Physiotherapy for Morton's Neuroma: Difference between revisions

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== Introduction ==
== Introduction ==
Civinini Morton’s Syndrome (CMS) is more commonly known as Morton’s neuroma. Interdigital neuritis is another term proposed by Weinfield and Myerson<ref>Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov;4(6):328-335.</ref> that better describes this condition's pathology. The presence of inflammatory tissue in histological examination justifies the description of Morton's neuroma as perineurial fibrosis. Pain and abnormal forefoot sensation are clinical symptoms that help with the diagnosis. Conservative treatment, including lifestyle adjustment, may not always be practical, and patients may choose surgery or various types of ultrasound-guided percutaneous injections as other management options.   
Civinini Morton’s Syndrome (CMS) is more commonly known as Morton’s neuroma. Weinfield and Myerson<ref>Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov;4(6):328-335.</ref> have also proposed the term "interdigital neuritis", which better describes the pathology of this condition. Neural degeneration and perineural fibrosis are typical of Morton's neuroma<ref>Riddick DA, Riddick DH, Jorge M. 7 - Footwear: foundation for lower extremity orthoses. In: Chui KK, Jorge M, Yen S-C, Lusardi MM, editors. Orthotics and prosthetics in rehabilitation (Fourth Edition). Elsevier, 2020. p164-82.</ref>; the presence of inflammatory tissue in histological examination justifies the description of Morton's neuroma as perineural fibrosis.<ref name=":10" /> Clinical symptoms that can help with diagnosis include pain and abnormal forefoot sensation. Conservative treatment, including lifestyle adjustment, may not always be practical. Thus, patients may choose to have surgery or various types of ultrasound-guided percutaneous injections to manage this condition.   
[[File:Foot Inneravtion.gif|thumb|Foot innervation]]
[[File:Foot Inneravtion.gif|thumb|Foot innervation]]


== Clinically Relevant Anatomy ==
== Clinically Relevant Anatomy ==
Magnetic resonance imaging (MRI) shows the medial and lateral plantar nerves arise from the posterior tibial 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> The [[Tibial Nerve|tibial nerve]] terminates in the foot by giving branches to the [[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" />
Magnetic resonance imaging (MRI) shows the [[Medial Plantar Nerve|medial]] and [[Lateral Plantar Nerve|lateral plantar nerves]] arise from the posterior [[Tibial Nerve|tibial 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> This bifurcation of the tibial nerve 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, which connects the fascia to the bone.<ref name=":8" />


The [[Medial Plantar Nerve|medial plantar nerve]] (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament and passes between the [[Abductor Hallucis|abductor hallucis]] muscle and [[Flexor Digitorum Brevis|flexor digitorum brevis]]. Upon reaching the metatarsal bases, it divides into three common digital plantar nerves.<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 MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the first lumbrical.  
The [[Medial Plantar Nerve|medial plantar nerve]] (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament and passes between [[Abductor Hallucis|abductor hallucis]] and [[Flexor Digitorum Brevis|flexor digitorum brevis]]. Upon reaching the metatarsal bases, it divides into three common digital plantar nerves.<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 MPN innervates the abductor hallucis, [[Flexor Hallucis Brevis|flexor hallucis brevis]], flexor digitorum brevis and the first lumbrical of the foot.  


The [[Lateral Plantar Nerve|lateral plantar nerve]] (LPN) innervates the [[Abductor Digiti Minimi (Foot)|abductor digiti minimi]] muscle, [[Flexor Digiti Minimi Brevis|flexor digiti minimi brevis]] muscle, [[Quadratus Plantae|quadratus plantae]], three lateral lumbricals of the foot, [[Adductor Hallucis|adductor hallucis]] muscle, plantar interossei muscles, and [[Dorsal Interossei of the Foot|dorsal interossei]] muscles.
The [[Lateral Plantar Nerve|lateral plantar nerve]] (LPN) innervates [[Abductor Digiti Minimi (Foot)|abductor digiti minimi]], [[Flexor Digiti Minimi Brevis|flexor digiti minimi brevis]], [[Quadratus Plantae|quadratus plantae]], the three lateral lumbricals of the foot, [[Adductor Hallucis|adductor hallucis]], the plantar interossei, and the [[Dorsal Interossei of the Foot|dorsal interossei]].


