Not sure of Mortons Neuroma

Apologies Garry, I mean George!
You were too quick for me, buy the time I had realised my error, and corrected it, you had already pounced! Anyway, I am sure you have been called a lot worse! Had an old football team mate called Gareth Flanagan so it was more of a slip up rather than forgetting!
Hope all is well mate,
Ryan

 

Peter, you don't need to send for an X-ray for this - just stick a tuning fork on it and you'll get your result

 

Lucy:

Congratulations on starting a very interesting thread.

First of all, the first person to correctly describe the medical condition of a 3rd intermetatarsal space neuroma was not T. G. Morton, but rather a British chiropodist, Lewis Durlacher. Therefore, 3rd intermetatarsal space neuromas should rightfully be called Durlacher's neuroma, not Morton's neuroma.

Secondly, for the vast majority of intermetarsal neuromas, I think it is a waste of time to inject local anesthetic into an interspace for diagnostic purposes since local anesthetic will stop all pain in the 3rd interspace, regardless of diagnosis. I rarely use this technique for this reason.

3rd intermetatarsal space neuromas are quite easy to diagnose once you have become skilled at proper history taking and manual diagnostic skills. However, these take some time to acquire, but with practice, allow one to be very certain of the diagnosis. Intermetatarsal neuromas will be, on history, described as a burning, tingling, numbing or pins and needles type pain in the affected plantar interdigital space. The pain is typically made worse by any shoe which applies medial to lateral compression forces on the metatarsal heads and digits during weightbearing activities (nearly all "dress shoes" for women and men's loafers) and is generally better in open toed sandals or lace-up oxford style running or walking shoes with plenty of medial to lateral width in the toe box. Heeled shoes over 2" in heel height differential often exacerbate neuroma symptoms also.

On clinical examination, the patient will have a slight to profound decrease in sharp/dull and light touch discrimination in the affected plantar interdigital space with an intermetatarsal neuroma, will have tenderness in between the metatarsal heads plantarly at about the MPJ level. In fact, large neuromas are actually palpable from the plantar aspect (try using skin lubricant such as K-Y jelly on the plantar skin to increase the ability to detect abnormal plantar masses on the plantar forefoot). In addition, the Mulder's sign (a palpable click in the interspace with side to side forefoot/digital compression with plantar palpation) is also a good test.

I just did a neuroma excision in the 3rd intermetatarsal space and 3rd digit peg-in-hole arthrodesis with MPJ release and k-wire fixation (hammertoe repair) this morning on a patient and will be doing another neuroma excision on another patient in the 3rd intermetatarsal space this Thursday morning. 3rd intermetatarsal space neuromas are always located plantar to the deep intermetatarsal ligament. Typically, the thickest part of the neuroma is centered just 1-2 mm proximal to the metatarsophalangeal joint. The neuroma I excised this morning was about 5 mm in medial-lateral diameter and 15 mm in length (from a woman's size 7 foot) with the normal nerve medial-lateral diameter in this region of the foot being about 1.5-2 mm. In other words, the nerve was about 3 times it's normal size and was occupying too much space for too small an area.

Over the last 25 years of performing neuroma surgery, I have found neuroma excision to be a very predictable and successful treatment. I can't remember the last patient that I did the surgery on that wasn't very happy with the results. However, unfortunately, I do see quite a few failed neuroma surgeries. I believe that most 3rd intermetatarsal neuroma surgeries fail due to inadequate hemostasis during surgery or making too short of a dorsal incision and transecting the proximal aspect of the intermetarsal nerve too close to the metatarsal head, in other words, in the weightbearing area of the forefoot. I was trained to make a relatively long dorsal incision and cut the nerve as proximal in the plantar forefoot as possible so that if an amputation neuroma did form post-surgically it wouldn't become painful since it is protected within the longitudinal arch muscles of the forefoot and not close to the metatarsal heads. I believe that this simple difference in surgical technique makes all the difference in the world for patients.

Hope this helps you better understand the anatomy and diagnosis of this relatively common pathology.

 

Hi Kevin,

Thanks for your interesting and informative post (as always). Whilst I agree with the vast majority of things you have said, I would disagree that injecting the IM space is a "waste of time". What I would add though is that I cannot remember the last time I injected a 3/4 IM space neuroma and tend to only ever need to use this technique for queried 2/3 IM neuromas as far more frequently the suspicion of 2nd and/or 3rd MTPJ pathology confuses things for me. Maybe with more experience I will use this less?

