Morton's Metatarsalgia Research Articles

Morton's Metatarsalgia: The Current State of the Issue

A typical complaint with Morton's neuroma is a burning paroxysmal pain in the area of the plantar surface of the metatarsal bones with irradiation into the III interdigital space, which forces the patient to take off his shoes and massage the foot in the most inappropriate situations. Given that women are mostly ill, clinical manifestations reduce the quality of life of patients, limit their daily professional and work activities. The paper presents the etiology, pathogenesis and clinical picture of this disease, diagnostic features. A radical method of treatment is surgery, which is relatively simple in technique and consists in dissecting the tissues that compress the nerve and creating optimal conditions for the nerve trunk, preventing its subsequent traumatization.

Rare nerve compression neuropathies

In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Renunciations in forefoot surgery. Critical analysis of surgical waiting lists

IntroductionThe high prevalence of forefoot pathology generates long surgical waiting lists (SWL). We have detected a considerable number of patients who withdraw surgery, which creates an important distortion in our activity and high expenditure of resources. Our objective is to study the factors related to these resignations, as well as, compare them with other pathologies of high prevalence and ambulatory surgical treatment: carpal tunnel syndrome (CTS) and internal meniscopathy (IM). Material and methodsRetrospective study of the surgical cancellations on 2399 patients included in the SWL of the Foot and Ankle Unit of our centre for forefoot surgery, between January/2014 and March/2018, both included. ResultsWe have found 389 renunciations, which represent 16.22% of the inclusions in SWL, with 84.83% of women. The pathologies with the highest rate of resignation have been Morton metatarsalgia (24%) and hallux rigidus (20.16%). The most frequent pathology, hallux valgus, records 15.96% of resignations that occur mostly between 6 and 9 months. In the CTS and IM, the resignation rate has been 17.42 and 8.92%, respectively, with higher resignation rates in the first 3 months. ConclusionsThe withdrawal of a scheduled intervention on the forefoot registers a high frequency in our environment, which can be related to factors such as the type of pathology, its natural history, response to orthopedic interventions, time in LEQ, and other non-specific ones on which we must investigate, to rationalize and establish duties in our SWL.

Renuncias en cirugía del antepié. Análisis crítico de las listas de espera

IntroductionThe high prevalence of forefoot pathology generates long surgical waiting lists (SWL). We have detected a considerable number of patients who withdraw surgery, which creates an important distortion in our activity and high expenditure of resources. Our objective is to study the factors related to these resignations, as well as, compare them with other pathologies of high prevalence and ambulatory surgical treatment: carpal tunnel syndrome (CTS) and internal meniscopathy (IM). Material and methodsRetrospective study of the surgical cancellations on 2,399 patients included in the SWL of the Foot and Ankle Unit of our center for forefoot surgery, between January/2014 and March/2018, both included. ResultsWe have found 389 renunciations, which represent 16.22% of the inclusions in SWL, with 84.83% of women. The pathologies with the highest rate of resignation have been Morton metatarsalgia (24%) and hallux rigidus (20.16%). The most frequent pathology, hallux valgus, records 15.96% of resignations that occur mostly between 6 and 9 months. In the CTS and IM, the resignation rate has been 17.42 and 8.92%, respectively, with higher resignation rates in the first 3 months. ConclusionsThe withdrawal of a scheduled intervention on the forefoot registers a high frequency in our environment, which can be related to factors such as the type of pathology, its natural history, response to orthopedic interventions, time in LEQ, and other non-specific ones on which we must investigate, to rationalize and establish duties in our SWL.

Constitutional risk factors for focal neuropathies in patients referred for electromyography.

It is well established that patient-related constitutional features predispose to focal peripheral neuropathies. Some of these risk factors were investigated in common focal neuropathies encountered in patients referred for electromyography. Gender, age, height and body mass index (BMI) were analysed retrospectively as risk factors for 11 focal neuropathies. In all, 9686 patients (age range 18-96years; 58% women) were included from three different centres, with identical methods and equipment. High BMI was related to carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), combined CTS and UNE, meralgia paraesthetica and lumbar radiculopathy. In women, CTS and Morton's metatarsalgia were more common, whilst long thoracic neuropathies, suprascapular neuropathies and UNE were more common in men. Older age increased the risk for CTS, UNE, Morton's metatarsalgia and radiculopathies. Age, gender and BMI are important risk factors for many common focal neuropathies.

