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New treatment for Morton's ?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by lgs, Mar 18, 2008.

  1. lgs

    lgs Active Member


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    Taken from the Daily Mail

    The shot of alcohol that cures foot pain
    By ANGELA BROOKS

    Last updated at 00:12am on 18th March 2008

    An injection of alcohol could be the answer for Morton's neuroma

    The new treatment, which is carried out on an outpatient basis, involves four injections spaced two weeks apart.

    For the trial, carried out at the Royal National Orthopaedic Hospital in Stanmore, Middlesex, 101 patients received injections containing 20 per cent of alcohol diluted in a local anaesthetic and delivered under ultrasound guidance.

    The patients' progress was followed for an average of two years, and 84 per cent were reported to be totally pain-free after treatment, while another 10 per cent reported partial symptom relief.

    At the moment, there are only about six consultants using this technique.

    But as Ian Reilly, a consultant podiatric surgeon from Northampton General Hospital, explains: "What researchers at the Royal National Orthopaedic Hospital say carries weight. Any good surgeon wants to avoid operating on patients if it is at all possible.

    "I think this story will spark a lot of interest from consultants."
     
  2. DaVinci

    DaVinci Well-Known Member

    Sclerosing alcohol for morton's neuroma has been around for a while now.

    See this Google scholar search. Some of the citations go back over 10 years ago now.
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. what is the mode of action of this treatment?
     
  5. At >£600 for 4 injections I'm sure it will :rolleyes:
     
  6. Mart

    Mart Well-Known Member

    One thing which has made me skeptical about this technique is the presence of a significant space filling lesion which is not properly identified until histology is carried out. Although presence of synovial sarcoma or other malignancy may be rare, destruction of the nerve has the potential to delay further investigation (no pain). Also given the proximity of the lesion to the vascular bundle I wonder what the long term effects, even of a benign mass, of compression of the digital artery might have given that this would likely be rendered painless.

    Any thoughts from those with experience of non mechanical approach?

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  7. drdebrule

    drdebrule Active Member

    I thought I should reply because I have clinical experience with the sclerosing alcohol injections. I have been doing them under ultrasound guidance for several years now with a good success rate perhaps 90%. I would not want to try them blindly without the ultrasound machine to visualize where I am aiming. I am aware of two European studies using ultrasound guidance and Gary Dockery, DPM did a study in the States here without using ultrasound and found similar success.

    The neuroma looks like a little hypeochoic black blob with a comet's tail sometime present in the interspace. I perform the injection just proximal to this. If there is not a little black blob present on the ultrasound screen then often I will find evidence of capsulitis at the MTPJ's and rethink my treatment plan. I have found that a lot of supposed neuromas are really lesser metatarsalgia with functional hallux limitus. If something doesn't look quite right you could do an MRI if needed.


    I have had a few patients come for one or two tune up injections one or two years later. I rarely excise neuromas surgically. Sometimes patients do experience significant pain after these injections, which usually resolves with ice and NSAIDs. I had one patient who developed an erythematous rash after injections, but have seen no other adverse effects.

    My personal preference still is usually to treat the patient biomechanically with orthotics and osteopathic manipulation first. If this treatment fails, then I consider the injections.

    I hope my comments are helpful.

    Michael B. DeBrule, DPM
    Marshall, MN
     
  8. Mart

    Mart Well-Known Member

    Hi Michael

    Thanks for reply.

    I understand the reasoning behind your approach and am curious to learn more about your US exams.

    I have been using US to supplement physical exams for metatarsalgia for over 1 year and have done many interspace exams for evidence of abnormality and read most of the published literature on the subject.

    My impression is that although the studies suggest good correlation of US exam with MRI and biopsy there are a number of pitfalls possible in interpreting images in this region, I still lack confidence in interpretation.

    This suggests to me that my experience and interpretation is lacking, but this is at odds with all of my other US experience which on the whole is very straightforward and is progressing nicely.

    I use good equipment, (GE loqiq expert 700 with 13MHz linear probe and power Doppler) the resolution is good enough to clearly visualize the neurovascular bundle both nerve and artery in most individuals in long and short axis.

    What I find ambiguous is that the echo appearance of the interspace is often inhomogenous with hypoechoic and hyperechoic elements visible at several sites and several non symptomatic interspaces in the same subject, those small hypoechoic areas which you describe are a common and I am assuming non specific finding.

