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==Overview==
 
==Overview==
'''Morton's neuroma''' is a [[benign]] [[neuroma]] of the interdigital [[plantar nerve]]. Although it is labeled a "neuroma", many sources do not consider it a true [[tumor]], but rather a thickening of existing tissue or a swollen, inflamed nerve located between the bones at the ball of the foot. The most common location of a Morton's neuroma is in either the second or the third spacing from the base of the big toe. It is characterised by [[numbness]] and [[Pain and nociception|pain]], relieved by removing footwear.
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'''Morton's neuroma''' is a [[benign]] [[neuroma]] of the [[Intermetatarsal|interdigital]] [[plantar nerve]]. Although it is [[Label|labeled]] a "[[neuroma]]", many sources do not consider it a true [[tumor]], but rather a [[Thickener|thickening]] of existing [[Tissue (biology)|tissue]] or a [[Swelling|swollen]], [[inflamed]] [[nerve]] [[Location parameter|located]] between the [[bones]] at the [[Ball (anatomy)|ball]] of the [[foot]]. The most common [[Location parameter|location]] of a [[Morton's neuroma]] is in either the second or the third [[Intermetatarsal|spacing]] from the [[base]] of the [[big toe]]. It is [[Characterization (mathematics)|characterised]] by [[numbness]] & [[Pain and nociception|pain]], and [[Pain relief|relieved]] by removing [[Foot|footwear]].
 
==Historical Perspective==
 
==Historical Perspective==
 
The [[Term logic|term]] [[neuroma]] originates from two [[Greek key|Greek]] words, ''[[NeuroArm|neuro]]-'' from the [[Greek key|Greek]] word for ''[[nerve]]'' (νεῦρον), and ''-oma'' (-ωμα) from the [[Greek key|Greek]] word for ''[[swelling]]''. In 1876, [[neuroma]] was first described by Thomas [[Morton's neuroma|Morton]] and [[Morton's neuroma]] was first correctly described by a chiropodist named Durlacher. In 2000, a small [[Study design|study]][[Review|reviewed]] the [[medical records]] of 85 [[People's Solidarity|people]] who had their [[feet]] [[Image|imaged]] with [[Magnetic resonance imaging|MRI]], and it was found out that 33% of the [[patients]] had [[morton's neuroma]] without any [[pain]].
 
The [[Term logic|term]] [[neuroma]] originates from two [[Greek key|Greek]] words, ''[[NeuroArm|neuro]]-'' from the [[Greek key|Greek]] word for ''[[nerve]]'' (νεῦρον), and ''-oma'' (-ωμα) from the [[Greek key|Greek]] word for ''[[swelling]]''. In 1876, [[neuroma]] was first described by Thomas [[Morton's neuroma|Morton]] and [[Morton's neuroma]] was first correctly described by a chiropodist named Durlacher. In 2000, a small [[Study design|study]][[Review|reviewed]] the [[medical records]] of 85 [[People's Solidarity|people]] who had their [[feet]] [[Image|imaged]] with [[Magnetic resonance imaging|MRI]], and it was found out that 33% of the [[patients]] had [[morton's neuroma]] without any [[pain]].
 
