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Physical Medicine and Rehabilitation for Morton Neuroma Workup

  • Author: Kevin Berry, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Jan 11, 2016
 

Laboratory Studies

No laboratory studies are indicated for the diagnosis of Morton's neuroma.

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Imaging Studies

Results of plain films are normal in Morton's neuroma.

Ultrasonography is gaining in popularity and may be equvialant in sensitivity to MRI in detecting Morton's neuroma.[3]  Indeed, a literature review by Bignotti et al indicated that ultrasonography and MRI are equally accurate for the diagnosis of Morton neuroma, with the modalities having sensitivities of 0.91 and 0.90, respectively.[5]

CT scanning has been used but may not be as sensitive as MRI. MRI, while not needed in most cases for establishing diagnosis of Morton's neuroma, has been studied widely.[6] Sensitivity of 87% and specificity as high as 100% have been reported. Asymptomatic neuromas may occur and confound accurate diagnosis.

Indications exist that Morton's neuromas smaller than 5 mm in diameter may not be significant clinically and that other diagnoses may be excluded carefully before such a small lesion is diagnosed as a symptomatic Morton's neuroma. Imaging with T1 weighting in a coronal plane is recommended for best visualization. In addition, on T2 imaging, the low signal of a Morton's neuroma may help to differentiate it from a true neuroma, ganglion cyst, or intermetatarsal bursal fluid collection.

Contrast enhancement usually is demonstrated with Morton's neuromas.

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Other Tests

Electromyography and nerve conduction study (EMG/NCS) of Morton's neuroma are not used often because of the technical difficulty in performing the them; needle stimulation of the common digital nerve and pickup on the adjacent toe or toes, which may be of short distance, is required. Surface stimulation results most often in volume conduction through the skin to the pickups because of the short distance involved and the large amount of stimulation needed to penetrate the deep tissue separating the nerve from the skin surface.

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Procedures

Temporary elimination of pain and numbness in the associated webspace by a common digital nerve block with an anesthetic agent supports a diagnosis of Morton's neuroma. If numbness of the associated webspace occurs but no decrease in pain is noted, other diagnoses should be considered.

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Histologic Findings

Tissue biopsy is neither needed nor recommended for Morton's neuroma.

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Contributor Information and Disclosures
Author

Kevin Berry, MD Physical Medicine and Rehabilitation Physician, Rehabilitation Options of Issaquah

Kevin Berry, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Coauthor(s)

Richard G Bowman, II, MD Rehabilitation and Electrodiagnostic Director, Physical Medicine and Rehabilitation, Pain Management, The Center for Pain Relief

Richard G Bowman, II, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Peter Gonzalez, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, Eastern Virginia Medical School

Peter Gonzalez, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

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.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Received honoraria from Allergan for speaking and teaching.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

References
  1. Morton TG. Peculiar painful affection of fourth metatarsophalangeal articulation. Am J Med Sci. 1876. 71:37.

  2. Kim JY, Choi JH, Park J, et al. An anatomical study of Morton's interdigital neuroma: the relationship between the occurring site and the deep transverse metatarsal ligament (DTML). Foot Ankle Int. 2007 Sep. 28(9):1007-10. [Medline].

  3. Pastides P, El-Sallakh S, Charalambides C. Morton's neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg. 2012 Mar. 18(1):22-4. [Medline].

  4. O'Connor FG, Wilder RP, Nirschl R. Foot Injuries in the Runner. In:Textbook of Running Medicine. New York: McGraw-Hill; 2001. 258-260.

  5. Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015 Aug. 25 (8):2254-62. [Medline].

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

  7. 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].

  8. Monacelli G, Cascioli I, Prezzemolo G, Spagnoli A, Irace S. [Surgical treatment of Morton's neuroma: our experience and literature review]. Clin Ter. 2008 May-Jun. 159(3):165-7. [Medline].

  9. Valente M, Crucil M, Alecci V. Operative treatment of interdigital Morton's neuroma. Chir Organi Mov. 2008 May. 92(1):39-43. [Medline].

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

  11. Villas C, Florez B, Alfonso M. Neurectomy versus neurolysis for Morton's neuroma. Foot Ankle Int. 2008 Jun. 29(6):578-80. [Medline].

  12. Title CI, Schon LC. Morton neuroma: primary and secondary neurectomy. J Am Acad Orthop Surg. 2008 Sep. 16(9):550-7. [Medline].

  13. 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].

  14. Faraj AA, Hosur A. The outcome after using two different approaches for excision of Morton's neuroma. Chin Med J (Engl). 2010 Aug. 123(16):2195-8. [Medline].

  15. Kundert HP, Plaass C, Stukenborg-Colsman C, Waizy H. Excision of Morton's Neuroma Using a Longitudinal Plantar Approach: A Midterm Follow-up Study. Foot Ankle Spec. 2015 Aug 7. [Medline].

  16. Rout R, Tedd H, Lloyd R, 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].

  17. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int. 2008 May. 29(5):483-7. [Medline].

  18. Yap LP, McNally E. Patient's assessment of discomfort during ultrasound-guided injection of Morton's neuroma: selecting the optimal approach. J Clin Ultrasound. 2012 May 15. [Medline].

  19. 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].

  20. Moore JL, Rosen R, Cohen J, Rosen B. Radiofrequency thermoneurolysis for the treatment of Morton's neuroma. J Foot Ankle Surg. 2012 Jan-Feb. 51(1):20-2. [Medline].

  21. Betts LO. Morton's Metatarsalgia. Med J Aust. 1940. 1:514.

  22. 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].

 
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Plantar view showing the relationships between the metatarsal heads, the intermetatarsal ligament, and the neuroma.
Neurectomy: typical incision location.
Neurectomy: superficial exposure.
Neurectomy: deeper dissection.
Neuroma and adherent fibrofatty tissue.
 
 
 
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