Corticosteroid Injection for the Treatment of Morton’s Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

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.

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

Foot & Ankle International ◽

10.1177/1071100720966332 ◽

2020 ◽

pp. 107110072096633

Author(s):

Melinda Yun Ting Hau ◽

Lauren Thomson ◽

Randeep Aujla ◽

Devendra Madhadevan ◽

Maneesh Bhatia

Keyword(s):

Corticosteroid Injection ◽

Controlled Trial ◽

Surgical Excision ◽

Medium Term ◽

Morton’S Neuroma ◽

Level Of Evidence ◽

Satisfaction Scale ◽

Morton's Neuroma ◽

Corticosteroid Injections

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.

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Ultrasound-Guided Hyaluronic Acid Injection for the Management of Morton’s Neuroma

Foot & Ankle International ◽

10.1177/1071100717739578 ◽

2017 ◽

Vol 39 (2) ◽

pp. 201-204 ◽

Cited By ~ 3

Author(s):

Kang Lee ◽

Il-Yeong Hwang ◽

Chang Hyun Ryu ◽

Jae Woo Lee ◽

Seung Woo Kang

Keyword(s):

Hyaluronic Acid ◽

Case Series ◽

Functional Improvement ◽

X Rays ◽

Ultrasound Guided ◽

Morton’S Neuroma ◽

Level Of Evidence ◽

Hyaluronic Acid Injection ◽

Acid Injection ◽

Morton's Neuroma

Background: Morton’s neuroma is one of the common causes of forefoot pain. In the present study, hyaluronic acid injection was performed on patients to determine the efficacy and adverse effects of hyaluronic acid in management of Morton’s neuroma. Methods: Eighty-three patients with Morton’s neuroma in their third intermetatarsal space with definite Mulder’s click were included in the study. Those with severe forefoot deformities such as forefoot cavus or hallux valgus on plain X-rays were excluded. Ultrasound-guided hyaluronic acid injections were performed on all patients weekly for 3 weeks. Pain during walking using visual analogue scale (VAS) and AOFAS Forefoot Scale were prospectively evaluated preinjection, and at 2, 4, 6, 12 months postinjection. Results: Significant improvement in VAS and AOFAS Forefoot Scale were seen overall at 2 months after hyaluronic acid injections ( P < .05). Then, there were almost no changes after 4 months, continuing until 12 months. The mean VAS was decreased from 73.1 initially to 23.0 at 12 months and AOFAS Forefoot Scale was increased from 32.2 to 86.5. There were no complications which occurred. Conclusion: In the present study, ultrasound-guided hyaluronic injection was clinically effective for pain relief and functional improvement for at least 12 months in patients with Morton’s neuroma. However, numbness associated with Morton’s neuroma should be addressed more cautiously since it may persist without much improvement. Level of Evidence: Level IV, retrospective case series.

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Radiographic Analysis of Feet With and Without Morton’s Neuroma

Foot & Ankle International ◽

10.1177/1071100716674998 ◽

2016 ◽

Vol 38 (3) ◽

pp. 310-317 ◽

Cited By ~ 3

Author(s):

Reza Naraghi ◽

Alexandra Bremner ◽

Linda Slack-Smith ◽

Alan Bryant

Keyword(s):

Control Group ◽

Morton’S Neuroma ◽

Level Of Evidence ◽

Intermetatarsal Angle ◽

Control Subjects ◽

Radiographic Measurements ◽

Valgus Angle ◽

Angular Measurements ◽

Morton's Neuroma ◽

And Control

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.

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Ultrasound Guided Alcohol Ablation of Morton's Neuroma

Foot & Ankle International ◽

10.3113/fai.2012.0196 ◽

2012 ◽

Vol 33 (3) ◽

pp. 196-201 ◽

Cited By ~ 27

Author(s):

Rachel E. Musson ◽

Jasdev S. Sawhney ◽

Leslie Lamb ◽

Antony Wilkinson ◽

Haron Obaid

Keyword(s):

Case Series ◽

Visual Analogue Score ◽

Safe Procedure ◽

Ultrasound Guided ◽

Morton’S Neuroma ◽

Retrospective Case ◽

Level Of Evidence ◽

Alcohol Injection ◽

Alcohol Ablation ◽

Morton's Neuroma

Background: Morton's neuroma is a common cause of metatarsalgia. This study evaluated the efficacy of ultrasound guided alcohol injection as a treatment for this condition. Method: Data from 87 treatment courses were included in this study with a mean follow of 14.3 months. Results: Technical success was 100%. One patient developed symptoms consistent with an allergic reaction to the injection and one patient declined further injection because of periprocedural pain. Partial or total treatment response was achieved in 66%, with 32% of patients having complete resolution of pain. The median visual analogue score (VAS) decreased from 8 pre-procedure to 4 post-procedure ( p < 0.0001). Procedural success was greater in patients under 55 years old and in those with solitary neuromas. Seventeen patients (20%) went on to have surgery due to continuing pain. Conclusion: Ultrasound guided alcohol ablation for the treatment of Morton's neuroma was a safe procedure that significantly reduced pain and may offer an alternative therapy to surgery. Level of Evidence: IV; Retrospective Case Series

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Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma

Foot & Ankle International ◽

10.1177/1071100719851121 ◽

2019 ◽

Vol 40 (9) ◽

pp. 1032-1036 ◽

Cited By ~ 2

Author(s):

Tammer Raouf ◽

Ryan Rogero ◽

Elizabeth McDonald ◽

Daniel Fuchs ◽

Rachel J. Shakked ◽

...