The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments, go through the plantar [[aponeurosis]] and divide into two 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">Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944831/pdf/ACTA-91-60.pdf The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of the art.] Acta Biomed. 2020 May 30;91(4-S):60-68.</ref> 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 into the transverse metatarsal ligament, it becomes less mobile, especially during weight-bearing activities.
The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments. They go through the plantar [[aponeurosis]] and divide into two branches, which supply 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">Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944831/pdf/ACTA-91-60.pdf The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of the art.] Acta Biomed. 2020 May 30;91(4-S):60-68.</ref>  


The branches of the common digital nerve in the third planter webspace are most commonly affected. The location of this nerve near the narrow space of the transverse metatarsal ligament may be a possible explanation for the development of Morton's Neuroma pathology within the third intermetatarsal space.<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 through the narrow space deep to the transverse metatarsal ligament, it becomes less mobile, especially during weight-bearing activities.<ref name=":5" />
 
The branches of the common digital nerve in the third planter webspace are most commonly affected in Morton's neuroma. It has been proposed that the location of this nerve (i.e. near the narrow space of the transverse metatarsal ligament) may be why Morton's neuroma often occurs within the third intermetatarsal space.<ref name=":5" />
[[File:Mortons-neuroma-1.gif|thumb|Morton's neuroma]]
[[File:Mortons-neuroma-1.gif|thumb|Morton's neuroma]]


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* Chronic traction damage<ref name=":6">Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005 Dec;71(6):646-55. </ref>
* Chronic traction damage<ref name=":6">Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005 Dec;71(6):646-55. </ref>
* Chronic, repetitive trauma <ref name=":6" />
* Chronic, repetitive trauma<ref name=":6" />
* Ischaemia of vasa nervorum<ref name=":5" /><ref name=":6" />
* Ischaemia of vasa nervorum<ref name=":5" /><ref name=":6" />
* Entrapment or mechanical compression<ref name=":10">Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013 Aug;6(4):307-17.
* Entrapment or mechanical compression<ref name=":10">Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013 Aug;6(4):307-17.
</ref><ref name=":0">Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. [https://www.ajronline.org/doi/epdf/10.2214/ajr.175.3.1750649 Morton's neuroma: is it always symptomatic?]. American journal of roentgenology. 2000 Sep;175(3):649-53.</ref>
</ref><ref name=":0">Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. [https://www.ajronline.org/doi/epdf/10.2214/ajr.175.3.1750649 Morton's neuroma: is it always symptomatic?]. American journal of roentgenology. 2000 Sep;175(3):649-53.</ref>
* Inflammation due to intermetatarsal bursitis<ref name=":10" />
* Inflammation due to intermetatarsal bursitis<ref name=":10" />
One of the theories explaining the occurrence of Morton's neuroma is based on the notion that the third common digital nerve is thicker than the others due to an anastomosis between two nerve trunks. The inflammation theory is explained by the increased mobility of the fourth ray compared to the third.<ref name=":5" /> The compression theory is based on the finding that the plantar nerve is compressed by the distal metatarsal transverse ligament.<ref name=":10" />  
'''Anatomical considerations:'''
 
* The third common digital nerve is thicker than the others due to an anastomosis between two nerve trunks<ref name=":5" />
* The fourth ray is more mobile than the third, which might lead to inflammation inflammation<ref name=":5" />  
* The plantar nerve is compressed by the distal metatarsal transverse ligament<ref name=":10" />  


=== Epidemiology ===
=== Epidemiology ===
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== Mechanism of Injury / Pathological Process ==
== Mechanism of Injury / Pathological Process ==


According to the literature, the most frequent mechanism of injury is nerve entrapment.<ref name=":0" /> The third common digital nerve is thicker due to the fusion between the medial and lateral plantar nerves. This leads to its entrapment by the surrounding ligament.<ref name=":0" /> Entrapment neuropathy causes perineural fibrosis and nerve degeneration.<ref name=":0" /> The thickening of the nerve progresses as a result of vascular hyalinisation, which causes more nerve trauma and entrapment. Adding to the pathological process is the use of high heel shoes, which forces excessive weight bearing through the forefoot.<ref name=":0" />   
According to the literature, the most frequent mechanism of injury is nerve entrapment.<ref name=":0" /> As the third common digital nerve is thicker due to the fusion of the medial and lateral plantar nerves, it can be entrapped by the surrounding ligament.<ref name=":0" /> Entrapment neuropathy causes perineural fibrosis and nerve degeneration.<ref name=":0" /> The thickening of the nerve progresses due to vascular hyalinisation, which causes more nerve trauma and entrapment. Wearing high-heel shoes can also add to the pathological process as these shoes cause excessive weight bearing through the forefoot.<ref name=":0" />   