English

INTRODUCTION: Sesamoiditis as a cause of fore foot pain is less often thought of, patients suffer for extended periods due to misdiagnosis and analgesic abuse resulting in dissatisfaction, depression and anxiety. METHODS: We performed a multicenter prospective epidemiological screening study in Bhubaneswar, Odisha from Nov' 2013 to July' 2014 in patients of foot pain for the presence of lesser sesamoids to study the incidences and causes of fore foot pain in Odisha Population. RESULTS: We screened 960 patients (1920 feet) in 500 male and 460 female patients. 5th Metatarsal sesamoids were present in 77 (8%) patients (M/F: 1.8:1), Bilateral in 67 (86 %) patients. (48%) patients lesser sesamoids were bipartite and (82%) were symptomatic. 52% recovered with conservative measures, 40 % patients required ultrasound guided injections and sesamoidectomy was performed in 8 % patients due to recurrence and/or failure. Other causes of fore foot pain were Rheumatoid Arthritis, Gouty Arthritis, Callosities, Hallux Valgus, Stress Fractures of the Metatarsals, Plantar Fasciitis, Infections, Morton's Metatarsalgia and Barefoot Walking (mechanical). DISCUSSION: High incidences of lesser sesamoids is attributed to genetics, low socioeconomic status, bare foot walking and high prevalence of Diabetes Mellitus, Smoking and Gout in our country. CT and MRI provide useful information regarding the presence and pathology involving these bones, and should be used in concert with clinical findings to guide successful patient management. An initial trial of conservative measures should follow minimally invasive ultrasound

Description of total population hospital admissions for Morton's metatarsalgia in Australia.

Morton's metatarsalgia is a painful perineural fibroma of a plantar nerve, most commonly of the second or third intermetatarsal spaces of the forefoot. The aim of this study was to investigate hospital admissions with a diagnosis of Morton's metatarsalgia in the Australian population from 1998 to 2008. Data regarding admissions with a diagnosis code of ICD-10 G57.6 were extracted from the Australian Institute of Health and Welfare databases of hospital morbidity from 1998 to 2008. The event of interest was an admission with ICD-10 G57.6 (Morton's metatarsalgia). The explanatory variables included sex and age group. Rates were calculated using the estimated resident population counts to determine denominators. Morton's metatarsalgia admissions were almost three-fold higher for women in the population compared to men. The rate of admissions for Morton's metatarsalgia was the highest for the total population in the 55- to 59-year-old age group. Among women admitted for Morton's metatarsalgia, the highest rate was in the 50- to 54-year-old age group; among men, the highest rate was in the slightly older 55- to 59-year-old age category. Population-level information on admissions for Morton's metatarsalgia show that admissions were three times higher among women compared to men. The highest admission rate was in the 50- to 55-year-old age group.

Filippo Civinini (1805-1844) and the discovery of plantar neuroma

Pathological abnormality (neuroma) related to the painful foot condition commonly called "Morton's metatarsalgia" was first observed in 1835 by Filippo Civinini (1805-1844) of Pistoia, in course of a cadaverous dissection, and clearly described in the anatomic letter entitled "Su un nervoso gangliare rigonfiamento alla pianta del piede" ("On the neural ganglion swelling of the foot sole"). In this study a brief review on the history of Morton's metatarsalgia is carried out, and the importance of Civinini in the discovery of the neuroma of the III intermetatarsal web is underlined.

The digital nerve stretch test: A sensitive indicator of Morton's neuroma and neuritis

We describe a physical sign not previously reported, which adds a sensitive and specific tool to assist the clinical diagnosis of interdigital neuralgia in the foot including Morton's entrapment neuropathy. A prospective record was kept of symptoms and signs in patients treated for Morton's neuroma or neuritis, including the web space pressure test, metatarsal approximation, Mulder's click and the digital nerve stretch test. Twenty-two consecutive patients underwent surgery for Morton's metatarsalgia. At surgery, 16 patients had a neuroma; four had an abnormally thickened, inflamed nerve, and one had evidence of neuritis, and underwent neurolysis. One patient had an epidermal cyst. Our digital nerve stretch test showed 100% sensitivity, with a 95% positive predictive value for Morton's neuroma and neuritis. However, it was also positive in the patient with an epidermal cyst. Although demonstrated in a small group, we believe this sign to be of value in the diagnosis of this condition, and worthy of further study and evaluation.