Keyword(s):

Case Series ◽

Postoperative Treatment ◽

Preoperative Imaging ◽

Pathology Report ◽

Morton’S Neuroma ◽

Retrospective Case ◽

Level Of Evidence ◽

Imaging Results ◽

Histopathologic Diagnosis ◽

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.

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Interdigital Commissural Approach for Morton’s Neuroma

Foot & Ankle International ◽

10.1177/1071100720936599 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1226-1233

Author(s):

Juan Manuel Yañez Arauz

Keyword(s):

Minimally Invasive ◽

Case Series ◽

Complication Rates ◽

Morton’S Neuroma ◽

Retrospective Case ◽

Level Of Evidence ◽

Long Term Outcome ◽

Significant Difference ◽

Morton's Neuroma

Background: Morton’s neuroma is a frequent cause of metatarsalgia. Operative treatment is indicated if nonoperative management has failed. The objective of the present study was to describe a technique of Morton’s neuroma excision by a minimally invasive commissural approach and evaluate the long-term outcome and complications. Methods: A retrospective study of 108 patients with Morton’s neuroma treated surgically with a commissural approach between September 1990 and December 2010 was performed. The surgical technique is described. Clinical outcomes and complications were evaluated. The average follow-up was 121 months. Eleven patients were men and 97 women. The average age was 49.4 years; 56.8% neuromas were at the third space and 43.2% at the second space. Six patients presented 2 neuromas in the same foot, and 9 patients had bilateral neuroma. Results: The visual analog scale (VAS) average pain score was 5.4 points preoperatively and 0.2 points at the final follow-up. The author found a significant difference between the VAS scores preoperatively and postoperatively ( P < .01). Excellent and good satisfaction outcomes were achieved in 93.6%. The postoperative complication incidence was 3%. Conclusion: The author believes a minimally invasive commissural approach has advantages over a dorsal or plantar incision. It is a simple and reproducible technique, with satisfactory outcomes, low complication rates, and a quick return to usual activities. Level of Evidence: Level IV, retrospective case series.

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

Foot & Ankle Specialist ◽

10.1177/1938640020957851 ◽

2020 ◽

pp. 193864002095785

Author(s):

Mohamed Abdelaziz Elghazy ◽

Kathryn C. Whitelaw ◽

Gregory R. Waryasz ◽

Daniel Guss ◽

Anne H. Johnson ◽

...

Keyword(s):

Case Series ◽

Operative Management ◽

Pain Scale ◽

Morton’S Neuroma ◽

Short Term ◽

Level Of Evidence ◽

Symptom Exacerbation ◽

Morton's Neuroma ◽

Neuroma Formation

Background Although the precise pathoetiology of Morton’s neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. Materials and methods Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton’s neuroma and who then underwent isolated IML decompression without neuroma resection. Results A total of 12 patients underwent isolated IML decompression for Morton’s neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. Conclusion Isolated IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. Level of Evidence: Level IV: Case series

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Effectiveness of Ultrasound-Guided Corticosteroid Injection in the Treatment of Morton's Neuroma

Foot & Ankle International ◽

10.3113/fai.2008.0483 ◽

2008 ◽

Vol 29 (5) ◽

pp. 483-487 ◽

Cited By ~ 54

Author(s):

Maja Markovic ◽

Ken Crichton ◽

John W. Read ◽

Peter Lam ◽

Henry Kim Slater

Keyword(s):

Corticosteroid Injection ◽

Ultrasound Guided ◽

Morton’S Neuroma ◽

Morton's Neuroma

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Combined Hip Abductor and External Rotator Strengthening and Hip Internal Rotator Stretching Improves Pain and Function in Patients With Patellofemoral Pain Syndrome: A Randomized Controlled Trial With Crossover Design

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121989729 ◽

2021 ◽

Vol 9 (4) ◽

pp. 232596712198972

Author(s):

Anis Jellad ◽

Amine Kalai ◽

Mohamed Guedria ◽

Mahbouba Jguirim ◽

Sana Elmhamdi ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Pain Syndrome ◽

Patellofemoral Pain Syndrome ◽

Patellofemoral Pain ◽

Level Of Evidence ◽

Randomized Controlled ◽

Group Standard ◽

Hip Muscle ◽

And Function

Background: Active rehabilitation has an important role in the management of patellofemoral pain syndrome (PFPS). Although some studies have shown the benefit of hip-muscle strengthening, the effect of combining hip-muscle stretching with strengthening has not yet been defined. Purpose: To evaluate the effect of combined strengthening of the hip external rotators and abductors and stretching of the hip internal rotators on pain and function in patients with PFPS. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 109 patients with PFPS (75 female and 34 male; mean age, 31.6 ± 10.8 years) were first randomly assigned to protocol A (n = 67) of the A-B arm (AB group; standard rehabilitation) or protocol B (n = 42) of the B-A arm (BA group; standard rehabilitation with strengthening of the hip external rotators and abductors and stretching of the hip internal rotators). Each protocol consisted of 3 sessions a week for 4 weeks. After a washout period, corresponding to a symptom-free period, rehabilitation programs were crossed over. A visual analog scale (VAS) evaluating perceived pain, the Functional Index Questionnaire (FIQ), and the Kujala score were administered at baseline, the end of each rehabilitation protocol, and 12 weeks after the completion of the second protocol for each group. Results: Until the final follow-up, VAS, FIQ, and Kujala scores were significantly improved in both the A-B and B-A arms ( P < .05 for all). Compared with protocol A, protocol B provided significant improvement in terms of pain and function in both the BA (VAS and Kujala; P < .001) and AB (VAS and Kujala; P < .001) groups. Conclusion: Combined strengthening of the hip abductors and external rotators with stretching of the hip internal rotators provided better outcomes, which were maintained for at least 12 weeks, in terms of pain and function in patients with PFPS.

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