I have only performed a few neuroma excisions as I am only in my surgical training but have seen a lot. My tutor always harps on about neuroma surgery failing due to the nerve being transected to distally. Why is it you feel poor heamostasis intro-op can contribute to poor otucome? Due to poor visualisation and poor dissection around the nerve?

I have enjoyed this interesting thread so far and it's been great getting so many different opinions on this subject. It's easy to fall into a comfort zone with the common pathologies and then have some manners put back on you when forced to think about these different aspects in more depth!

Regards,
Ryan

 

Thats interesting. I see dozens of people who have post operative complications from neuroma surgery and the average "healing time" (to get to the point of less pain than post op) seems to average well over a year. I wonder.

 

I'm pretty certain that the gold standard for diagnosis of osseous pathology is a detailed history, clinical examination, and use of appropriate imaging techniques, such as X-ray, coupled with MRI if findings equivocal.

I have found a tuning fork to be unreliable, thus call me old fashioned, I will let the imaging do its job.

and so what if, your tuning fork yields a negative response. Do you not recruit an X-ray?

Further an X-ray will determine if a stress# is displaced or not. can your tuning fork do that?

 

Which then comes back to the ´there is a neuroma it must be the cause of your symptoms - surgery is required´approach

 

Actually I think its more "there are symptoms, it must be a neuroms".

Mortons misnomer

 

Kevin, whilst i agree that putting local into any area will cause analgesia, as Ryan said my main reason for doing this is to rule out a Perineural fibroma (morton's) from adjacent mtpj pathology.

Whilst thorough clinical examination is paramount, there are some that i'm just not sure whether its the MTPj causing pain.

You mentioned lack of heamostasis as a cause of post op problems, do you mean for post op haematoma prevalence or visualisation intra operatively.

Cheers,

George

 

Peter, excuse my poor attempt at humour - there's always little chance of protraying it, apart from a great big smiley face

Gold standard is correct, and the tuning fork is a very "old skool" approach, but if you're scraping them off the ceiling, chances are there's a #. Obviously, if there's a full history of either acute trauma (?? # combined with the described bruising) or repetitive light trauma (?? stress #) , but a negative reponse from my "old skool" approach, I'd request an X-ray and potentially further imaging. (this is all baring in mind the increased time frame required for a stress # to actually appear on an X-ray)

By the way, I'd love to have a tuning fork which can determine a displaced stress# - could you recommend where I might buy one!

 

Hi James,

working in the NHS for 14 years can knock some humour out of you, thus I didn't pick up on it. My concern was for the pt that the OP referred to, she mentioned some bruising, and before embarking on on Rx provision, I was thinking it might be better to get a hard Dx 1st. If its a neuroma alone, great, waiting a few days for an X-ray won't harm it, but if its a stress# or other bony pathology, waiting around and toe-taping might, just might do it more harm than good.

IYKWIM,


Cheers,

Peter

 

While I see the point your making Peter, I work without much in the way of diagnostic tools except palpation. And some of the assumptions made are that Lucy in this case has attempted to palpate the area to see if the metatarsal is sensitive or not.

If Lucy tapes the toes and instructs the patient that if this is more painful take the tape off and call me there should no harm done.

It could be argued if you we so inclined that plantarflexing the toes will cause a dorsiflexion moment at the Metatarsal which would change the angles of the GRF Vectors acting on the metatarsal which may be a positive if there is any bony stress, if you wanted to.

 

Ryan:

If there is an injury to the lateral aspect of the plantar plate of the third metatarsophalangeal joint which then causes sufficient inflammatory response and swellling to also cause a mechanically-induced neuritis of the 3rd intermetatarsal nerve, then please tell me how a local anethetic injection into the 3rd intermetatarsal nerve helps you better arrive at the proper diagnosis?

When I perform intermetatarsal neuroma surgery, I use an ankle tourniquet during the surgery until after the neuroma is carefully dissected and excised, then I let the tourniquet down and make certain I have electrocauterized or tied off any and all bleeders before closing the wound. I believe that letting the tourniquet down after closing these procedures will tend to create more bleeding which may lead to more chance of scarring in the area of surgery. That is why I carefully take care of bleeders before I close the wound for intermetatarsal neuroma surgery, to make certain I have a minimum of post-op bleeding around the cut end of the nerve.