== Clinical Presentation  ==
== Clinical Presentation  ==


There are two types of clinical presentation in Morton's neuroma: clinically symptomatic and asymptomatic.  
Individuals with Morton's neuroma can be clinically symptomatic or asymptomatic. Persons with clinically symptomatic Morton's neuroma may present with the following symptoms:<ref name=":0" />  
 
Clinically symptomatic Morton's neuroma presents with the following symptoms:<ref name=":0" />


* Pain or paresthesias in the intermetatarsal region, toes, and dorsal web space. Pain is worsened by weight-bearing or the use of high-heeled shoes. Removing shoes and gently massaging the forefoot usually relieve the pain.
* Pain or paresthesias in the intermetatarsal region, toes, and dorsal web space. Pain is worsened by weight-bearing or the use of high-heeled shoes. Removing shoes and gently massaging the forefoot usually relieve the pain.
* Pain is usually sharp and can become debilitating to the point that the patient is afraid and anxious about walking or even putting their foot on the ground.<ref name=":5" />
* Pain is usually sharp and can become debilitating to the point that the patient is afraid and anxious about walking or even putting their foot on the ground.<ref name=":5" />
* The patient can complain of a burning sensation in the intermetatarsal spaces.<ref name=":11">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. </ref>
* The patient may complain of a burning sensation in the intermetatarsal spaces.<ref name=":11">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. </ref>
* Mass can be palpated.
* A mass can be palpated.
* Symptoms can be present as a result of trauma.
* Symptoms can be present as a result of trauma.
* The patient describes an altered sensation as a “pebble in the shoe”.<ref name=":2">Bhatia M, Thomson L. Morton’s neuroma–current concepts review. Journal of Clinical Orthopaedics and Trauma. 2020 May 1;11(3):406-9.</ref>
* Paints may describe altered sensations and report that it feels like they have a “pebble in the shoe”.<ref name=":2">Bhatia M, Thomson L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211826/ Morton’s neuroma–current concepts review]. Journal of Clinical Orthopaedics and Trauma. 2020 May 1;11(3):406-9.</ref>
* Pain worsens with walking or running.<ref name=":2" />
* Pain worsens with walking or running.<ref name=":2" />


The presence of the hallux valgus is considered a predisposing factor in the development of Morton's neuroma.<ref name=":2" />  
The presence of [[Hallux Valgus|hallux valgus]] is considered a predisposing factor in the development of Morton's neuroma.<ref name=":2" />  


== Diagnostic Tests ==
== Diagnostic Tests ==
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== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


* Ultrasound (US): high diagnostic accuracy. The technique and experience of a person performing the test are essential to make a proper diagnosis. <ref name=":5" /><ref name=":1" />
* Ultrasound (US): high diagnostic accuracy. Proper diagnosis depends on the technique and experience of a person performing the test. <ref name=":5" /><ref name=":1" />
* Magnetic resonance imaging (MRI):  the gold standard investigation to identify a neuroma. <ref name=":2" />Primary indications for MRI are unclear clinical assessment and cases when more than one intermetatarsal space (IMS) is affected. <ref name=":5" />  
* Magnetic resonance imaging (MRI):  the gold standard investigation to identify a neuroma.<ref name=":2" /> Primary indications for MRI are unclear clinical assessment and cases when more than one intermetatarsal space (IMS) are affected.<ref name=":5" />
* X-rays: essential as a first-line imaging approach to rule out tarsal–metatarsal joint stiffness, metatarsal hypermetria, Frieberg’s disease, toe deformities and metatarsophalangeal (MTP) instabilities.
* X-rays: essential as a first-line imaging approach to rule out tarsal–metatarsal joint stiffness, metatarsal hypermetria, Frieberg’s disease, toe deformities and metatarsophalangeal (MTP) instabilities.


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=== Footwear ===
=== Footwear ===
Goal: To limit the nerve compression in the early stages of Morton's neuroma  
Goal: To limit the nerve compression in the early stages of Morton's neuroma.