==Pathophysiology==
 
==Pathophysiology==
[[Morton's neuroma]] is [[Association (statistics)|associated]] with [[symptomatic]] [[Collapse (medical)|collapse]] of the [[Transverse arch of the foot|transverse arch]] by [[Perineural fibroma|perineural]] [[fibrosis]] around a [[plantar]] [[digital nerve]] of the [[foot]] due to [[Chronic (medical)|chronic]][[Traction (orthopedics)|traction]] and increased [[pressure]]/[[Compression bandage|compression]] on the interdigital [[nerve]]. It is [[Location parameter|located]] at the [[Third metatarsal bone|third]] [[Intermetatarsal|intermetatarsal space]] most commonly (between [[Third metatarsal bone|third]] and [[Fourth metatarsal bone|fourth metatarsals]]), and sometimes [[Second metatarsal bone|second]] or [[Fourth metatarsal bone|fourth]] interspaces or [[bifurcation]] of the fourth [[plantar]] [[digital nerve]]. [[Gross pathology|Gross pathological]] [[Features (pattern recognition)|features]] of [[morton's neuroma]] include adherent fibrofatty [[Tissue (biology)|tissue]], small, [[Firming agent|firm]], [[oval]], [[Yellowing|yellowish]]-[[White (mutation)|white]], [[Slow|slowly]] [[Growth|growing]], [[palpable]] [[nodule]] on [[skin]] (no discoloration of [[skin]] on the [[Top note|top]] of [[nodule]]) and </=2cm in [[Size consistency|size]]. [[Histopathological]] [[analysis]] is [[Characterization (mathematics)|characterized]] by extensive [[fibrosis]] around and within the [[nerve]], [[Digit ratio|digital]] [[artery]], [[Thrombosis|thrombosis,]] [[Epineurium|epineural]] and [[Endoneurium|endoneural]] [[arterial]][[Thickener|thickening]]/[[vascular]] [[Hyaline|hyalinization]], and [[Degenerate|degenerated]]/[[Demyelination|demyelinated]] [[axons]].
+
[[Morton's neuroma]] is [[Association (statistics)|associated]] with [[symptomatic]] [[Collapse (medical)|collapse]] of the [[Transverse arch of the foot|transverse arch]] by [[Perineural fibroma|perineural]] [[fibrosis]] around a [[plantar]] [[digital nerve]] of the [[foot]] due to [[Chronic (medical)|chronic]][[Traction (orthopedics)|traction]] and increased [[pressure]]/[[Compression bandage|compression]] on the [[Intermetatarsal|interdigital]] [[nerve]]. It is [[Location parameter|located]] at the [[Third metatarsal bone|third]] [[Intermetatarsal|intermetatarsal space]] most commonly (between [[Third metatarsal bone|third]] and [[Fourth metatarsal bone|fourth metatarsals]]), and sometimes [[Second metatarsal bone|second]] or [[Fourth metatarsal bone|fourth]] [[Intermetatarsal|interspaces]] or [[bifurcation]] of the fourth [[plantar]] [[digital nerve]]. [[Gross pathology|Gross pathological]] [[Features (pattern recognition)|features]] of [[morton's neuroma]] include [[Attachment (psychology)|adherent]] fibrofatty [[Tissue (biology)|tissue]], small, [[Firming agent|firm]], [[oval]], [[Yellowing|yellowish]]-[[White (mutation)|white]], [[Slow|slowly]] [[Growth|growing]], [[palpable]] [[nodule]] on [[skin]] (no discoloration of [[skin]] on the [[Top note|top]] of [[nodule]]) and </=2cm in [[Size consistency|size]]. [[Histopathological]] [[analysis]] is [[Characterization (mathematics)|characterized]] by extensive [[fibrosis]] around and within the [[nerve]], [[Digit ratio|digital]] [[artery]], [[Thrombosis|thrombosis,]] [[Epineurium|epineural]] and [[Endoneurium|endoneural]] [[arterial]][[Thickener|thickening]]/[[vascular]] [[Hyaline|hyalinization]], and [[Degenerate|degenerated]]/[[Demyelination|demyelinated]] [[axons]].
 
==Causes==
 
==Causes==
 
The exact [[Causes|cause]] is unknown. However, [[morton's neuroma]] is [[Belief revision|believed]] to be [[Association (statistics)|associated]] with [[Wear red day|wearing]] tight [[Shoe insert|shoes]] with tapered [[toe]] [[box]] or high [[Heel|heels]], overpronation, [[abnormal]] [[Position effect|positioning]] of [[toes]], [[flat feet]], [[Foot|forefoot]] [[Problem Solved|problems]] such as [[Bunion|bunions]] and [[Hammer toe|hammer toes]], and high [[Arches of the foot|foot arches]].
 
The exact [[Causes|cause]] is unknown. However, [[morton's neuroma]] is [[Belief revision|believed]] to be [[Association (statistics)|associated]] with [[Wear red day|wearing]] tight [[Shoe insert|shoes]] with tapered [[toe]] [[box]] or high [[Heel|heels]], overpronation, [[abnormal]] [[Position effect|positioning]] of [[toes]], [[flat feet]], [[Foot|forefoot]] [[Problem Solved|problems]] such as [[Bunion|bunions]] and [[Hammer toe|hammer toes]], and high [[Arches of the foot|foot arches]].
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[[Risk factors]] for [[morton's neuroma]] include [[Improper rotation|improper]] [[Foot|footwear]]/tight [[Shoe insert|shoes]] with tapered [[toe]] [[box]], [[abnormal]] [[Position effect|positioning]] of [[toes]], [[flat feet]], [[Foot|forefoot]] [[Problem Solved|problems]] such as [[Bunion|bunions]] and [[Hammer toe|hammer toes]], high [[Arches of the foot|foot arches]], high [[Heel|heels]], overpronation, [[Gait Abnormalities|gait abnormalities]], and high-[[Impacted|impact]] [[Sports Medicine|sports]] such as [[Rock climbing|rock-climbing]], ballet dancing, jogging, [[running]], [[snow]] skiing, racquet and court [[Sports medicine|sports]].
 
