Physiotherapy for Morton's Neuroma: Difference between revisions
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== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
MRI | Magnetic resonance imaging (MRI) shows the medial and lateral plantar nerves arising from the posterior tibial nerve. <ref name=":7" /> The [[Tibial Nerve|tibial nerve]] terminates in the foot by giving branches to [[Medial Plantar Nerve|medial]] and [[Lateral Plantar Nerve|lateral plantar]] nerves. This bifurcation occurs inside the retinaculum or proximal to the flexor retinaculum. <ref name=":8">Torres AL, Ferreira MC. [https://www.scielo.br/j/aob/a/3PgtjmSVwWMDmCYZgbPhghq/?format=pdf&lang=en Study of the anatomy of the tibial nerve and its branches in the distal medial leg]. Acta ortopedica brasileira. 2012;20:157-64.</ref> The two plantar nerves penetrate the tunnel made of the deep fascia of the [[Abductor Hallucis|abductor hallucis muscle]] and the fibrous septum connecting the fascia to the bone. <ref name=":8" /> | ||
The | The [[Medial Plantar Nerve|medial plantar nerve]] (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament, passes between [[Abductor Hallucis|abductor hallucis]] muscle and [[Flexor Digitorum Brevis|flexor digitorum brevis]]. Upon reaching the bases of the metatarsal, it divides into three common digital plantar nerves.<ref name=":9" />MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the first lumbrical. | ||
The | The [[Lateral Plantar Nerve|lateral plantar nerve]] (LPN) innervates abductor digiti minimi muscle, flexor digiti minimi brevis muscle, quadratus plantae, 3 lateral lumbricals of the foot, adductor hallucis muscle, plantar interossei muscles, and dorsal interossei muscles. | ||
The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments, go through the plantar [[aponeurosis]] and divide into 2 branches supplying the plantar skin of the toes. Smaller portions of the CPD nerves innervate the adjacent [[metatarsals]], metatarsophalangeal joints and plantar skin, under the metatarsal heads. <ref name=":5" />The ''third common digital'' nerve begins as the medial plantar nerve and receives a communicating branch from the lateral plantar nerve. Because it passes in the narrow space deep to the transverse metatarsal ligament it becomes less mobile, especially during weight bearing activities. The location of this nerve may be a possible explanation for the development of the Morton's Neuroma pathology.<ref name=":5" /> | |||
MRI depicted the MP and LP nerves arising from the posterior tibial (PT) nerve<ref name=":7">Govsa F, Bilge O, Ozer MA. Anatomical study of the communicating branches between the medial and lateral plantar nerves. Surgical and Radiologic Anatomy. 2005 Dec;27(5):377-81.</ref> | |||
All the remaining intrinsic muscles including the adductor hallucis are supplied by the lateral plantar nerve. Therefore, knowledge of the anatomy and variations of the plantar nerve will help in the future planning of treatments to correct the congenital or post-injury partial loss of the foot functions [<nowiki/>[[/synapse.koreamed.org/articles/1119788#B5|5]]]. In this article, we report a superficial course of MPN and described its unique morphology and discuss the clinical significance of this variation.<ref name=":9">Koo GB, Lee JH, Jang JH, Song IH, Kim JY. Superficial course of the medial plantar nerve: case report. Anatomy & cell biology. 2019 Mar 1;52(1):87-9.</ref> | |||
The common digital nerve and its branches in the third planter webspace are most commonly affected | The common digital nerve and its branches in the third planter webspace are most commonly affected | ||
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Neuroma consists of a bulge in the interdigital nerve just distal to the metatarsal transverse ligament and proximal to the forking of the digital nerves ([[/www.ncbi.nlm.nih.gov/pmc/articles/PMC7944831/figure/F1/|Figure 1]]). Entrapment of the interdigital nerve between the intermetatarsal ligaments is the principal reason in the occurrence of CMS | Neuroma consists of a bulge in the interdigital nerve just distal to the metatarsal transverse ligament and proximal to the forking of the digital nerves ([[/www.ncbi.nlm.nih.gov/pmc/articles/PMC7944831/figure/F1/|Figure 1]]). Entrapment of the interdigital nerve between the intermetatarsal ligaments is the principal reason in the occurrence of CMS | ||
== Aetiology == | == Aetiology == | ||
Revision as of 20:22, 13 October 2022
Introduction[edit | edit source]
Civinini Morton’s Syndrome (CMS) is more commonly known as Morton’s Neuroma. Interdigital neuritis is another term that was proposed by Weinfield and Myerson[1] which more correctly describes the pathology of this condition. The presence of inflammatory tissue in histological examination justifies description of Morton's neuroma as perineurial fibrosis. Pain and abnormal forefoot sensation are clinical symptoms that helps with the diagnosis. Conservative treatment including lifestyle adjustment may not always be effective and patient can choose surgery or various types of ultrasound guided percutaneous injections as an option.