 

Hi Lucycool,

Your history taking is the most important action you can undertake, therefore I have a few wee questions.

What is this patients occupation?

What sort of footwear does the patient wear on a daily / regular basis?

Is the patient overweight?

How long has the bruising to the 3rd digit been present, and has there been any history of trauma to the sight?

(This question is not meant to sound rude, so please read as purely a question) Does she, or does she not have a forefoot equinus? (I'm sure admin will link some other threads to do with ff equinus for your further reading)

That's a few to be getting on with to try and flesh out our case history.

Kind regards,

James

 

Kein,
Thanks for your reply. I can't say I had considered excessive bleeding a contributing factor in the poor outcomes associated with neuroma excision (except of course in cases of hematoma). Like yourself, we have predictable outcomes following this surgery and I would say that of the dissapointed patients we have had, excessive scarring and fibrosis would be one of the most common complaints.

As for the senario you mentioned. If the inflammatory response was severe enough to induce a mechanical neuritis, I would expect that the whole MTPJ would be significantly inflamed, not just the lateral portion and as a result, a small volume of local anaesthetic to the intermetatarsal space would not completely alleviate the patient's symptoms.

Would the test help me better arrive at the proper diagnosis? Well I would like to think I would be moving away from suspecting neuroma if this would be the case. If I am wrong in my assumption that the joint pain would not completely resolve, well then I guess I would end up in the wrong direction with my suspicions and would have to work harder on my diagnostic skills. I am not afraid to ask for an opinion from a more experienced colleague and if there was a shadow of doubt, I'd be referring for ultrasound.

Thanks again,
Ryan.

 

Pt is a housewife, mid 50s. Not overweight at all, no trauma that she remembers. Bruising now gone, but came without any trauma. She usually wears boots with 1-1.5" heel.

I've strapped down her toes and will see..

Am loving this thread!!

Thank you all soo much!!

Lucy

 

Hello Kevin,

Maybe it should be Durlacher's neuroma, but most of the world call it Morton's, so maybe it's best to go with the general consensus? I have never been a fan of naming pathology (or procedures) after people and prefer anatomical descriptions such as 'perineural fibroma' of whatever space it's in and the part of the nerve at which it is sited. If anyone is interested though, there's a paper in JAPMA detailing the names of intermetatarsal neuromas (neuromae, neuromata?):

Ethan E. Larson, Stephen L. Barrett, Bruno Battiston, Christopher T. Maloney, Jr, and A. Lee Dellon. Accurate Nomenclature for Forefoot Nerve Entrapment
A Historical Perspective J Am Podiatr Med Assoc 95(3): 298–306, 2005

And here's a link to someone's website with a picture of these:

http://www.doctorbastawros.com/neuroma.html

I've operated on a reasonable amount of them and I've found the point at which the fibrous nerve tissue is at its greatest circumference is just distal to the deep transverse metatarsal ligament - so maybe UK neuromas have a slightly distally displaced wide point relative to their US cousins? Interestingly, a slightly more distal presentation may tally with the main areas of fibrosis and demyelination within the neuroma if you are to believe page 412 of Hetherington's Hallux Valgus and Forefoot surgery (quoting Graham CE, Graham DM: Morton's neuromas: a microscopic evaluation. Foot Ankle 5:150, 1984):

http://www.ocpm.edu/hallux/HV chapter 28-Entrapment Neuropathies.pdf

There is lots of information in that chapter for everyone anyway.

I also read an article years ago in Foot and Ankle International about level of transection for improving outcomes - I can't recall the reference right now, but essentially I learned to ensure that I had to transect the nerve a reasonable distance proximal to the metatarsal head (approximately 3-4 cm) to avoid any recurrent/ stump neuromas as there are often branches of the nerve distal to this point deviating plantarly which may be missed.