Tools: patient education, footwear modification<blockquote>According to the study <ref name=":5" />, after 4.5 months since the diagnosis and when the neuroma is larger than 5-6 mm, orthotics and/or shoe modifications are no longer effective in symptom management. They can offer a palliative solution to better manage a person's life with pain.<ref name=":5" /></blockquote>
Tools: patient education, footwear modification.<blockquote>According to Colò et al.,<ref name=":5" /> if an individual is more than 4.5 months post-diagnosis and the neuroma is larger than 5-6 mm, orthotics and/or shoe modifications are no longer effective for symptom management. At this stage, they offer a palliative solution to achieve an "''acceptable life with pain''."<ref name=":5" /></blockquote>


==== Patient Education ====
==== Patient Education ====
Patient to be educated on :  
The patient should receive education on:  


* avoiding narrow and high-heeled shoes  
* Avoiding narrow and high-heeled shoes
* staying compliant with footwear prescription
* Staying compliant with footwear prescription
* activity modification<ref name=":13">Simpson H. Morton's Neuroma Course. Plus 2022</ref>
* Activity modification<ref name=":13">Simpson H. Morton's Neuroma Course. Plus 2022</ref>
[[File:Rocker sole shoe.jpeg|thumb|Rocker sole shoe]]
[[File:Rocker sole shoe.jpeg|thumb|Rocker sole shoe]]


==== Footwear modification ====
==== Footwear Modification ====
The most appropriate footwear should have the following design:<ref name=":5" /><ref name=":3">Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375221/pdf/13047_2019_Article_320.pdf 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</ref>
The most appropriate footwear will have the following features:<ref name=":5" /><ref name=":3">Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375221/pdf/13047_2019_Article_320.pdf 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</ref>


* sufficiently long<ref name=":5" />
* Sufficiently long<ref name=":5" />
* wide toe box<ref name=":5" />
* Wide toe box<ref name=":5" />
* low heel<ref name=":5" />
* Low heel<ref name=":5" />
* thick external sole, which should not be excessively flexible<ref name=":5" />
* Thick external sole, which should not be excessively flexible<ref name=":5" />
* metatarsal padding<ref name=":3" />
* Metatarsal padding<ref name=":3" />
* A rocker-bottom sole may be helpful<ref>Janisse DJ, Janisse E. Shoe modification and the use of orthoses in treating foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8. </ref>
* A rocker-bottom sole may be helpful<ref>Janisse DJ, Janisse E. Shoe modification and the use of orthoses in treating foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8. </ref>
[[File:Metatarsal Pad - Shutterstock Image - ID 1603933129.jpg|thumb|Metatarsal pad]]
[[File:Metatarsal Pad - Shutterstock Image - ID 1603933129.jpg|thumb|Metatarsal pad]]


=== Orthotics ===
=== Orthotics ===
Goal:  
Goals:  


# To displace the pressure sites
# To displace pressure sites
# To provide pain relief
# To provide pain relief


* The most common orthotic provided initially is ''' the metatarsal bar'''. Its purpose is to:
* The most common orthotic provided initially is''' the metatarsal bar'''. It aims to:
** Spread the heads of the metatarsals to relieve pressure
** Spread the heads of the metatarsals to relieve pressure
** Improve symptoms
** Improve symptoms


* Limited to no evidence of improvement in patient-reported outcomes with the use of '''inversion or eversion insoles'' (varus/valgus foot wedge). <ref name=":2" />
* There is limited to no evidence of improvement in patient-reported outcomes with the use of '''inversion or eversion insoles'' (varus/valgus foot wedge). <ref name=":2" />


* According to de Oliveira et al. <ref name=":12">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. </ref>, '''customised insole with metatarsal and arch support''' offers pain relief during ambulation and improves function. <ref name=":12" />
* According to de Oliveira et al.,<ref name=":12">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. </ref> a '''customised insole with metatarsal and arch support''' offers pain relief during ambulation and improves function.
* '''Custom-made toe inserts '''modelled in silicone rubber can be added when the claw-toe deformity is present. <ref name=":0" />
* '''Custom-made toe inserts '''modelled in silicone rubber can be added when a claw-toe deformity is present.<ref name=":0" />
* Custom '''orthotics through foam impression methods'''. The foot is placed in a neutral subtalar position, with a prolonged longitudinal vault to support the first metatarsal (flat support). Goal: to mimic the physiological pattern of the metatarsal weight bearing, from lateral to medial, before the pressure on the big toe. <ref name=":5" />
* Custom '''orthotics through foam impression methods'''. The foot is placed in a neutral subtalar position, with a prolonged longitudinal vault to support the first metatarsal (flat support). The goal is to mimic the physiological pattern of metatarsal weight bearing, from lateral to medial, before pressure moves to the big toe. <ref name=":5" />


=== Steroid Injections ===
=== Steroid Injections ===
Goal: to provide pain relief
Goal: to provide pain relief.


