Histologic Evaluation of Intermetatarsal Morton’s Neuroma

Giakoumis, Matrona; Ryan, Jay D.; Jani, Jigna C.

doi:10.7547/1030218

Cited by 12 publications

(7 citation statements)

References 22 publications

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“…Excess traction by surrounding structures provides a mechanical stimulus to the sheath, which could react with the proliferation of fibroblasts. The reactive fibrosis observed in Morton's neuroma specimens and described in the literature (Ringertz & Unander-Scharin, 1950;Lassmann et al 1976;Giakoumis et al 2013) can be regarded as a consequence of nerve entrapment. The excess fibrous content of these laminae, no more intertwined with loose connective layers, changes the sheath into a stiff channel that, instead of protecting the nerve, still worsens its entrapment; besides, the accumulation of collagen compresses the small vessels that run within the sheath, thus causing nerve ischemia, that in turn worsens fibrosis.…”

Section: Discussionmentioning

confidence: 92%

“…; Giakoumis et al. ) can be regarded as a consequence of nerve entrapment. The excess fibrous content of these laminae, no more intertwined with loose connective layers, changes the sheath into a stiff channel that, instead of protecting the nerve, still worsens its entrapment; besides, the accumulation of collagen compresses the small vessels that run within the sheath, thus causing nerve ischemia, that in turn worsens fibrosis.…”

Section: Discussionmentioning

confidence: 99%

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The role of fasciae in Civinini–Morton's syndrome

et al. 2015

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This study evaluates the pathogenetic role of the perineural connective tissue and foot fasciae in Civinini-Morton's neuroma. Eleven feet (seven male, four female; mean age: 70.9 years) were dissected to analyse the anatomy of inter-metatarsal space, particularly the dorsal and plantar fasciae and metatarsal transverse ligament (DMTL). The macrosections were prepared for microscopic analysis. Ten Civinini-Morton neuromas obtained from surgery were also analysed. Magnetic resonance images (MRIs) from 40 patients and 29 controls were compared. Dissections showed that the width of the inter-metatarsal space is established by two fibrous structures: the dorsal foot fascia and the DMTL, which, together, connect the metatarsal bones and resist their splaying. Interosseous muscles spread out into the dorsal fascia of the foot, defining its basal tension. The common digital plantar nerve (CDPN) is encased in concentric layers of fibrous and loose connective tissue, continuous with the vascular sheath and deep foot fascia. Outside this sheath, fibroelastic septa, from DMTL to plantar fascia, and little fat lobules are present, further protecting the nerve against compressive stress. The MRI study revealed high inter-individual variability in the forefoot structures, although only the thickness of the dorsal fascia represented a statistically significant difference between cases and controls. It was hypothesized that alterations in foot support and altered biomechanics act on the interosseous muscles, increasing the stiffness of the dorsal fascia, particularly at the points where these muscles are inserted. Chronic rigidity of this fascia increases the stiffness of the inter-metatarsal space, leading to entrapment of the CDPN.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

The role of fasciae in Civinini–Morton's syndrome

et al. 2015

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“…The common plantar digital nerve is surrounded by concentric layers of fibrous and loose connective tissue which creates a protective tunnel for the nerve to move independently of the surrounding tissue during gait [62]. A proposed pathological process involves the connective tissue becoming thickened and fibrotic in Morton’s neuroma [63] changing the protective tunnel into a nerve entrapment with ischemia [62]. Manipulation/mobilisation may reduce pain by decreasing the stiffness in the connective tissue surrounding the nerve.…”

Section: Discussionmentioning

confidence: 99%

The effectiveness of non‐surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta‐analysis