    Quite often I will find a densely hypoechoic area which is palpably compressible and moves with lateral compression and dorsal compression through interspace, this area will then become undifferentiated and invisible after period of compression (this suggests to me that this is likely an area of edematous fatty tissue).

    Most frequently when a physically palpable or audable mulders sign is present the nebulous fatty tissue will show sudden motion, usually in a dorsal direction, but no distinctly differentiated region is clear, and the focus of motion is also unclear even using the fastest possible frame rate (20 Hz).

    I have re-examined an interspace with MRI confirmation of 7mm dia neuroma from radiologist (I did not see images though)and could see no hint of hypo or hyper echoicity in this region, there was no mulders sign.

    I have not tried this yet but am curious regarding your experience; theoretically it would seem likely that infiltration of fluid ( eg plain lidocaine) around a neuroma would create a hypoechoic halo within the fatty tissue and not penetrate so quickly (or at all) into the denser fibrous mass. This would differentiate fibrous from non fibrous elements and make the exam less ambiguous.

    If the lesion were a bursa, neuroma or synovial sarcoma would you expect it to be compressible in each of these cases and also valid way of narrowing down Dx?

    My understanding of the nature of the excised tissue from neuroma excisions (I have never done one) is that the mass often has a largely non fibrous appearance which might explain US appearance being somewhat variable.

    Lastly do you have any images which you could post to illustrate your experience, even better some video clips which are generally far more enlightening and can make US more powerful than static imaging.

    If I post some of my annotated and ambiguous interspace images would you mind commenting on them for me?

    Cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  9. drdebrule

    drdebrule Active Member

    Martin,

    Thanks for your comments.

    What I think you are really saying is that ultrasound can be ambiguous and it is not always possible to say exactly what you are looking at. Sonography will reveal neuroma in 85-90% of cases, but it will miss some. If you can find continuity with the plantar nerve then you are doing great. Maybe 20-30% of neuromas may have a small amount of hyperechoic material contained within (mixed presentation) or may be rarely anechoic. I also lack confidence in interpretation. How do you know that you are not getting a false negative from a small sized transducer probe artifact? That is why it is important to order MRI once in a while if you are not sure or send out for second opinion.

    I have never tried to compress an interspace area and see if a hypoechoic area disappears after a period of time. If it does it could be fatty tisuue swelling, but I have also seen hypoechoic areas that seem to be coming off of the MTP joint capsule. My clinical pearl is that compression of the hypechoic region identified on your screen should correlate with the patient's pain. I have also suspected there there are asymptomatic subclinical neuromas in the adjacent interspaces. Sometimes you may have encountered these. Injections seem to form a halo around the mass and do not appear to penetrate the mass.

    I don't think US can truly differentiate bursae from neuroma from syn. sarcoma. Excisional surgery or biopsy is best. In theory the bursae would tend to be more homogenously hypoechoic and may spread out or thin during palpation, but how do you know that you pressed hard enough or in the right place to cause a change in appearance. The neuroma and syn. sarcoma should not spread out or thin during palpation (in theory). I think if your mass is greater than 20mm in length you should suspect something other than neuroma.

    I do not have any video or images uploaded to share, but I would try my best to comment on any pictures you post on this site.

    Michael
     
  10. Foot Lady

    Foot Lady Member

    "At the moment, there are only about six consultants using this technique."

    I have a patient who would benefit from the injections.

    Does anyone know where the 6 consultants are in the UK who do these treatments, if indeed they are UK based.

    Kate
     
  11. Heather J Bassett

    Heather J Bassett Well-Known Member

    II think if your mass is greater than 20mm in length you should suspect something other than neuroma.

    Hi, our team has recently had several up to and over 30mm, we have a specialist sonographer we use.

    2-3 of the feet have had 2 and 3 "neuromas" that size. :eek:

    Does this mean MRI or surgery? or both or ?
    Appreciate your expertise
    kind regards
     
  12. Mart

    Mart Well-Known Member

    Hi

    I am curious why you say this?

    Any chance that you could involve them in this discussion to give some practical advice?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  13. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi Martin, th 20mm plus was a quote from DRDEBRULE? It was not something I was saying rather something I was quering?
    Not sure if that makes sense?
    Cheers
     
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