Clinically Relevant Anatomy[edit | edit source]
Magnetic resonance imaging (MRI) shows the medial and lateral plantar nerves arising from the posterior tibial nerve. [2] The tibial nerve terminates in the foot by giving branches to medial and lateral plantar nerves. This bifurcation occurs inside the retinaculum or proximal to the flexor retinaculum. [3] The two plantar nerves penetrate the tunnel made of the deep fascia of the abductor hallucis muscle and the fibrous septum connecting the fascia to the bone. [3]
The medial plantar nerve (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament, passes between abductor hallucis muscle and flexor digitorum brevis. Upon reaching the bases of the metatarsal, it divides into three common digital plantar nerves.[4]MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the first lumbrical.
The lateral plantar nerve (LPN) innervates abductor digiti minimi muscle, flexor digiti minimi brevis muscle, quadratus plantae, 3 lateral lumbricals of the foot, adductor hallucis muscle, plantar interossei muscles, and dorsal interossei muscles.
The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments, go through the plantar aponeurosis and divide into 2 branches supplying the plantar skin of the toes. Smaller portions of the CPD nerves innervate the adjacent metatarsals, metatarsophalangeal joints and plantar skin, under the metatarsal heads. [5]The third common digital nerve begins as the medial plantar nerve and receives a communicating branch from the lateral plantar nerve. Because it passes in the narrow space deep to the transverse metatarsal ligament it becomes less mobile, especially during weight bearing activities. The location of this nerve may be a possible explanation for the development of the Morton's Neuroma pathology.[5]
MRI depicted the MP and LP nerves arising from the posterior tibial (PT) nerve[2]
All the remaining intrinsic muscles including the adductor hallucis are supplied by the lateral plantar nerve. Therefore, knowledge of the anatomy and variations of the plantar nerve will help in the future planning of treatments to correct the congenital or post-injury partial loss of the foot functions [5]. In this article, we report a superficial course of MPN and described its unique morphology and discuss the clinical significance of this variation.[4]
The common digital nerve and its branches in the third planter webspace are most commonly affected
benign perineural fibrosis of a common plantar digital nerve, typically within the third intermetatarsal space.
compressive neuropathy of the common plantar digital nerve
Neuroma consists of a bulge in the interdigital nerve just distal to the metatarsal transverse ligament and proximal to the forking of the digital nerves (Figure 1). Entrapment of the interdigital nerve between the intermetatarsal ligaments is the principal reason in the occurrence of CMS
Aetiology[edit | edit source]
ischemia and mechanical compression of the plantar nerve against the transverse intermetatarsal ligament[6]
chronic repetitive trauma, ischemia, entrapment, and intermetatarsal bursitis
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.[5]
It affects about 30% of the population and
prefers the female sex, with a female to male ratio of 5:1 (2) and an average age of 50 years at time of sur- gery (3).