Matthews

Hurn

Harding

et al. 2019

Journal of Foot and Ankle Research

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Background Morton’s neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits footwear choices and weight bearing activities. This paper aims to review non-surgical interventions for MN, to evaluate the evidence base for the clinical management of MN. Methods Electronic biomedical databases (CINAHL, EMBASE, MEDLINE and Cochrane) were searched to January 2018 for studies evaluating the effectiveness of non-surgical interventions for Morton’s neuroma. Outcome measures of interest were treatment success rate (SR) (binary) and pain as measured using 100-point visual analogue scale (VAS) (continuous). Studies with and without control groups were included and were evaluated for methodological quality using the Downs and Black Quality Index. Results from randomised controlled trials (RCT) were compared between-groups, and case series were compared pre- versus post-treatment. Effect estimates are presented as odds ratios (OR) for binary data or mean differences (MD) for continuous data. Random effects models were used to pool effect estimates across studies where similar treatments were used. Heterogeneity was assessed using the I 2 statistic. Results A total of 25 studies met the inclusion criteria, seven RCTs and 18 pre/post case series. Eight different interventions were identified, with corticosteroid or sclerosing injections being the most often reported (seven studies each). Results from a meta-analysis of two RCTs found corticosteroid injection decreased pain more than control on VAS (WMD: -5.3, 95%CI: -7.5 to − 3.2). Other RCTs reported efficacy of: manipulation/mobilisation versus control (MD: -15.3, 95%CI: -29.6 to − 1.0); extracorporeal shockwave therapy versus control (MD: -5.9, 95%CI: -21.9 to 10.1). Treatment success was assessed for extracorporeal shockwave therapy versus control (OR: 0.3, 95%CI: 0.0 to 7.1); and corticosteroid injection vs footwear/padding (OR: 6.0, 95%CI: 1.9 to 19.2). Sclerosing and Botox injections, radiofrequency ablation and cryoneurolysis have been investigated by case series studies, however these were of limited methodological quality. Conclusions Corticosteroid injections and manipulation/mobilisation are the two interventions with the strongest evidence for pain reduction, however high-quality evidence for a gold standard intervention was not found. Although the evidence base is expanding, further high quality RCTs are needed. Electronic supplementary material The online version of this article (10.1186/s13047-019-0320-7) contains supplementary material, which is available to authorized users.

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“…16 Histologically, Morton’s neuroma exhibits perineural degeneration and increased fibroblastic infiltration rather than being inflammatory; the surrounding secondary bursitis, however, does exhibit inflammatory changes. 3,6,8,17,26 We postulate that the prolonged effect of the corticosteroid injection in these patients may have been due to permanent elimination rather than temporary suppression of the inflammatory response of the bursitis. Further research into this mechanism is required to investigate this in more detail.…”

Section: Discussionmentioning

confidence: 94%

Medium-Term Results of Corticosteroid Injections for Morton’s Neuroma

et al. 2020

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Background: The objective of this study was to evaluate the medium-term results of corticosteroid injections for Morton’s neuroma. Methods: This was a prospective follow-up study of a previous randomized controlled trial (RCT). Forty-five neuromas in 36 patients were injected with a single corticosteroid injection either with or without ultrasound guidance. As the results of the RCT showed no difference in outcomes between techniques, the data were pooled for the purpose of this study. Questionnaires were sent out and responses were collected via mail or telephone interview. Results were available in 42 out of 45 neuromas. There was a sex split of 68% female/32% male with a mean age of 62.6 years (SD, 12 years). Results: At mean follow-up of 4.8 years (SD, 0.91 years), the original corticosteroid injection remained effective in 36% ( n = 16) of the patients. In these cases, the visual analog scale (VAS) pain score ( P < .001) and Manchester-Oxford Foot Questionnaire Index (MOxFQ Index) ( P = .001) remained significantly better than preintervention scores. The remaining cases underwent either a further injection or surgery. Fifty-five percent of the 11 neuromas that received a second injection continued to be asymptomatic in the medium term. Overall, 44% ( n = 20) of the initial cohort underwent surgical excision by the medium-term follow-up. The VAS score, MOxFQ Index, and satisfaction scale score across all groups were not significantly different. Conclusion: Corticosteroid injections for Morton’s neuroma remained effective in over a third of cases for up to almost 5 years. A positive outcome at 1 year following a corticosteroid injection was reasonably predictive of a prolonged effect from the injection. Level of Evidence: Level II, prospective comparative study.

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Histologic Evaluation of Intermetatarsal Morton’s Neuroma

Cited by 12 publications

References 22 publications

The role of fasciae in Civinini–Morton's syndrome

The role of fasciae in Civinini–Morton's syndrome

The effectiveness of non‐surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta‐analysis

Medium-Term Results of Corticosteroid Injections for Morton’s Neuroma

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