In the management of Morton's neuroma, steroid injections are pretty standard. The injection method varies: it is guided by ultrasound or a landmark technique.  
Steroid injections are fairly standard in the management of Morton's neuroma. The injection method varies: they can be guided by ultrasound or using a landmark technique.  


* Based on a randomised control trial, Mahadevan et al. <ref>Mahadevan D, Attwal M, Bhatt R, Bhatia M. [https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.98B4.36880 Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial]. Bone Joint J. 2016 Apr;98-B(4):498-503.</ref> found no statistical difference in patient outcomes after a steroid injection using ultrasound or without.
* An randomised controlled trial by Mahadevan et al.<ref>Mahadevan D, Attwal M, Bhatt R, Bhatia M. [https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.98B4.36880 Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial]. Bone Joint J. 2016 Apr;98-B(4):498-503.</ref> found no statistical difference in patient outcomes after a steroid injection using ultrasound or without.
* Choi and colleagues<ref>Choi JY, Lee HI, Hong WH, Suh JS, Hur JW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173242/pdf/cios-13-266.pdf Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review.] Clin Orthop Surg. 2021 Jun;13(2):266-277.</ref>demonstrated a satisfactory clinical outcome in pain reduction after corticosteroid injections, but 30% of patients eventually required surgery for pain management.
* Choi et al.<ref>Choi JY, Lee HI, Hong WH, Suh JS, Hur JW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173242/pdf/cios-13-266.pdf Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review.] Clin Orthop Surg. 2021 Jun;13(2):266-277.</ref> demonstrated a satisfactory clinical outcome in pain reduction after corticosteroid injections, but 30% of patients eventually required surgery for pain management.
* Lizano-Diez et al. <ref>Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton's Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot Ankle Int. 2017 Sep;38(9):944-951.</ref>found no difference in pain and function between the injection of a corticosteroid plus a local anaesthetic versus local anaesthetic only.  
* Lizano-Diez et al.<ref>Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton's Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot Ankle Int. 2017 Sep;38(9):944-951.</ref> found no difference in pain and function between the injection of a corticosteroid plus a local anaesthetic versus local anaesthetic only.


=== Modality ===
=== Modality ===


* [[Extracorporeal Shockwave Therapy (ESWT)|Extracorporeal shockwave therapy]]<ref name=":4">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.</ref> ESWT may reduce pain in patients with Morton's neuroma.<ref name=":4" />
* [[Extracorporeal Shockwave Therapy (ESWT)|Extracorporeal shockwave therapy (ESWT)]]<ref name=":4">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.</ref> may reduce pain in patients with Morton's neuroma.<ref name=":4" />
* [[Transcutaneous Electrical Nerve Stimulation (TENS)|TENS]] (Transcutaneous Electrical Nerve Stimulation) can help with pain management. <ref name=":13" />
* [[Transcutaneous Electrical Nerve Stimulation (TENS)|Transcutaneous Electrical Stimulation (TENS)]] can help with pain management.<ref name=":13" />


=== Manipulation/Mobilisation ===
=== Manipulation/Mobilisation ===
According to Cashley and Cochrane <ref name=":14">Cashley DG, Cochrane L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523570/pdf/main.pdf Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases]. J Chiropr Med. 2015 Jun;14(2):90-8.</ref>, foot manipulation and mobilisation of other foot and ankle joints can decrease foot pain in patients diagnosed with plantar digital neuralgia (Morton's neuroma). The authors recommend performing joint manipulation once a week for four weeks, followed by two more visits at 14-day intervals. <ref name=":14" />  
According to Cashley and Cochrane,<ref name=":14">Cashley DG, Cochrane L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523570/pdf/main.pdf Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases]. J Chiropr Med. 2015 Jun;14(2):90-8.</ref> foot manipulation and mobilisation of the other foot and ankle joints can decrease foot pain in patients diagnosed with plantar digital neuralgia (Morton's neuroma). The authors recommend performing joint manipulation once a week for four weeks, followed by two more visits at 14-day intervals.<ref name=":14" />  


=== Strengthening Exercises ===
=== Strengthening Exercises ===
According to Simpson <ref name=":13" />, strengthening exercises for toe flexors and the intrinsics can help with muscle activation during the mid-stance of the gait cycle and prevent the metatarsal heads from dropping.   
According to Helene Simpson,<ref name=":13" /> strengthening exercises for the toe flexors and the intrinsics can help with muscle activation during the mid-stance of the gait cycle and prevent the metatarsal heads from dropping.   