The pathology is bilateral in 21% of cases, affects the third intermetatarsal space (IMS) in 66% of cases, the second in 32%, known as Hauser’s Neuroma, and the fourth in 2%. Multiple locations are almost rare[5]
four etiopathogenetic theories have been propounded [7]: chronic traction damage (repetitive trauma, ischemia, entrapment, and intermetatarsal bursitis.[8], inflammatory environment due to intermetatarsal bursitis (19), compression by the deep transverse intermetatarsal ligament (20) and ischemia of vasa nervorum (21).[5][7]
It was proposed that the common digital nerve of the third IMS is thicker than the others, as it is the result of an anastomosis between two nerve trunks (23). Another possible anatomical consideration is the increased mobility of the fourth ray (moving on the cuboid), compared to the third (fixed to the cuneiform), which could predispose to inflammation. In addition, some authors affirm that the distal metatarsal transverse ligament may compress the interdigital nerve
Mechanism of Injury / Pathological Process[edit | edit source]
A thicker third intermetatarsal nerve formed by the fusion of the medial and lateral plantar nerves is more easily entrapped by the overlying intermetatarsal ligament. However, later studies revealed that other intermetatarsal spaces can also be affected[6]
Morton's neuroma most likely represents an entrapment neuropathy causing perineural fibrosis, nerve degeneration, leukocyte infiltration, and epineural and endoneural vascular hyalinization that results in a significantly thicker intermetatarsal nerve [6]
Such thickening can create further trauma that results in more thickening and subsequently more entrapment. Excessive weight bearing on the forefoot related to the use of high-heeled shoes has also been implicated and may explain the higher prevalence of Morton's neuroma in middle-aged women[6]
most common in the third intermetatarsal space followed by the second[9]
Clinical Presentation[edit | edit source]
clinically symptomatic
Clinically asymptomatic
pain or paresthesias in the intermetatarsal region worsened by weight-bearing or the use of high-heeled shoes, often relieved by removing shoes and gentle massage of the forefoot. On physical examination, a positive web space compression test or a painful palpable click (Mulder's sign) was considered suggestive of Morton's neuroma.
Patients classically experience sharp pain, a burning sensation, and paresthesias during weight bearing in the region of the intermetatarsal spaces. The pain is relieved by rest and shoe removal. On physical examination, a mass can be palpated in one third of patients. This finding is often accompanied by a characteristic click or Mulder's sign[6]
The classical description of a Morton’s neuroma is paraesthesia within the affected digital nerve, accompanied by forefoot pain and is more commonly seen in females. 17% of patients describe some trauma to the foot resulting in symptoms.5 The most common characteristic of the pain is burning in nature. Altered sensations and feeling a “pebble in the shoe” is reported by more than 50% of patients. The pain is often exacerbated by walking, use of tight or heeled shoes and is reported by runners[10]
no visual cues to the presence of a neuroma. Any deformity of the foot specially hallux valgus can lead to overcrowding of the toes and increased pressure on the lesser toes, and is therefore an important predisposing factor. [10]
describe abnormal forefoot sensations such as a burning or ache [11]. Pain localisation is most common in the plantar aspect of the forefoot, followed by the toe(s) and then the dorsal web space. Diagnosis can reliably be made based on clinical presentation and testing with ultrasound proposed as an accurate and cost-effective imaging method to confirm the diagnosis, especially in cases where the clinical diagnosis is equivocal [12]. Ultrasound without a clinical diagnosis may lead to a false diagnosis of MN for asymptomatic interdigital nerve enlargements[13]
he typical symptom is a burning pain between the metatarsal heads, often radiating to the two corresponding toes, with cramps and hyperesthesia/dysesthesia (26). The pain is intense and so debilitating that the patients become afraid and anxious about walking or even putting their foot to the ground. The disorder is that of a severe, sharp, sometimes piercing pain that occurs abruptly while walking. At onset, relief of pain can be obtained by massaging the foot or manipulating the toes. In the worst cases, pain becomes debilitating and patients are timorous about walking. In other cases, patients describe milder symptoms of burning or tingling sensations[5]
Diagnostic Procedures[edit | edit source]
Ultrasound has high diagnostic accuracy for Morton's neuromas, and is frequently used to guide corticosteroid with local anaesthetic injection following the diagnostic scan. However, ultrasound is a highly operator-dependent imaging method, thus technique and experience are extremely important.[9]
if there is any doubt of the diagnosis, an MRI scan is the gold standard investigation to identify a neuroma,[10]
A positive digital nerve stretch test 1 and a positive Mulder’s click test