[[Risk factors]] for [[morton's neuroma]] include [[Improper rotation|improper]] [[Foot|footwear]]/tight [[Shoe insert|shoes]] with tapered [[toe]] [[box]], [[abnormal]] [[Position effect|positioning]] of [[toes]], [[flat feet]], [[Foot|forefoot]] [[Problem Solved|problems]] such as [[Bunion|bunions]] and [[Hammer toe|hammer toes]], high [[Arches of the foot|foot arches]], high [[Heel|heels]], overpronation, [[Gait Abnormalities|gait abnormalities]], and high-[[Impacted|impact]] [[Sports Medicine|sports]] such as [[Rock climbing|rock-climbing]], ballet dancing, jogging, [[running]], [[snow]] skiing, racquet and court [[Sports medicine|sports]].
 
==Natural History, Complications and Prognosis==
 
==Natural History, Complications and Prognosis==
Morton's neuroma can make walking difficult. Nonsurgical treatment does not always improve symptoms.
+
[[Symptoms]] of [[morton's neuroma]] begin gradually and initially occur only occasionally while [[Wear red day|wearing]] the narrow-[[Toe|toed]] [[Shoe insert|shoes]] and [[Performance status|performing]] [[Certain safety factor|certain]] aggravating [[Activities of daily living|activities]]. [[Symptoms]] may go away temporarily by [[Elimination communication|removing]] the [[Shoe insert|shoe]], [[Massage|massaging]] the [[foot]] and [[Avoidance reaction|avoiding]] the aggravating [[Shoe insert|shoes]]/[[Activities of daily living|activities]]. [[Symptoms]] become even more [[Intensity|intense]] & start to worsen progressively with time and may persist for several [[Day spa|days]] or weeks. Ultimately, the temporary changes in the [[nerve]] become permanent if left untreated for prolonged [[periods]] of [[Time constant|time]]. Common [[complications]] of [[morton's neuroma]] include [[Difficulty walking|difficult walking]], [[trouble]] [[Performance status|performing]] [[Activities of daily living|activities]] that [[Puto|put]][[pressure]] on the [[foot]] ([[Pressor|pressing]] the [[gas]] pedal of an [[Automobile accident|automobile]]), [[feet]] hurt with [[Wear red day|wearing]] [[Certain safety factor|certain]] types of [[Shoe insert|shoes]] especially high-[[Heel|heels]], [[Permanent cosmetics|permanent]] non-[[painful]][[numbness]] & small [[RiskMetrics|risk]] of [[infection]] around [[toes]] [[after surgery]]. Non-[[Surgery|surgical]] [[Treatments|treatment]] is successful in 80% of the [[Case-based reasoning|cases]] but does not always [[Improving agent|improve]] [[symptoms]] and [[surgery]] to remove the [[Thickener|thickened]] [[Tissue (biology)|tissue]] is successful in about 85% of [[Case-based reasoning|cases]].
 
==History and Symptoms==
 
==History and Symptoms==
 
[[Morton's neuroma]] is most commonly [[Location parameter|located]] at the [[Third metatarsal bone|third]] [[intermetatarsal]] [[Spacetime|space]], with other [[Site Master File|sites]] being involved including [[Second metatarsal bone|second]] or [[Fourth metatarsal bone|fourth]] [[Intermetatarsal|interspaces]], at the [[bifurcation]] of the fourth [[plantar]] [[digital nerve]] and [[Fifth metatarsal|fifth]] [[Intermetatarsal|interspace]] [[Rare|rarely]]. [[Patient]] complaints of [[feeling]] like <nowiki>''</nowiki>[[walking]] on a marble<nowiki>''</nowiki>. Most common [[symptom]] of [[morton's neuroma]] includes persistent [[pain]] on [[weight]] bearing [[Affect|affecting]] the [[contiguous]] [[Half cell|halves]] of two [[toes]], with the [[nature]] of [[pain]] being [[Shooting, shoveling, and shutting up|shooting]], [[Burn|burning]], stabbing, [[raw]], gnawing or [[Sick|sickening]] [[sensations]]. Other [[symptoms]] may include [[numbness]], [[parasthesia]], [[dysesthesia]], [[Function (biology)|functional]] [[impairment]] and [[psychological]] [[distress]] [[Association (statistics)|associated]]<nowiki/>with severe decrease in the [[quality of life]].
 