The variation in the management of Morton's Metatarsalgia

Background: Morton's Metatarsalgia is a painful condition and can often be debilitating. The value of surgical exicion has been doubted due to low success rate of surgical intervention. Objective: The purpose of this study is to examine the variation in the management steps of Morton's Metatarsalgia. Methods: Several surgeons from different European countries answered a questionnaire in regard to their routine management of a typical Morton's neuroma patient. Results: Twenty-five surgeons (100%) stated they would routinely elicit intermetatarsal tenderness in comparison to 14 (56%) and 10 (40%) surgeons who would routinely elicit intermetatrsal tenderness and Mulder's click, respectively. The majority of them (84%) will routinely request plain foot radiograph, while seven surgeons (28%) use ultrasound routinely. Coservative management is initiated by 16 surgeons (64%). Local injection was first line of treatment among 13 surgeons (56%). Surgical treatment is favoured by 10 surgeons (40%), while only 1 surgeon (4%) would use ultrasound-guided injection routinely. The popular surgical approach is dorsal incision (75%). If a surgical option was chosen then neurectomy is attempted by 17 (68%) surgeons. Conclusion: Considerable variation exists among continental surgeons in their initial management of a typical Morton's neuroma patient. This is probably due to lack of understanding of the true aetiology of the Morton's “neuroma”.

Rheumatoid nodule as a cause of Morton's metatarsalgia

A 46-year-old-lady with seropositive rheumatoid arthritis presented with a typical history of Morton's metatarsalgia. Examination revealed a palpable tender mass between the third and fourth toes of her right foot. She underwent excision of the lesion. Histology revealed a Morton's neuroma embedded within the substance of a rheumatoid nodule. This has rarely been described previously and supports the concept of direct neural irritation as a factor in the pathogenesis of Morton's metatarsalgia.

Morton's metatarsalgia: sonographic findings and correlated histopathology.

The results of 79 high resolution ultrasound examinations of the forefoot that were performed for suspected Morton's metatarsalgia were retrospectively assessed. Scans were only obtained if the pain was poorly localized or if there were atypical features that made the clinical diagnosis uncertain. Ultrasound detected 92 hypoechoic intermetatarsal web space masses in 63 patients. Surgery was performed on 23 web spaces in 22 patients where the response to nonsurgical management had been poor. The surgical specimens were retrieved and reviewed by a pathologist in 21 cases. The histopathology in 20 of 21 operated cases was that of Morton's neuroma; however, prominent mucoid degeneration was also found to involve the adjacent loose fibroadipose tissues in 19 of 20 neuroma specimens. Ultrasound was sensitive in the detection of web space abnormality (sensitivity, 0.95), but could not clearly separate Morton's neuroma from associated mass-like mucoid degeneration in the adjacent loose connective tissues. The implications of these observations for both diagnosis and treatment are discussed.

Morton's neuroma: an immunohistochemical study

Fifteen swellings of the interdigital nerve of 12 patients with Morton's metatarsalgia and 3 controls were studied by routine histology and immunohistochemical technique employing monoclonal antibodies against neurofilaments, human epithelial membrane antigen and a polyclonal antibody anti S-100 for the myelinic sheath. With the latter methods, individual nerve fasciculi were accurately identified in the context of the connective tissue mass of the ‘neuroma’. The basic aspect of the lesion showed by this study is the proliferation of connective cells affecting not only the perineurium and the endoneurium, but also individual nerve fasciculi. The latter were classified as compact or loose in relation to the fibrous proliferative process taking place inside fasciculi. Comparison of Morton's ‘neuroma’ and controls showed a prevalence of loosened fasciculi in the former. Fibroblastic proliferation and dissociation of the nerve fibres involved individual nerves in different degrees; no correlation was observed between pathological features and duration of symptoms. In more than two-thirds of cases in this series, Morton's metatarsalgia was associated with cavus or forefoot deformities.

Results of excision of the interdigital nerve in the treatment of morton's metatarsalgia

Thirty-one patients (thirty-two feet) had excision of the interdigital nerve as treatment of their Morton's metatarsalgia. A longitudinal dorsal incision was used in all cases. Out of 32 cases, 25 had a macroscopically visible neuroma and only two had no evidence of a neuroma on histological examination. All thirty-two patients were available for follow-up at an average of 44.7 months (range 14–71 months) postoperatively. 81% of patients had a good or excellent result, 12.5% had a fair result, with residual pain and some restriction of activities, 6.5% had no improvement after their operation. It is noteworthy that 19 patients (60%) benefited from wearing adapted shoes or inner soles for a considerable time after the operation. Even at final follow-up, only 10 patients (30%) had no restrictions in the choice of their shoes.

