Difference between revisions of "Morton's neuroma overview"

Jump to: navigation, search
(Overview)
(Medical Therapy)
(One intermediate revision by the same user not shown)
Line 42: Line 42:
 
==Medical Therapy==
 
==Medical Therapy==
  
Non-[[Surgery|surgical]] [[Treatments|treatment]] is [[Institute of Medicine|instituted]] first for the [[Treatments|treatment]] of [[morton's neuroma]]. Firstly, the conservative [[Measure (mathematics)|measures]] are [[Usage analysis|used]] for the [[pain relief]] such as decreasing the [[pressure]] on [[Metatarsal|metatarsal heads]] by [[Usage analysis|using]] [[Metatarsals|metatarsal]] [[support]], [[bars]], padded [[shoe insert]] just [[proximal]] to the [[Metatarsal|metatarsal head]], [[Tapping AFM|tapping]] the [[toe]] [[area]], [[orthotics]], [[Specialize|specialized]] [[orthopedic]] [[Shoe insert|shoes]], [[Shoe insert|shoes]] with [[Wide and fast|wider]] [[toe]] [[Box|boxes]] allowing [[Spreading activation|spread]] of [[Metatarsal bones|metatarsal heads]], determining [[Proper linear model|proper]] [[Shoe insert|shoe]] width, [[physical therapy]], [[Massage|massaging]] [[Ball (anatomy)|ball]] of the [[foot]], [[Strength training|strength]] [[exercises]] for [[Intrinsic factor|intrinsic]] [[foot]] [[muscles]], [[stretching]] [[exercises]] for [[foot]] [[tendons]] & [[ligaments]], [[Rest cure|resting]] the [[foot]], applying [[Ice pack|ice packs]] to the [[sore]] [[foot]] [[Area|areas]]<nowiki/>and [[weight loss]] in [[overweight]] [[patients]]. When conservative [[Measure (mathematics)|measures]] [[Failure|fail]], [[Medical therapy template|medical therapy]] is [[Usage analysis|used]] which includes [[Tricyclic antidepressant|tricyclic antidepressants]], [[anticonvulsants]], [[Serotonin-norepinephrine reuptake inhibitor|serotonin-norepinephrine reuptake inhibitors]], [[ultrasound]]-[[Guidant|guided]] [[Intermetatarsal|interdigital]] [[Injection (medicine)|injection]] of [[Nerve block|nerve blocking]] [[AgentSheets|agents]] such as [[steroids]], [[Local anaesthetic|local anaesthetics]], [[Anti-inflammatory drug|anti-inflammatory drugs]] or [[alcohol]] sclerosing [[injections]] via '''[[dorsal]] approach''' into the [[Site management organization|site]] of [[tenderness]], [[oral]] or [[Injected|injectable]] [[Anti-inflammatory drug|anti-inflammatory drugs]] and [[painkillers]].
+
Non-[[Surgery|surgical]] [[Treatments|treatment]] is [[Institute of Medicine|instituted]] first for the [[Treatments|treatment]] of [[morton's neuroma]]. Firstly, the conservative [[Measure (mathematics)|measures]] are [[Usage analysis|used]] for the [[pain relief]] such as decreasing the [[pressure]] on [[Metatarsal|metatarsal heads]] by [[Usage analysis|using]] [[Metatarsals|metatarsal]] [[support]], [[bars]], padded [[shoe insert]] just [[proximal]] to the [[Metatarsal|metatarsal head]], [[Tapping AFM|tapping]] the [[toe]] [[area]], [[orthotics]], [[Specialize|specialized]] [[orthopedic]] [[Shoe insert|shoes]], [[Shoe insert|shoes]] with [[Wide and fast|wider]] [[toe]] [[Box|boxes]] allowing [[Spreading activation|spread]] of [[Metatarsal bones|metatarsal heads]], low [[Heel|heels]], [[Good Friends (Cereal)|good]] [[arch support]] & [[Stiff pattern|stiff]] [[soles]], determining [[Proper linear model|proper]] [[Shoe insert|shoe]] width, [[physical therapy]], [[Massage|massaging]] [[Ball (anatomy)|ball]] of the [[foot]], [[Strength training|strength]] [[exercises]] for [[Intrinsic factor|intrinsic]] [[foot]] [[muscles]], [[stretching]] [[exercises]] for [[foot]] [[tendons]] & [[ligaments]], [[Rest cure|resting]] the [[foot]], applying [[Ice pack|ice packs]] to the [[sore]] [[foot]] [[Area|areas]] and [[weight loss]] in [[overweight]] [[patients]]. When conservative [[Measure (mathematics)|measures]] [[Failure|fail]], [[Medical therapy template|medical therapy]] is [[Usage analysis|used]] which includes [[Tricyclic antidepressant|tricyclic antidepressants]], [[anticonvulsants]], [[Serotonin-norepinephrine reuptake inhibitor|serotonin-norepinephrine reuptake inhibitors]], [[ultrasound]]-[[Guidant|guided]] [[Intermetatarsal|interdigital]] [[Injection (medicine)|injection]] of [[Nerve block|nerve blocking]] [[AgentSheets|agents]] such as [[steroids]], [[Local anaesthetic|local anaesthetics]], [[Anti-inflammatory drug|anti-inflammatory drugs]] or [[alcohol]] sclerosing [[injections]] via '''[[dorsal]] approach''' into the [[Site management organization|site]] of [[tenderness]], [[oral]] or [[Injected|injectable]] [[Anti-inflammatory drug|anti-inflammatory drugs]] and [[painkillers]].
 
 
 
==Surgery==
 
==Surgery==
  

Revision as of 03:59, 15 June 2019

Morton's neuroma Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Morton's Neuroma from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

X Ray

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Morton's neuroma overview On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Morton's neuroma overview

All Images
X-rays
Echo and Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Morton's neuroma overview

CDC on Morton's neuroma overview

Morton's neuroma overview in the news

Blogs on Morton's neuroma overview

Directions to Hospitals Treating Morton's neuroma

Risk calculators and risk factors for Morton's neuroma overview

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, low heels, good arch support & stiff soles, 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 areas and 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


Linked-in.jpg