Imaging Studies

A large body of literature addresses the use of imaging modalities to aid in the diagnosis of Morton neuroma (also referred to as interdigital neuroma or interdigital neuritis).^[17]The condition is most commonly diagnosed strictly on the basis of the history and physical examination findings. In a retrospective review that included 269 patients with 313 clinically suspected neuromas, Raouf et al found that Morton neuroma could be diagnosed quite accurately on clinical grounds alone, calling into question the utility and costs of performing preoperative imaging and intraoperative histopathology for diagnosis.^[18]

In equivocal cases, ultrasonography (US), magnetic resonance imaging (MRI), or both may be helpful.^{[19, 20, 21, 22]}

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

The skill of the technologists and physicians performing and interpreting MRI or US plays a key role in determining just how valuable these modalities can be in clinical practice.

On US, a Morton neuroma typically appears as a hypoechoic oblong mass oriented along the long axis of the foot. Prospective studies in symptomatic patients reveal that US can reliably detect these neuromas.^{[17, 23]}Furthermore, it can help identify contributing pathologic lesions, such as lipomas or bursae.^[24]Nonetheless, in a small series, 26 (54%) of 48 asymptomatic patients had greater than 5 mm enlargement of an interdigital nerve on US.^[22]This finding emphasizes the importance of the history and clinical examination and the risk of false positives.

US may be used to determine the size of a Morton neuroma, but its reliability appears to depend, to a large degree, on observer experience.^[25]It may also be used to identify posttreatment changes (eg, ill-defined borders, reduced or absent pain with the application of transducer pressure) after laser therapy for Morton neuroma.^[26]

MRI can provide reliable information regarding the pathoanatomy of the forefoot.^[27]Characteristically, a Morton neuroma shows low intensity on T1- and T2-weighted MRI sequences, because of its high degree of fibrous content. In contrast, an intermetatarsal bursa is associated with increased intensity on T2-weighted images, because of its fluid content.^[28]MRI with gadolinium contrast enhancement and with fat suppression probably provides the most reliable images for diagnosis.^[29] MRI can also be useful for postoperative evaluation after resection of a Morton neuroma.^[30]

Other Tests

Electrodiagnostic testing has been described to aid in diagnosis, but its use is not common, and its utility remains to be defined.^{[31, 32]}

Procedures

An injection of local anesthetic with sterile technique may be useful in the diagnostic evaluation of Morton neuroma.^[7]The temporary resolution of pain, paresthesia, 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 postoperative outcomes.

Treatment & Management

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Media Gallery

Plantar view showing relationships between metatarsal heads, intermetatarsal ligament, and neuroma.
Image demonstrates key provocative physical examination maneuver: simultaneous forefoot compression coupled with intermetatarsal space compression.
Histopathology reveals nerve fibers and pacinian corpuscles entrapped within fibromyxoid connective tissue.
Surgery for Morton neuroma. Dorsal incision.
Surgery for Morton neuroma. Superficial exposure.
Surgery for Morton neuroma. Deeper dissection.
Surgery for Morton neuroma. Neuroma and adherent fibrofatty tissue.
Surgery for Morton neuroma. Distal plantar transverse incision.
Surgery for Morton neuroma. Plantar longitudinal incision.

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Author

Lyle T Jackson, MD Orthopedic Surgeon, Foot and Ankle Surgery, Slocum Center for Orthopedics and Sports Medicine

Lyle T Jackson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: IINDEPENDENT CONTRACTOR - EDITOR FOR FOOT AND ANKLE TOPICS for: DYNAMED, EBSCO PUBLISHING INC.

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, AO Foundation, Orthopaedic Trauma Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Smith-Nephew<br/>Received income in an amount equal to or greater than $250 from: smith nephew.

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

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor, Department of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

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.

Sections Surgery for Morton (Interdigital) Neuroma
Overview
Presentation
Workup
Treatment
Media Gallery
References

Surgery for Morton (Interdigital) Neuroma Workup

Imaging Studies

Other Tests

Procedures

References

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