I rarely use diagnostic blocks for neuromas as the majority are picked up through clinical signs/ examination as Kevin has said and symptoms. As a routine, I get an ultrasound scan done even before (or during in image-guided) injection. All our tests are subject to error. I did a plantar plate tear repair 2 weeks ago that had clinical signs and symptoms of a neuroma, but the scan was positive for a plantar plate tear and she did have a positive painful Lachmann's and a retracted toe, but negative for a neuroma. I had already done the dorsal work (PIPJ fusion EDL z-plastry lengthening) and I opened up the bottom to find a huge neuroma. I excised the neuroma and went on to the plantar plate tear repair - not that remarkable really, just some distal attenuation. It just goes to show that in such a small space, the overlapping pathologies can cloud each other (and it also shows not to trust our new sonographer ). Generally, I use a dorsal approach with surgery for neuromas when conservative care has failed obviously, but this case was complicated by the plantar plate tear/ attenuation. I have used diagnostic blocks when ruling out influence of proximal pathology (eg, tarsal tunnel, radiculopathy) on forefoot pain that is atypical. Isolating specific points in a small area such as joint capsule or a surrounding pathologic nerve is potentially open to error due to the reasons already discussed by everyone else. Would injecting the webspace with LA prior to surgery have made any difference in this case? I don't know, but I doubt it.

It's interesting to see that Kevin removes the tourniquet prior to sewing up. I recently attended the podiatry institute's rearfoot course in Atlanta and many of the attendees and faculty do not routinely use a tourniquet for much of their surgery - quite a good way to ensure good anatomic dissection and good haemostasis. I can't say that fibrosis of the intermetatarsal space post op is a major issue in my post op patients so far though (touch wood). It would be nice to see a long term study on the post-operative course of neuromas with a tourniquet drop prior to suturing vs leaving it on.

A few years ago a read a paper on the digital nerve stretch test:
http://www.footanklesurgery-journal.com/article/S1268-7731(06)00038-5/abstract
They claim great diagnostic success with the test, but I would say it is less successful in my experience. Having said all that, it is yet another sign that you can use in making the diagnosis. In order to get a complete picture and arrive at a reasonable diagnosis, I believe you need to know a variety of signs, symptoms, clinical tests and imaging and respect their relative strengths and weaknesses (and reliability) in making any diagnosis. The more work I do, the more I question many of these tests.

 

Ryan:

See Lee's excellent posting. I agree with the majority of it.

I consider doing a diagnostic injection for suspected 3rd interspace neuromas to be a waste of time since if the patient has no plantar plate tenderness but has a positive Mulder's sign, maximum tenderness between the 3rd and 4th metatarsal heads and a history of burning, numbing, tingling or needing to massage the foot to help relieve the pain, then I'm going to treat it as an intermetatarsal neuroma. In this way I won't need to give the patient a painful, non-therapeutic injection to "help me make the diagnosis". However, I do often recommend a cortisone injection for these neuromas since they often work quite well, but these injections are therapeutic, not simply diagnostic.

I simply don't see the point of giving the patient a non-necessary injection of local anesthetic since I seem to be able to properly diagnose 3rd intermetatarsal neuromas just fine without it.

Good discussion.

 

Lee:

:good:

Once you see the amount of bleeding that occurs due to post-tourniquet hyperemia in your neuroma excision surgeries when you let the tourniquet down before skin closure, I suspect that you will not likely ever go back to letting the tourniquet down after the skin is closed when performing this procedure for your patients.

By the way, when I did my surgical residency, we never used a tourniquet. I believe this is an excellent way to teach residents how to do foot surgery with a minimum of tissue trauma. It sure impressed me during my surgical training.

 

Thanks for the reply Kevin,

I've got a list of 8 patients for surgery in the morning (chances are at least one will be a neuroma) so I'll try this. Here in the UK, it is pretty much standard to do all surgery under a tourniquet skin to skin. I have done several procedures free bleeding (but not a neuroma - yet) and can see the pro's and con's. Do you do much deep closure/ space mangement?

In my pupillage, we did loads of salvage surgery in high risk patients (ray resections, debridement, amptutations, etc...). It was standard practice to release the tourniquet and manage bleeding in these patients at that centre. I also was fortunate enough to hear John Ruch extolling the virtues of surgery without a tourniquet and demonstrating his anatomic dissection in Atlanta - good hands too.

Thanks,
Lee

 

Kevin,
I too agree with the majority of what Lee has written.

I think I mentioned earlier though, I generally don't have a problem diagnosing 3rd interspace neuromas. I do tend to get a little stuck sometimes when the 2nd and 3rd MTPJs are tender and there is also tenderness within the 2/3 intermetatarsal space and it is difficult to ascertain whcih site(s) are most symptomatic and I find injecting these cases can sometimes (not all the time) be useful.