[[Morton's neuroma]] is most commonly [[Location parameter|located]] at the [[Third metatarsal bone|third]] [[intermetatarsal]] [[Spacetime|space]], with other [[Site Master File|sites]] being involved including [[Second metatarsal bone|second]] or [[Fourth metatarsal bone|fourth]] [[Intermetatarsal|interspaces]], at the [[bifurcation]] of the fourth [[plantar]] [[digital nerve]] and [[Fifth metatarsal|fifth]] [[Intermetatarsal|interspace]] [[Rare|rarely]]. [[Patient]] complaints of [[feeling]] like <nowiki>''</nowiki>[[walking]] on a marble<nowiki>''</nowiki>. Most common [[symptom]] of [[morton's neuroma]] includes persistent [[pain]] on [[weight]] bearing [[Affect|affecting]] the [[contiguous]] [[Half cell|halves]] of two [[toes]], with the [[nature]] of [[pain]] being [[Shooting, shoveling, and shutting up|shooting]], [[Burn|burning]], stabbing, [[raw]], gnawing or [[Sick|sickening]] [[sensations]]. Other [[symptoms]] may include [[numbness]], [[parasthesia]], [[dysesthesia]], [[Function (biology)|functional]] [[impairment]] and [[psychological]] [[distress]] [[Association (statistics)|associated]]<nowiki/>with severe decrease in the [[quality of life]].

Revision as of 00:05, 15 June 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mohsin, M.B.B.S.[2]Faizan Sheraz, M.D. [3]

Overview

Morton's neuroma is a benign neuroma of the interdigital plantar nerve. Although it is labeled a "neuroma", many sources do not consider it a true tumor, but rather a thickening of existing tissue or a swollen, inflamed nerve located between the bones at the ball of the foot. The most common location of a Morton's neuroma is in either the second or the third spacing from the base of the big toe. It is characterised by numbness & pain, and relieved by removing footwear.

Historical Perspective

The term neuroma originates from two Greek words, neuro- from the Greek word for nerve (νεῦρον), and -oma (-ωμα) from the Greek word for swelling. In 1876, neuroma was first described by Thomas Morton and Morton's neuroma was first correctly described by a chiropodist named Durlacher. In 2000, a small studyreviewed the medical records of 85 people who had their feet imaged with MRI, and it was found out that 33% of the patients had morton's neuroma without any pain.

Pathophysiology

Morton's neuroma is associated with symptomatic collapse of the transverse arch by perineural fibrosis around a plantar digital nerve of the foot due to chronictraction and increased pressure/compression on the interdigital nerve. It is located at the third intermetatarsal space most commonly (between third and fourth metatarsals), and sometimes second or fourth interspaces or bifurcation of the fourth plantar digital nerve. Gross pathological features of morton's neuroma include adherent fibrofatty tissue, small, firm, oval, yellowish-white, slowly growing, palpable nodule on skin (no discoloration of skin on the top of nodule) and </=2cm in size. Histopathological analysis is characterized by extensive fibrosis around and within the nerve, digital artery, thrombosis, epineural and endoneural arterialthickening/vascular hyalinization, and degenerated/demyelinated axons.

Causes

The exact cause is unknown. However, morton's neuroma is believed to be associated with wearing tight shoes with tapered toe box or high heels, overpronation, abnormal positioning of toes, flat feet, forefoot problems such as bunions and hammer toes, and high foot arches.

Differentiating Morton's Neuroma from other diseases

Morton's neuroma must be differentiated from other causes of pain in the forefoot such as capsulitis, intermetatarsal bursitis, arthritis of intermetatarsal joints, calluses, stress fractures, and Freiberg's disease.

Epidemiology and Demographics

Morton's neuroma is more common in women than men.

Risk Factors

Risk factors for morton's neuroma include improper footwear/tight shoes with tapered toe box, abnormal positioning of toes, flat feet, forefoot problems such as bunions and hammer toes, high foot arches, high heels, overpronation, gait abnormalities, and high-impact sports such as rock-climbing, ballet dancing, jogging, running, snow skiing, racquet and court sports.