X-rays appears to be essential as a first line imaging approach, to investigate other possible causes of metatarsalgia such as (36): tarsal–metatarsal joint stiffness, metatarsal hypermetria, Frieberg’s disease, toe deformities and MTP instabilities. However, in order to eliminate possible doubts, sonographic (US) confirmation is usually the instrumental investigation mostly utilized (14), certainly reliable and easy to prescribe, as it is fast and inexpensive for the patient. The imaging must be carried out with plantar and back, transversal and longitudinal US scans with a 7.5 MHz high frequency probe. The neuroma appears as homogeneously hypoechoic mass, well recognizable by the adjacent hyperechoic fat and by the shadow of the metatarsal cortex. Shapiro (37) and Quinn (38) state a diagnostic reliability around 95% for lesions larger than 5 mm, being 2 mm the maximum limit of the normal nerve.[5]
MRI is superior in the differential diagnosis, for its sensitivity on pathologies such as stress fractures, capsulo-synovitis of the MTP, synovial articular forms, or other pathologies of the soft tissues such as lipomas, angiomas, tendon ganglia or connective malignancies of the forefoot (43). Main indications for MRI are unclear clinical assessment and cases when more than one IMS is affected (1). Finally, it must be bear in mind that a negative result does not exclude the diagnosis (false negative 17%) [5]
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Management / Interventions[edit | edit source]
Footwear[edit | edit source]
staged care approach from wider, low heeled footwear and metatarsal padding[13]Properly fitted footwear with a wide toe box, low heel and a metatarsal pad
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.[5]
Thus, the first approach in CMS should consist in patients’ education to avoid narrow and high-heeled shoes (4). The objective of shoes modifications is to deliver the pressures uniformly over the sole of foot. Shoes should be sufficiently long, comfortable, broad toe-boxed, flat heeled and should bear a sufficiently thick external sole, not excessively flexible (Figure 2) (2). A rocker-bottom sole may be helpful[14]. Some authors showed that footwear and padding may be successful in relieving symptoms in 32% of cases after a mean of 4.5 months (17, 49) but they seem to achieve lower satisfaction rates when compared with other more invasive methods such as steroid injections [15].
A threshold period of 4.5 months appears to emerge from the results of the studies, indicating that beyond this period and in larger neuromas than 5-6 mm, orthotics and/or shoes modification do not seem to give convincing results, proving to be more a clinical condition for living acceptably with pain than a real treatment.[5]
Orthotics[edit | edit source]
The commonest form of treatment (initially) is the Metatarsal Bar. This insole, made by orthotists spreads the heads of the metatarsals to relieve pressure on the neuroma and thus improve symptoms. However, this does require the patient to wear broad toe box shoes and use the inserts so a degree of compliance is required. There is no evidence to support the use of inversion or eversion insoles, with studies demonstrating no significant improvement in patient reported outcomes[10]
de Oliveira HAV et al The study demonstrated that customized insole with metatarsal and arch support relieved walking pain and improved patient-reported measures of function in patients with Morton’s neuroma.[16]
Varus/valgus foot wedge a cobra style hard compressed felt padding adhered to the plantar surface of a fibreboard insole to supinate or pronate the foot. These were worn in the participant’s usual footwear (low heeled lace-up or loose fitting slip on shoes)
In the case of CMS, some authors prefers a custom orthotics through foam impression methods, in a neutral subtalar position, with a prolonged longitudinal vault to support the first metatarsal, with a flat metatarsal support (without olive or bar), in order to favor the physiological pattern of the metatarsal weight bearing, from lateral to medial, before the pressure on the big toe[5]
Other authors suggested that a retrocapital bar or pad, just proximal to the metatarsal heads displaces the pressure sites and can be beneficial for symptoms (Figure 3). Metatarsal padding helps to spread and cushion metatarsal heads to relieve the pain from the pinched nerve. If needed, a cup can be added beneath the painful metatarsal head or heads. Custom-made toe inserts modeled in silicone rubber can be added in patients having associated claw-toe deformity [6]
Steroid Injections[edit | edit source]
The use of therapeutic injections is very common in the management of Morton’s neuroma, and multiple therapies have been used. The injection can be guided by USS or done using a landmark technique. A randomised trial by Mahadevan et al did not show any statistical difference in patient outcomes after a steroid injection using USS or without.12 Santiago et al. noted that short term improvement in visual analogue scale (VAS) over 3 months in the group of patients having USS guided injections wa[10]
Modality[edit | edit source]
extracorporeal shockwave therapy[17] ESWT may reduce pain in patients with Morton's neuroma.[17]
Manipulation/Mobilisation[edit | edit source]
Manipulation/mobilisation (involving distraction and plantarflexion of the metatarsophalangeal joints and mobilisation of other foot and ankle joints as required)
Study by Cashley and Cochrane [18]once a week for 4 weeks followed by 2 further visits at 14-day intervals
Differential Diagnosis
[edit | edit source]
The differential diagnosis includes intermetatarsal bursitis, true neuroma, inflammatory arthritis, pigmented villonodular synovitis, osteomyelitis, foreign body granuloma, stress fracture, Freiberg's infraction, and metatarsophalangeal joint dislocation[6].
