The clinical diagnosis of symptomatic forefoot neuroma in the general population: a Delphi consensus study

Abstract

BackgroundThere is limited evidence for defining what specific method or methods should be used to clinically influence clinical decision making for forefoot neuroma. The aim of this study was to develop a clinical assessment protocol that has agreed expert consensus for the clinical diagnosis of forefoot neuroma.MethodsA four-round Delphi consensus study was completed with 16 expert health professionals from either a clinical or clinical academic background, following completion of a structured literature review. Clinical experience ranged from 5 to 34 years (mean: 19.5 years). Consensus was sought on the optimal methods to achieve the clinical diagnosis of forefoot neuroma. Round 1 sought individual input with an open ended question. This developed a list of recommendations. Round 2 and 3 asked the participants to accept or reject each of the recommendations in the list in relation to the question: “What is the best way to clinically diagnose neuroma in the forefoot?” Votes that were equal to or greater than 60% were accepted into the next round; participant’s votes equal to or less then 20% were excluded. The remaining participant’s votes between 20 to 60% were accepted and placed into the following round for voting. Round 4 asked the participants to rank the list of recommendations according to the strength of recommendation they would give in relation to the question: “What is the best way to clinically diagnose neuroma in the forefoot?” The recruitment and Delphi rounds were conducted through email.ResultsIn round 1, the 16 participants identified 68 recommendations for the clinical diagnosis of forefoot neuroma. In round 2, 27 recommendations were accepted, 11 recommendations were rejected and 30 recommendations were assigned to be re-voted on. In round 3, 36 recommendations were accepted, 22 recommendations were rejected and 11 recommendations were assigned to be re-voted on. In round 4, 21 recommendations were selected by the participants to form the expert derived clinical assessment protocol for the clinical diagnosis of forefoot neuroma. From these 21 recommendations, a set of themes were established: location of pain, non weight bearing sensation, weight bearing sensation, observations, tests and imaging.ConclusionFollowing the identification of 21 method recommendations, a core set of clinical diagnostic methods have been prepared as a clinical assessment protocol for the diagnosis of forefoot neuroma. Based on expert opinion, the core set will assist clinicians in forming a clearer diagnosis of forefoot neuroma.Electronic supplementary materialThe online version of this article (10.1186/s13047-017-0241-2) contains supplementary material, which is available to authorized users.

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey

“…This number allowed for drop out at each stage. Dando [10] reported that the inclusion of a wide range of professions from a range of clinical backgrounds with a geographical diversity is good practice as it develops the participants to be a representative group [11]. A heterogenous group, with a range of stakeholders, encourages different outlooks and decision-making, which in turn enriches the data leading to better outcomes of credibility and acceptability [12].…”

Forefoot pain

“…People with pain from a Morton’s neuroma often describe it as “like walking on a pebble,” particularly if it is worse when walking bare foot 14. It may present as paraesthesia radiating to the toes.…”

“…It may present as paraesthesia radiating to the toes. Neuropathic type pain, often described as “ burning” or “electric shock” sensations, may also indicate a Morton’s neuroma, particularly if it radiates into the toes 14. Neuropathic pain symptoms can also occur owing to oedema secondary to plantar plate damage or hallux rigidus 512.…”

“…Palpate for pain in the intermetatarsal spaces, particularly in the 2/3 and 3/4 spaces. The patient is likely to report tenderness at this location in Morton’s neuroma 14. Stress fractures over the metatarsal heads can present with reproducible point tenderness on palpation, although stress fractures are often insidious in their presentation and clinicians should have a low threshold for use of imaging to confirm the diagnosis 10…”

“…Various tests have been described to diagnose Morton’s neuroma. Perhaps the most commonly performed is Mulder’s test (fig 2), although it should be noted that it may produce a false positive in normal feet 14…”