TREATMENT OF MORTON’S NEUROMA: A SYSTEMATIC REVIEW

Paper Review March 2019

Mortons Neuroma (MN) is a forefoot diagnosis affecting the digital nerve which many surgeons believe is over-diagnosed (and often already diagnosed by the patient courtesy of Dr Google!). This month we look at a recent systematic review which evaluates different treatment modalities for MN and their outcomes.

Overview:

This paper addresses research which has investigated conservative, infiltrative and surgical treatments for MN. While conservative treatment shows the least promise, this is largely due to poor outcome measures in the current body of research and poor quality of trials.

What it all means:

Essentially more good quality research, including RCT’s and case studies are needed including risk-benefit ratios for surgery. However, based on the current available research, operative treatments showed better results compared to conservative treatments.

Key points:

• 4 theories have been proposed for the cause of MN:
  1. Chronic traction damage.
  2. Inflammatory environment due to intermetatarsal bursitis.
  3. Compression by the deep transverse intermetatarsal ligament.
  4. Ischemia of vasa nervorum.

• Treatment for MN is usually conservative initially before proceeding to infiltrative treatments and surgery (if conservative therapy fails).

• Conservative therapy includes:
  • Education to avoid tight shoes.
  • Manipulation.
  • Insoles or orthotic appliances.

• Infiltrative Therapy includes:
  • Injections of local anaesthetics, steroids or alcohol.
  • Percutaneous radio-frequency ablation.

• Bibliographic searches were conducted in MEDLINE, Cochrane Library, DARE. Case series and RCTs assessing patients’ satisfaction or pain improvement were also included.

• Of the 283 titles found, only 29 met the inclusion criteria.

• Operative and infiltrative treatments offer the best outcomes with surgery being superior.

• However, “the complication rate is higher with surgery, while the recurrence rate is higher with both infiltrative and conservative treatments”.

• There is often incomplete reporting of complications and recurrences within research studies.

• Variations in outcome measures make comparing current studies difficult.

Putting it into practice:

1. Accuracy of diagnosis is crucial. If in doubt, refer on.

2. There are “Therapeutic algorithms” available in the literature which recommend conservative and infiltrative treatments first. It’s also thought, by some authors, that this helps the practitioner to select which MN patients would benefit most from surgery rather than referring them all. The authors of this study suggest that we consider the risk / benefit ratio for each treatment and discuss this with the patient.

3. Although this review suggests that operative treatments lead to better results, this is largely due to the absence of good research addressing conservative management. With focus on “insoles” there are many different prescription adaptations which can be tried and what works for one patient may not work for another…

4. Use a medium-density full-length Bio-Advanced prefab orthotic and try some of the following adaptations to see if symptoms are improved:
   1. Metatarsal dome
   2. Metatarsal bar
   3. Neuroma plug
   4. Balance pad
   5. 1^st metatarsal cut out or Kinetic wedge
   6. Rearfoot wedging

NB: Always base your prescriptions on your findings and clinical reasoning.