Surgery[edit | edit source]
In any cases, when modifications fail or if affected individuals are no longer willing to make adjustments to their lifestyle or shoe wear (64, 65), patients may always choose to undergo surgery or other non-operative treatments such as US guided percutaneous radiofrequency (66), alcohol or corticosteroids injection and percutaneous electrostimulation-guided alcoholization with phenol [6]Needle-electrode guided percutaneous alcoholization is an outpatient, minimally invasive procedure with low rate of complications. Better results of those obtained with traditional conservative treatments and comparable with those reported with other alcohols injections or surgical nerve excision were observed.[19]
Operative management options primarily involve either nerve decompression or neurectomy. [20]
Resources
[edit | edit source]
add appropriate resources here
References[edit | edit source]
- ↑ Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov;4(6):328-335.
- ↑ 2.0 2.1 Govsa F, Bilge O, Ozer MA. Anatomical study of the communicating branches between the medial and lateral plantar nerves. Surgical and Radiologic Anatomy. 2005 Dec;27(5):377-81.
- ↑ 3.0 3.1 Torres AL, Ferreira MC. Study of the anatomy of the tibial nerve and its branches in the distal medial leg. Acta ortopedica brasileira. 2012;20:157-64.
- ↑ 4.0 4.1 Koo GB, Lee JH, Jang JH, Song IH, Kim JY. Superficial course of the medial plantar nerve: case report. Anatomy & cell biology. 2019 Mar 1;52(1):87-9.
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art. Acta Biomed. 2020 May 30;91(4-S):60-68.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic?. American journal of roentgenology. 2000 Sep;175(3):649-53.
- ↑ 7.0 7.1 Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005 Dec;71(6):646-55.
- ↑ Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013 Aug;6(4):307-17.
- ↑ 9.0 9.1 Mak MS, Chowdhury R, Johnson R. Morton's neuroma: review of anatomy, pathomechanism, and imaging. Clinical Radiology. 2021 Mar 1;76(3):235-e15.
- ↑ 10.0 10.1 10.2 10.3 10.4 Bhatia M, Thomson L. Morton’s neuroma–current concepts review. Journal of Clinical Orthopaedics and Trauma. 2020 May 1;11(3):406-9.
- ↑ Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic Accuracy of Clinical Tests for Morton's Neuroma Compared With Ultrasonography. J Foot Ankle Surg. 2015 Jul-Aug;54(4):549-53.
- ↑ Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015 Aug;25(8):2254-62.
- ↑ 13.0 13.1 Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. J Foot Ankle Res. 2019 Feb 13;12:12
- ↑ Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8.
- ↑ Saygi B, Yildirim Y, Saygi EK, Kara H, Esemenli T. Morton neuroma: comparative results of two conservative methods. Foot Ankle Int. 2005 Jul;26(7):556-9.
- ↑ de Oliveira HAV, Natour J, Vassalli M, Rosenfeld A, Jennings F, Jones A. Effectiveness of customized insoles in patients with Morton's neuroma: a randomized, controlled, double-blind clinical trial. Clin Rehabil. 2019 Dec;33(12):1898-1907.
- ↑ 17.0 17.1 Seok H, Kim SH, Lee SY, Park SW. Extracorporeal Shockwave Therapy in Patients with Morton's Neuroma A Randomized, Placebo-Controlled Trial. J Am Podiatr Med Assoc. 2016 Mar;106(2):93-9.
- ↑ Cashley DG, Cochrane L. Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases. J Chiropr Med. 2015 Jun;14(2):90-8.
- ↑ Samaila EM, Ambrosini C, Negri S, Maluta T, Valentini R, Magnan B. Can percutaneous alcoholization of Morton's neuroma with phenol by electrostimulation guidance be an alternative to surgical excision? Long-term results. Foot Ankle Surg. 2020 Apr;26(3):314-319.
- ↑ Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot & Ankle Specialist. 2013 Aug;6(4):307-17.
