Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Surgery for Morton Neuroma Workup

  • Author: Lyle Jackson, MD; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Nov 03, 2015
 

Imaging Studies

A large body of literature addresses the use of imaging modalities to aid in the diagnosis of Morton neuroma.[8] 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.[9, 10, 11, 12]

Standing radiographs are helpful for evaluation of overall osseous structure and joint abnormalities.

The skill of the technologists and physicians performing and interpreting MRIs or ultrasounds 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 oriented along the long axis of the foot. Prospective studies in symptomatic patients reveal that ultrasound can be used reliably to detect the neuromas.[8, 13] Furthermore, they can be helpful in identifying contributing pathologic lesions, such as lipomas or bursae.[14] Nonetheless, in a small series of asymptomatic patients, 26 (54%) of 48 of the individuals had ultrasonographic enlargement of an interdigital nerve of greater than 5 mm.[12] This finding emphasizes the importance of history and clinical examination and the risk of false positives.

MRI technology and applications continue to evolve and can provide reliable information regarding the pathoanatomy of the forefoot.[15] 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.[16] MRI with gadolinium contrast enhancement and with fat suppression probably provides the most reliable images for diagnosis.[17]

Next

Other Tests

Electrodiagnostic testing has been described to aid in diagnosis, but its use is not common, and its utility has yet to be determined.[18, 19]

Previous
Next

Diagnostic Procedures

An injection of local anesthetic with sterile technique may be useful in the diagnostic evaluation of Morton neuroma.[20] 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.

Previous
Next

Histologic Findings

See Pathophysiology.

Previous
 
 
Contributor Information and Disclosures
Author

Lyle Jackson, MD Resident Physician, Department of Orthopedic Surgery, Greenville Hospital System, University of South Carolina School of Medicine

Lyle Jackson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

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

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

Disclosure: Received honoraria from Smith Nephew for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

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, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

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, Florida Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Patrick L. O'Connor, MD, to the development and writing of this article.

References
  1. Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov. 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. 1993 Jan. 14(1):15-7. [Medline].

  4. Adams WR 2nd. Morton's neuroma. Clin Podiatr Med Surg. 2010 Oct. 27(4):535-45. [Medline].

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

  6. 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. 2009 Mar-Apr. 48(2):251-6. [Medline].

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

  8. 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].

  9. 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. 2007 Mar-Apr. 8(2):148-55. [Medline].

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

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

  12. Symeonidis PD, Iselin LD, Simmons N, Fowler S, Dracopoulos G, Stavrou P. Prevalence of interdigital nerve enlargements in an asymptomatic population. Foot Ankle Int. 2012 Jul. 33(7):543-7. [Medline].

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

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

  15. Claassen L, Bock K, Ettinger M, Waizy H, Stukenborg-Colsman C, Plaass C. Role of MRI in detection of Morton's neuroma. Foot Ankle Int. 2014 Oct. 35 (10):1002-5. [Medline].

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

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

  18. Aydinlar EI, Uzun M, Beksac B, Ozden VE, Karaarslan E, Oge AE. Simple electrodiagnostic method for morton neuroma. Muscle Nerve. 2013 May 6. [Medline].

  19. Pardal-Fernández JM, Palazón-García E, Hernández-Fernández F, de Cabo C. Contribution of a new electrophysiologic test to Morton's neuroma diagnosis. Foot Ankle Surg. 2014 Jun. 20 (2):109-14. [Medline].

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

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

  22. 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. 2009 May-Jun. 99(3):191-3. [Medline].

  23. Thomson CE, Beggs I, Martin DJ, McMillan D, Edwards RT, Russell D, et al. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. J Bone Joint Surg Am. 2013 May 1. 95(9):790-8, S1. [Medline].

  24. Makki D, Haddad BZ, Mahmood Z, Shahid MS, Pathak S, Garnham I. Efficacy of corticosteroid injection versus size of plantar interdigital neuroma. Foot Ankle Int. 2012 Sep. 33(9):722-6. [Medline].

  25. Espinosa N, Seybold JD, Jankauskas L, Erschbamer M. Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma. Foot Ankle Int. 2011 Jun. 32(6):576-80. [Medline].

  26. Fanucci E, Masala S, Fabiano S, Perugia D, Squillaci E, Varrucciu V. Treatment of intermetatarsal Morton's neuroma with alcohol injection under US guide: 10-month follow-up. Eur Radiol. 2004 Mar. 14(3):514-8. [Medline].

  27. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton's neuroma: a five-year follow-up. Foot Ankle Int. 2013 Aug. 34(8):1064-7. [Medline].

  28. Coughlin MJ, Mann RA, Salzmann CL. Diseases of Nerves. Surgery of the Foot and Ankle. 8th ed. Philadelphia, Pa: Mosby/Elsevier; 2007. Vol 1: 625.

  29. 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. 2009 Sep. 14(5):574-8. [Medline].

  30. Colgrove RC, Huang EY, Barth AH, Greene MA. Interdigital neuroma: intermuscular neuroma transposition compared with resection. Foot Ankle Int. 2000 Mar. 21(3):206-11. [Medline].

  31. Akermark C, Crone H, Skoog A, Weidenhielm L. A prospective randomized controlled trial of plantar versus dorsal incisions for operative treatment of primary Morton's neuroma. Foot Ankle Int. 2013 Sep. 34(9):1198-204. [Medline].

  32. Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. Foot Ankle Int. 2008 Feb. 29(2):136-41. [Medline].

  33. Nery C, Raduan F, Del Buono A, Asaumi ID, Maffulli N. Plantar approach for excision of a Morton neuroma: a long-term follow-up study. J Bone Joint Surg Am. 2012 Apr 4. 94(7):654-8. [Medline].

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

  35. Park EH, Kim YS, Lee HJ, Koh YG. Metatarsal Shortening Osteotomy for Decompression of Morton's Neuroma. Foot Ankle Int. 2013 Jul 26. [Medline].

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

  37. Colgrove RC, Huang EY, Barth AH, Greene MA. Interdigital neuroma: intermuscular neuroma transposition compared with resection. Foot Ankle Int. 2000 Mar. 21(3):206-11. [Medline].

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

  39. Richardson DR, Dean EM. The recurrent Morton neuroma: what now?. Foot Ankle Clin. 2014 Sep. 19 (3):437-49. [Medline].

  40. Akermark C, Saartok T, Zuber Z. A prospective 2-year follow-up study of plantar incisions in the treatment of primary intermetatarsal neuromas (Morton's neuroma). Foot Ankle Surg. 2008. 14(2):67-73. [Medline].

  41. Kasparek M, Schneider W. Surgical treatment of Morton's neuroma: clinical results after open excision. Int Orthop. 2013 Sep. 37(9):1857-61. [Medline]. [Full Text].

 
Previous
Next
 
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.
Dorsal incision.
Superficial exposure.
Deeper dissection.
Neuroma and adherent fibrofatty tissue.
Distal plantar transverse incision.
Plantar longitudinal incision.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.