Surgery for Morton Neuroma Workup

  • Author: Thomas M Schaller, MD; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Jul 28, 2010
 

Imaging Studies

  • A large body of literature addresses the use of imaging modalities to aid in the diagnosis of Morton neuroma.[7] The condition is most commonly diagnosed based strictly upon the history and physical examination findings. In equivocal cases, the use of ultrasound, magnetic resonance imaging (MRI), or both may be helpful.[8, 9, 10]
    • The skill of the technologists and physicians performing and interpreting these studies plays a key role in determining just how valuable these modalities can be in clinical practice.
    • The ultrasound appearance is typically that of a hypoechoic oblong mass that is oriented along the long axis of the foot. Prospective studies in symptomatic patients reveal that ultrasound can be used reliably to detect the neuromas.[11, 7] Furthermore, they can be helpful in identifying contributing pathologic lesions, such as lipomas or bursae.[12]
    • MRI technology and applications continue to evolve and can provide reliable information regarding the pathoanatomy of the forefoot. The characteristic MRI findings of a Morton neuroma are low intensity on T1- and T2-weighted sequences due to the high degree of fibrous content. In contrast, an intermetatarsal bursa is associated with increased intensity on the T2-weighted images due to its fluid content.[13] MRI with gadolinium contrast enhancement and with fat suppression probably provides the most reliable images for diagnosis.[14]
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Diagnostic Procedures

  • An injection of local anesthetic with sterile technique may be useful in the diagnostic evaluation of Morton neuroma. The temporary resolution of pain, paresthesias, or both in response to the injection may confirm the location of the pathology. A positive response to the injection tends to be predictive of satisfactory postsurgical outcomes.
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Histologic Findings

See Pathophysiology.

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Contributor Information and Disclosures
Author

Thomas M Schaller, MD  Orthopedic Trauma Surgeon, Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina

Thomas M Schaller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, AO Foundation, and Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Heidi M Stephens, MD, MBA  Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

References

  1. Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. Nov 1996;4(6):328-335. [Medline].

  2. Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. Mosby-Year Book;1999.

  3. Thompson FM, Deland JT. Occurrence of two interdigital neuromas in one foot. Foot Ankle. Jan 1993;14(1):15-7. [Medline].

  4. Levitsky KA, Alman BA, Jevsevar DS. Digital nerves of the foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot Ankle. May 1993;14(4):208-14. [Medline].

  5. Thomas JL, Blitch EL 4th, Chaney DM, Dinucci KA, Eickmeier K, Rubin LG, et al. Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. Mar-Apr 2009;48(2):251-6. [Medline].

  6. Mulder J. The Causative Mechanism in Morton's Metatarsalgia. J Bone Joint Surg Br. 1951;33:94-95.

  7. Rout R, Tedd H, Lloyd R, Ostlere S, Lavis GJ, Cooke PH, et al. Morton's neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians. Qual Prim Care. 2009;17(4):277-82. [Medline].

  8. Lee MJ, Kim S, Huh YM, Song HT, Lee SA, Lee JW, et al. Morton neuroma: evaluated with ultrasonography and MR imaging. Korean J Radiol. Mar-Apr 2007;8(2):148-55. [Medline].

  9. Zanetti M, Weishaupt D. MR imaging of the forefoot: Morton neuroma and differential diagnoses. Semin Musculoskelet Radiol. Sep 2005;9(3):175-86. [Medline].

  10. Giannini S, Bacchini P, Ceccarelli F, Vannini F. Interdigital neuroma: clinical examination and histopathologic results in 63 cases treated with excision. Foot Ankle Int. Feb 2004;25(2):79-84. [Medline].

  11. Read JW, Noakes JB, Kerr D. Morton's metatarsalgia: sonographic findings and correlated histopathology. Foot Ankle Int. Mar 1999;20(3):153-61. [Medline].

  12. Iagnocco A, Coari G, Palombi G. Sonography in the study of metatarsalgia. J Rheumatol. Jun 2001;28(6):1338-40. [Medline].

  13. Timins ME. MR imaging of the foot and ankle. Foot Ankle Clin. Mar 2000;5(1):83-101, vi. [Medline].

  14. Terk MR, Kwong PK, Suthar M. Morton neuroma: evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology. Oct 1993;189(1):239-41. [Medline].

  15. Saygi B, Yildirim Y, Saygi EK, Kara H, Esemenli T. Morton neuroma: comparative results of two conservative methods. Foot Ankle Int. Jul 2005;26(7):556-9. [Medline].

  16. Fridman R, Cain JD, Weil L Jr. Extracorporeal shockwave therapy for interdigital neuroma: a randomized, placebo-controlled, double-blind trial. J Am Podiatr Med Assoc. May-Jun 2009;99(3):191-3. [Medline].

  17. Lee KT, Lee YK, Young KW, Kim HJ, Park SY. Results of operative treatment of double Morton's neuroma in the same foot. J Orthop Sci. Sep 2009;14(5):574-8. [Medline].

  18. Valente M, Crucil M, Alecci V. Operative treatment of interdigital Morton's neuroma. Chir Organi Mov. Mar 14 2008;[Medline].

  19. Coughlin MJ, Pinsonneault T. Operative treatment of interdigital neuroma. A long-term follow-up study. J Bone Joint Surg Am. Sep 2001;83-A(9):1321-8. [Medline].

  20. Pace A, Scammell B, Dhar S. The outcome of Morton's neurectomy in the treatment of metatarsalgia. Int Orthop. Apr 2010;34(4):511-5. [Medline].

  21. Benedetti RS, Baxter DE, Davis PF. Clinical results of simultaneous adjacent interdigital neurectomy in the foot. Foot Ankle Int. May 1996;17(5):264-8. [Medline].

 
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Plantar view showing the relationships between the metatarsal heads, the intermetatarsal ligament, and the neuroma.
This image demonstrates the key provocative physical examination maneuver: simultaneous forefoot compression coupled with intermetatarsal space compression.
The histopathology reveals nerve fibers and pacinian corpuscles entrapped within fibromyxoid connective tissue.
Typical incision location.
Superficial exposure.
Deeper dissection.
Neuroma and adherent fibrofatty tissue.
 
 
 
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