid injection. The optimal cutoff value for the size of the neuroma was 6.3 mm (sensitivity, 81%; specificity, 95%; positive predictive value, 84%; negative predictive value, 88%) for predicting the failure of corticosteroid injection. Age was not associated with a specific cutoff value.

CONCLUSIONS

This study found that, with a cut-off value of 6.3 mm, larger Morton's neuromas were associated with failure of corticosteroid injection.

Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial

AIMS

The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton's neuroma (MN).

PATIENTS AND METHODS

In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (sd) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis.

RESULTS

The mean visual analogue score for pain improved significantly in both groups (Group A - from 64 mm, sd 25 mm to 29 mm, sd 27; Group B - from 69 mm, sd 23 mm to 37 mm, sd 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months.

CONCLUSION

This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN.

TAKE HOME MESSAGE

In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results.

Percutaneous Image-Guided Musculoskeletal Tumor Treatments

OBJECTIVE

The purpose of this article is to review the current guidelines and recommendations for percutaneous image-guided treatment of musculoskeletal tumors.

CONCLUSION

With the ongoing technologic advances, it is essential that the musculoskeletal interventionalist is familiar with the current tools and techniques available for the treatment of soft-tissue and bone tumors. Fortunately, many of these tools are readily available in a standard interventional radiology department and can be easily applied to the musculoskeletal system.

Extracorporeal Shockwave Therapy in Patients with Morton's Neuroma A Randomized, Placebo-Controlled Trial

BACKGROUND

The aim of this study was to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) for the treatment of Morton's neuroma by measuring changes in patient pain, function, and neuroma size.

METHODS

Patients with Morton's neuroma were randomly assigned to either the ESWT group or the sham stimulation group. Outcome measures, including visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society lesser toes (AOFAS) scores, were assessed at baseline and 1 and 4 weeks after treatment. The Johnson satisfaction test was also performed 1 and 4 weeks after treatment. The neuroma diameter was measured using ultrasonography at baseline and 4 weeks after treatment.

RESULTS

Patients receiving ESWT exhibited significantly decreased VAS scores 1 and 4 weeks after treatment relative to baseline, and AOFAS scores were significantly improved 4 weeks after treatment relative to baseline. In the sham stimulation group, VAS and AOFAS scores showed no significant changes at any time after treatment. Neither group showed significant changes in Johnson satisfaction test results or neuroma diameter.

CONCLUSIONS

These results suggest that ESWT may reduce pain in patients with Morton's neuroma.

What factors predict the need for further intervention following corticosteroid injection of Morton's neuroma?

BACKGROUND

This study investigated factors that may predict the need for Morton's neuroma (MN) to undergo further treatment within 2 years of a single ultrasound-guided corticosteroid injection.

METHODS

A retrospective study was undertaken over a three-year period. The data was stratified into two groups: Group A - did not receive further intervention and Group B - received further treatment. We investigated age, gender, neuroma size and presence of other forefoot pathology or ipsilateral neuromas.

RESULTS

54 patients (57 feet) were reviewed. 29 feet (51%) required further treatment within 2 years (11 repeat injections, 18 surgical excisions). Binary logistic regression showed that larger neuromas (p=0.011) and younger patients (p=0.007) predicted the need for further intervention but not gender (p=0.272). The distribution of concomitant forefoot pathology and ipsilateral neuromas were similar between the two groups.

CONCLUSION

Size and age appear to be predictors for further treatment of MN within 2 years of corticosteroid injection.

Excision of Morton's Neuroma Using a Longitudinal Plantar Approach: A Midterm Follow-up Study

BACKGROUND

Operative procedures are indicated in the treatment of Morton's neuroma (MN) when conservative therapies have been unsuccessful. A dorsal approach for neurolysis or neurectomy was strongly recommended. The aim of this case series study was to prospectively analyze the midterm clinical outcome and complications following the excision of a MN using a plantar longitudinal approach.

METHODS

Between September 2000 and January 2009, we included 44 patients (51 feet, 56 neuromas) in a prospective study treated by excision of a primary MN using a plantar longitudinal approach. The MN diagnosis was based on clinical symptoms, magnetic resonance imaging findings, and pain relief after infiltration of local anesthetics. Histological examinations were performed in all resected specimens. The patients returned for final follow-up at a mean of 54 (range = 12 to 99) months, comparing preoperative and postoperative perception of pain on a Visual Analogue Scale (VAS) and assessing clinical findings.

RESULTS

The average amount of pain, according to VAS, was 8 (range = 6-9) points preoperatively and 0.4 (range = 0-5) points at final follow-up. Complications occurred in 7.1% of interventions and scar problems in 5.2%, including delayed wound healing, hypertrophic scar formation, and inclusion cyst.

CONCLUSION

The present study shows a strong relief of pain after MN resection using a plantar longitudinal incision, coupled with a low rate of local complications. This surgical procedure seems to be a reliable choice for the excision of MN, even in cases with MN in adjacent webspaces, because it is technically simple and the plantar scar is not bothersome if properly located.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Prospective, Case series.

Ultrasound-guided intervention in the ankle and foot

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

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.