== Other treatment option ==
== Other treatment Options ==
Surgery is considered when conservative treatment fails, or the patient is no longer willing to adjust their lifestyle to manage symptoms of Morton's neuroma. The following operative and non-operative treatment options are available:
Surgery is considered when conservative treatment fails, or the patient is no longer willing to adjust their lifestyle to manage symptoms of Morton's neuroma. The following operative and non-operative treatment options are available:


Line 156: Line 160:
* Ultrasound-guided percutaneous radiofrequency  
* Ultrasound-guided percutaneous radiofrequency  
* Alcohol injection
* Alcohol injection
* Percutaneous electrostimulation-guided alcoholization with phenol<ref name=":0" />
* Percutaneous electrostimulation-guided alcoholisation with phenol<ref name=":0" />


== Resources ==
== Resources ==

Revision as of 23:06, 22 October 2022


Original Editor - Ewa Jaraczewska
Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson

Introduction[edit | edit source]

Civinini Morton’s Syndrome (CMS) is more commonly known as Morton’s neuroma. Weinfield and Myerson[1] have also proposed the term "interdigital neuritis", which better describes the pathology of this condition. Neural degeneration and perineural fibrosis are typical of Morton's neuroma[2]; the presence of inflammatory tissue in histological examination justifies the description of Morton's neuroma as perineural fibrosis.[3] Clinical symptoms that can help with diagnosis include pain and abnormal forefoot sensation. Conservative treatment, including lifestyle adjustment, may not always be practical. Thus, patients may choose to have surgery or various types of ultrasound-guided percutaneous injections to manage this condition.

Foot innervation

Clinically Relevant Anatomy[edit | edit source]

Magnetic resonance imaging (MRI) shows the medial and lateral plantar nerves arise from the posterior tibial nerve.[4] This bifurcation of the tibial nerve occurs inside the retinaculum or proximal to the flexor retinaculum.[5] The two plantar nerves penetrate the tunnel made of the deep fascia of the abductor hallucis muscle and the fibrous septum, which connects the fascia to the bone.[5]

The medial plantar nerve (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament and passes between abductor hallucis and flexor digitorum brevis. Upon reaching the metatarsal bases, it divides into three common digital plantar nerves.[6] The MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the first lumbrical of the foot.

The lateral plantar nerve (LPN) innervates abductor digiti minimi, flexor digiti minimi brevis, quadratus plantae, the three lateral lumbricals of the foot, adductor hallucis, the plantar interossei, and the dorsal interossei.

The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments. They go through the plantar aponeurosis and divide into two branches, which supply 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.[7]

The third common digital nerve begins as the medial plantar nerve and receives a communicating branch from the lateral plantar nerve. Because it passes through the narrow space deep to the transverse metatarsal ligament, it becomes less mobile, especially during weight-bearing activities.[7]

The branches of the common digital nerve in the third planter webspace are most commonly affected in Morton's neuroma. It has been proposed that the location of this nerve (i.e. near the narrow space of the transverse metatarsal ligament) may be why Morton's neuroma often occurs within the third intermetatarsal space.[7]

Morton's neuroma

Neuroma[edit | edit source]

A neuroma is also referred to as a pinched nerve. Morton's neuroma is a compressive neuropathy of the common plantar digital nerve caused by an entrapment of the nerve between the intermetatarsal ligaments.

Aetiology[edit | edit source]

There are several aetiopathogenetic theories behind the development of Morton's neuroma. These include:

  • Chronic traction damage[8]
  • Chronic, repetitive trauma[8]
  • Ischaemia of vasa nervorum[7][8]
  • Entrapment or mechanical compression[3][9]
  • Inflammation due to intermetatarsal bursitis[3]

Anatomical considerations:

  • The third common digital nerve is thicker than the others due to an anastomosis between two nerve trunks[7]
  • The fourth ray is more mobile than the third, which might lead to inflammation inflammation[7]
  • The plantar nerve is compressed by the distal metatarsal transverse ligament[3]

Epidemiology[edit | edit source]

More females than males develop Morton's neuroma, with a female-to-male ratio of 5:1.[7] It affects around 30% of the population. The average age for Morton's neuroma is 50 years. It affects both feet, and in most cases, the third intermetatarsal space is involved, followed by the second (Hauser’s neuroma).[10] Multiple locations are scarce.[7]

Mechanism of Injury / Pathological Process[edit | edit source]