Natural History, Complications and Prognosis

Symptoms of morton's neuroma begin gradually and initially occur only occasionally while wearing the narrow-toed shoes and performing certain aggravating activities. Symptoms may go away temporarily by removing the shoe, massaging the foot and avoiding the aggravating shoes/activities. Symptoms become even more intense & start to worsen progressively with time and may persist for several days or weeks. Ultimately, the temporary changes in the nerve become permanent if left untreated for prolonged periods of time. Common complications of morton's neuroma include difficult walking, trouble performing activities that putpressure on the foot (pressing the gas pedal of an automobile), feet hurt with wearing certain types of shoes especially high-heels, permanent non-painfulnumbness & small risk of infection around toes after surgery. Non-surgical treatment is successful in 80% of the cases but does not always improve symptoms and surgery to remove the thickened tissue is successful in about 85% of cases.

History and Symptoms

Morton's neuroma is most commonly located at the third intermetatarsal space, with other sites being involved including second or fourth interspaces, at the bifurcation of the fourth plantar digital nerve and fifth interspace rarely. Patient complaints of feeling like ''walking on a marble''. Most common symptom of morton's neuroma includes persistent pain on weight bearing affecting the contiguous halves of two toes, with the nature of pain being shooting, burning, stabbing, raw, gnawing or sickening sensations. Other symptoms may include numbness, parasthesia, dysesthesia, functional impairment and psychological distress associatedwith severe decrease in the quality of life.

Physical Examination

Patients may have antalgic posture. Physical examination may be remarkable for tenderness to palpation, limitation of range of motion, dysesthetic pain and Mulder's sign which includes replication of symptoms or clicking sensations upon direct pressure between the metatarsal heads or compression of transverse arch in forefoot between the finger and thumb. Negative signs include no obvious deformities, erythema or signs of inflammation.

Laboratory Findings

Blood tests are done to check for inflammation-related conditions, including certain forms of arthritis.

X-Ray

A foot x-ray may be done to rule out bone pathologies such as arthritis or any stress fractures.

MRI

MRI can successfully diagnose soft tissue abnormalities associated with Morton's neuroma.

Other Imaging Findings

Imaging findings on high-resolution ultrasound may help to find out or differentiate any soft tissue abnormalities from morton's neuroma.

Other Diagnostic Tests

Nerve testing such as electromyography cannot definitely diagnose Morton's neuroma, but may be used to rule out conditions that cause similar symptoms.

Medical Therapy

Non-surgical treatment is instituted first for the treatment of morton's neuroma. Firstly, the conservative measures are used for the pain relief such as decreasing the pressure on metatarsal heads by using metatarsal support, bars, padded shoe insert just proximal to the metatarsal head, tapping the toe area, orthotics, specialized orthopedic shoes, shoes with wider toe boxes allowing spread of metatarsal heads, determining proper shoe width, physical therapy, massaging ball of the foot, strength exercises for intrinsic foot muscles, stretching exercises for foot tendons & ligaments, resting the foot, applying ice packs to the sore foot areasand weight loss in overweight patients. When conservative measures fail, medical therapy is used which includes tricyclic antidepressants, anticonvulsants, serotonin-norepinephrine reuptake inhibitors, ultrasound-guided interdigital injection of nerve blocking agents such as steroids, local anaesthetics, anti-inflammatory drugs or alcohol sclerosing injections via dorsal approach into the site of tenderness, oral or injectable anti-inflammatory drugs and painkillers.

Surgery

Surgery is the last resort in the treatment of morton's neuroma. In some cases, surgery may be needed to remove the thickened tissue/affected nerve in order to help release the pressure on the affected nerve, relieve the pain and improve foot function. Few complications after surgery are possible and include permanentnonpainful numbness if a portion of the affected nerve is removed and also a risk of infection around the toes. Morton's neuroma can be removed surgically either via dorsal or plantar approach, with each approach having its own merits and demerits. Depending upon each individual case, different surgical procedures that can be used for the treatment of morton's neuroma include neurectomy, cryogenic surgery/neuroablation, and decompression surgery.

Primary prevention

Primary preventive measures for morton's neuroma include avoiding ill-fitting shoes, high heels, narrow-toed shoes, overpronation, high-impact sports such as rock-climbing, ballet dancing, jogging, running, snow skiing, wearing comfortable shoes with wide toe box, low heels & good arch support and wearing athletic shoes (with enough padding in the soles) while running or playing sports.

References


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