Histological comparison of the third interdigital nerve in patients with Morton's metatarsalgia and control patients.

This study compares the histology of the plantar-digital nerve supplying the third web space in asymptomatic patients with those who have clinically diagnosed Morton's metatarsalgia. Despite several studies concentrating on the histological changes in the interdigital nerve, the relevance of these changes is a matter of contention while the exact pathological process responsible for the symptoms has not been determined. The histological findings in control patients were identical to Morton's patients with the exception of demyelination, which was more common in the Morton's group. This suggests that the characteristic nodule and fibrotic changes seen in the interdigital nerves of patients with Morton's neuroma cannot account for the symptoms and that the changes seen in the neurovascular bundle are degenerative in origin and are found in asymptomatic patients.

Treatment of Morton's neuroma as a nerve compression. The role for neurolysis

The almost universal surgical approach for the treatment of Morton's metatarsalgia is to resect the neuroma through a dorsal incision. Considering that the mechanism for the metatarsalgia is chronic repetitive compression of the common plantar digital nerve between the metatarsal heads, this report explores the use of neurolysis in five patients with 11 involved nerves. In surgery, the intermetatarsal ligament is divided, intrinsic fibrosis is released, and the epineurium is opened. The mean follow-up period is 33 months. Complete pain relief was achieved in four of the five patients, with the fifth patient, 13 years after a crush injury to the foot, achieving good pain relief. All five patients resumed their usual jobs and athletic activities. One patient wears sneakers instead of regular shoes. The patient with the crush injury wears custom-made shoes.

The supra-transverse intermetatarsocapital bursa: a description and its relation to painful syndromes of the forefoot

Very many painful syndromes of the forefoot remain without a satisfactory explanation; although this region contains quite specific structures, it has suffered from the application of analogies with disorders of the hand. Among these specific components, the presence of the supra-transverse intermetatarsocapital bursa provides an explanation of such clinical entities as the acute syndrome of the second intermetatarsal space and gives fresh impetus to the debate on the etiopathogenesis of Morton's metatarsalgia. On the basis of 25 dissections, the authors studied the region between the metatarsal heads, confirming the presence of these bursae and specifying their site and size and particularly their relations with the common plantar digital nerve at its bifurcation into collateral nerves.

観血的治療により完治したモルトン氏病の２例

Morton's metatarsalgia presents characteristic pain in the forefoot where the common plantar nerve forms tumorous lesion under the deep transverse matatarsal ligament. In this paper we reported two cases of Morton's metatarsalgia treated with surgical management.In case 1 operated specimen formed asymmetrical spindle-like lesion of the nerve between the third and the fourth metatarsus, and in case 2 the nerve didn't form tumorous lesion but was partly changed in color. The asymmetrical lesion in case 1 is an interesting view etiologically.Histologically, in addition to the characteristics of Morton's metatarsalgia both cases showed bleeding spots in the nerve. We consider this bleeding to be the evidence of minor trauma or direct stimulus from the deep transverse metatarsal ligament.In case that conservative therapy is ineffective, operation should be scheduled. Resection of the nerve by dorsal skin incision meets with good results.

Morton's neuroma: a review of recent concepts.

A number of new concepts in the pathology, diagnosis, and management of Morton's metatarsalgia have been presented in the recent literature. Probably as many questions as answers have been generated by these publications. The taut transverse metatarsal ligament appears to play a critical role compressing the interdigital nerve but the exact pathomechanics producing the neuroma and the role of the intermetatarsal bursa remain unclear. Electrodiagnostic techniques for this condition are in the early development stage and may be clinically applicable in the near future. Support for and recommendation against the preoperative injection of the intermetatarsal bursa and interdigital nerve area have been discussed. The necessity of interdigital neurectomy has been questioned but currently in North America, simple transverse metatarsal ligament division has not been widely utilized. Continued studies along these lines should improve our understanding of Morton's metatarsalgia, increase our diagnostic accuracy, and facilitate more effective management.

Morton's metatarsalgia. Clinical, electrophysiological and histological observations.

In an attempt to improve the accuracy of diagnosis, 16 patients suffering from Morton's metatarsalgia were investigated clinically and electrophysiologically. The histological findings were related to these observations. The precise aetiology of Morton's metatarsalgia remains obscure, but the findings are compatible with an entrapment syndrome. Nerve conduction studies have a place in the investigation of patients with atypical presentation of pain in the foot. Further refinement of the electrophysiological technique should be possible.