According to the literature, the most frequent mechanism of injury is nerve entrapment.[9] As the third common digital nerve is thicker due to the fusion of the medial and lateral plantar nerves, it can be entrapped by the surrounding ligament.[9] Entrapment neuropathy causes perineural fibrosis and nerve degeneration.[9] The thickening of the nerve progresses due to vascular hyalinisation, which causes more nerve trauma and entrapment. Wearing high-heel shoes can also add to the pathological process as these shoes cause excessive weight bearing through the forefoot.[9]

Clinical Presentation[edit | edit source]

Individuals with Morton's neuroma can be clinically symptomatic or asymptomatic. Persons with clinically symptomatic Morton's neuroma may present with the following symptoms:[9]

  • Pain or paresthesias in the intermetatarsal region, toes, and dorsal web space. Pain is worsened by weight-bearing or the use of high-heeled shoes. Removing shoes and gently massaging the forefoot usually relieve the pain.
  • Pain is usually sharp and can become debilitating to the point that the patient is afraid and anxious about walking or even putting their foot on the ground.[7]
  • The patient may complain of a burning sensation in the intermetatarsal spaces.[11]
  • A mass can be palpated.
  • Symptoms can be present as a result of trauma.
  • Paints may describe altered sensations and report that it feels like they have a “pebble in the shoe”.[12]
  • Pain worsens with walking or running.[12]

The presence of hallux valgus is considered a predisposing factor in the development of Morton's neuroma.[12]

Diagnostic Tests[edit | edit source]

[15]

MRI of Morton's neuroma
X-ray of Morton's neuroma
Ultrasound of Morton's neuroma

Diagnostic Procedures[edit | edit source]

  • Ultrasound (US): high diagnostic accuracy. Proper diagnosis depends on the technique and experience of a person performing the test. [7][10]
  • Magnetic resonance imaging (MRI): the gold standard investigation to identify a neuroma.[12] Primary indications for MRI are unclear clinical assessment and cases when more than one intermetatarsal space (IMS) are affected.[7]
  • X-rays: essential as a first-line imaging approach to rule out tarsal–metatarsal joint stiffness, metatarsal hypermetria, Frieberg’s disease, toe deformities and metatarsophalangeal (MTP) instabilities.

Differential Diagnosis[edit | edit source]

The differential diagnosis includes the following conditions:[9]

  • Intermetatarsal bursitis
  • True neuroma
  • Inflammatory arthritis
  • Pigmented villonodular synovitis
  • Osteomyelitis
  • Foreign body granuloma
  • Stress fracture
  • Freiberg's infraction
  • Metatarsophalangeal joint dislocation.

Physiotherapy Management / Interventions[edit | edit source]

Footwear[edit | edit source]

Goal: To limit the nerve compression in the early stages of Morton's neuroma.

Tools: patient education, footwear modification.

According to Colò et al.,[7] if an individual is more than 4.5 months post-diagnosis and the neuroma is larger than 5-6 mm, orthotics and/or shoe modifications are no longer effective for symptom management. At this stage, they offer a palliative solution to achieve an "acceptable life with pain."[7]

Patient Education[edit | edit source]

The patient should receive education on:

  • Avoiding narrow and high-heeled shoes
  • Staying compliant with footwear prescription
  • Activity modification[16]
Rocker sole shoe

Footwear Modification[edit | edit source]

The most appropriate footwear will have the following features:[7][17]

  • Sufficiently long[7]
  • Wide toe box[7]
  • Low heel[7]
  • Thick external sole, which should not be excessively flexible[7]
  • Metatarsal padding[17]
  • A rocker-bottom sole may be helpful[18]
Metatarsal pad

Orthotics[edit | edit source]

Goals:

  1. To displace pressure sites
  2. To provide pain relief
  • The most common orthotic provided initially is the metatarsal bar. It aims to:
    • Spread the heads of the metatarsals to relieve pressure
    • Improve symptoms
  • There is limited to no evidence of improvement in patient-reported outcomes with the use of 'inversion or eversion insoles (varus/valgus foot wedge). [12]
  • According to de Oliveira et al.,[19] a customised insole with metatarsal and arch support offers pain relief during ambulation and improves function.
  • Custom-made toe inserts modelled in silicone rubber can be added when a claw-toe deformity is present.[9]
  • Custom orthotics through foam impression methods. The foot is placed in a neutral subtalar position, with a prolonged longitudinal vault to support the first metatarsal (flat support). The goal is to mimic the physiological pattern of metatarsal weight bearing, from lateral to medial, before pressure moves to the big toe. [7]

Steroid Injections[edit | edit source]

Goal: to provide pain relief.

Steroid injections are fairly standard in the management of Morton's neuroma. The injection method varies: they can be guided by ultrasound or using a landmark technique.

  • An randomised controlled trial by Mahadevan et al.[20] found no statistical difference in patient outcomes after a steroid injection using ultrasound or without.
  • Choi et al.[21] demonstrated a satisfactory clinical outcome in pain reduction after corticosteroid injections, but 30% of patients eventually required surgery for pain management.
  • Lizano-Diez et al.[22] found no difference in pain and function between the injection of a corticosteroid plus a local anaesthetic versus local anaesthetic only.

Modality[edit | edit source]

Manipulation/Mobilisation[edit | edit source]

According to Cashley and Cochrane,[24] foot manipulation and mobilisation of the other foot and ankle joints can decrease foot pain in patients diagnosed with plantar digital neuralgia (Morton's neuroma). The authors recommend performing joint manipulation once a week for four weeks, followed by two more visits at 14-day intervals.[24]

Strengthening Exercises[edit | edit source]

According to Helene Simpson,[16] strengthening exercises for the toe flexors and the intrinsics can help with muscle activation during the mid-stance of the gait cycle and prevent the metatarsal heads from dropping.

Other treatment Options[edit | edit source]

Surgery is considered when conservative treatment fails, or the patient is no longer willing to adjust their lifestyle to manage symptoms of Morton's neuroma. The following operative and non-operative treatment options are available:

  • Surgical nerve excision (neurectomy)[25]
  • Surgical nerve decompression[26]
  • Ultrasound-guided percutaneous radiofrequency
  • Alcohol injection
  • Percutaneous electrostimulation-guided alcoholisation with phenol[9]

Resources[edit | edit source]

  1. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis
  2. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of the art
  3. Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard

References[edit | edit source]

  1. ↑ Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov;4(6):328-335.
  2. ↑ Riddick DA, Riddick DH, Jorge M. 7 - Footwear: foundation for lower extremity orthoses. In: Chui KK, Jorge M, Yen S-C, Lusardi MM, editors. Orthotics and prosthetics in rehabilitation (Fourth Edition). Elsevier, 2020. p164-82.
  3. ↑ 3.0 3.1 3.2 3.3 Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013 Aug;6(4):307-17.
  4. ↑ 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.
  5. ↑ 5.0 5.1 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.
  6. ↑ 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.
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 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 the art. Acta Biomed. 2020 May 30;91(4-S):60-68.
  8. ↑ 8.0 8.1 8.2 Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005 Dec;71(6):646-55.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 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.
  10. ↑ 10.0 10.1 Mak MS, Chowdhury R, Johnson R. Morton's neuroma: a review of anatomy, pathomechanism, and imaging. Clinical Radiology. 2021 Mar 1;76(3):235-e15.
  11. ↑ 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.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Bhatia M, Thomson L. Morton’s neuroma–current concepts review. Journal of Clinical Orthopaedics and Trauma. 2020 May 1;11(3):406-9.
  13. ↑ Skalina T, Weerakkody Y. Mulder sign. Reference article, Radiopaedia.org. Available from https://radiopaedia.org/articles/mulder-sign (accessed on 14 Oct 2022)
  14. ↑ 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
  15. ↑ The Physio Channel. Metatarsal Squeeze Test for Mortons Neuroma and Mulders Sign. 2019. Available from: https://www.youtube.com/watch?v=yJ7LUCCmFAU[last accessed 15/10/2022]
  16. ↑ 16.0 16.1 16.2 Simpson H. Morton's Neuroma Course. Plus 2022
  17. ↑ 17.0 17.1 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
  18. ↑ Janisse DJ, Janisse E. Shoe modification and the use of orthoses in treating foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8.
  19. ↑ 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.
  20. ↑ Mahadevan D, Attwal M, Bhatt R, Bhatia M. Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial. Bone Joint J. 2016 Apr;98-B(4):498-503.
  21. ↑ Choi JY, Lee HI, Hong WH, Suh JS, Hur JW. Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review. Clin Orthop Surg. 2021 Jun;13(2):266-277.
  22. ↑ Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton's Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot Ankle Int. 2017 Sep;38(9):944-951.
  23. ↑ 23.0 23.1 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.
  24. ↑ 24.0 24.1 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.
  25. ↑ 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.
  26. ↑ Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot & Ankle Specialist. 2013 Aug;6(4):307-17.
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