That is not to say that I love injecting local anesthetic or that I am never able to establish the diagnosis here. It has maybe come across that this is something I frequently do, it is not, I cannot remember the last time I used it but I am sure I will again in the future. I see plenty of 'typical' neuromas and am happy with my diagnosis of these, it is the occasional mixed picture where like I said, I can get a little stuck.

I do appreciate the limitations of the test but I also have had experience of where this test has helped me clinically and therefore helped my patient so I am happy to use local anaesthetic as a diagnostic aid. Like I said earlier, as the years roll by and my experience grows, maybe I'll use it less and less- maybe not.

I too am finding this an interesting discussion.

Regards,
Ryan

 

2nd MTPJ-associated pathology nightmares! What sort of imaging do you guys use?

Anyway, got a list tomorrow so I should sleep before then, so...

http://www.youtube.com/watch?v=U_LsCRgs_Pg

I'm out

 

Hi Lee,
hope all is well mate. We don't really use a great deal of imaging for 2nd MTPJ pathology other than x-ray. Tend to find clinical examination will provide enough information in the majority of cases.

In cases of the mixed picture I described earlier, we will use US if in doubt

For plantar plate pathology, we tend not to bother with anything other than routine x-rays.
I'm struggling to think of an instance where we would use MR other than failed neuroma surgery (other peoples of course!!!!) with recurrence of or more commonly persistent symptoms. I suppose where symptoms are diffuse and non specific we may again use MR- we treat a lot of delicate souls over in west London!

Hopefully see you next Friday- starting to wish I was doing my lecture on LA for suspected neuromas now!!!

Ryan

 

Lee:

I was trained by Wilfred Laine, DPM and John Hembree, DPM, at the Veteran's Adminsitration Hospital in Palo Alto and rotated and did surgery also at Stanford during my first year surgery residency from 1983-1984. Dr. Laine was a big Dalton McGlamry/John Ruch/Podiatry Institute fan also and so we were trained largely using their techniques and often watched their surgical videos as residents. I was very good at John Ruch's ankle block technique after my training with Drs. Laine and Hembree. I even taught the technique to the surgery residents and students in the surgery department at CCPM once I returned for my biomechanics fellowship at CCPM during 1984-1985.

For neuroma surgery, I first dissect the distal digital branches to transect them. I then carefully dissect proximally until I have freed the proximal nerve that dives down plantarly into the plantar musculature. I then place traction distally on the neuroma and use a curved Metzenbaum scissor to transect the proximal nerve as far plantar and proximal as possible into the plantar musculature of the foot. Once the nerve is transected, the cut end of the nerve retracts deeper into the foot and will no longer be visible.

Once the neuroma has been completely excised from the foot, the ankle tourniquet is released and I start using a "Bovie" (i.e. electrocautery) to first stop the superfical bleeders, working my way toward the deeper bleeders until there is little to no visible bleeding. I normally spend about 5 minutes of time coagulating bleeders after releasing the tourniquet. I will use 6.0 mg of Celestone Soluspan solution (1.0 cc) to bath the operative site before closure. Closure is generally two deep subcutaneous sutures of 4-0 Vicryl followed by a running subcuticular stitch of 4-0 Prolene. The skin is reinforced with skin adherent and 1/4" steri-strips and bandaged with adaptic gauze, 4 x 4 gauze, Kling, Coban and tape.

The patient is placed into a tube stockinet and given a post-op shoe. They are told to keep the foot elevated above their heart for 48 hours after surgery and are advised to not take any aspirin or antiinflammatories for the week before surgery or the two days following surgery to reduce the potential for excessive post-op bleeding.

Hope this helps better explain the technique I currently use for the excision of 3rd intermetatarsal neuromas.

 

Hi all,

again as with Ryan my main purpose of using LA in the IM space is to rule out 2nd MTPJ pathology. I see quite a lot of patients who complain of pain in the 2nd MTPj and the adjacent IM space. I understand it will not differentiate between other pathologies around the space itself, however i find it quite useful if i know the 2nd MTPj is also painful.

Some patients i have seen post op 2/3 perineural fibroma excision are still in pain because they were also originally suffering with capsulitis / synovitis of the 2nd MTPj, its nice to know this pre-op so it can also be addressed.

Kevin, when you mentioned the word "Bovie" it made me laugh as it took me back to May of this year whilst i was in Hartford, CT and was asked for the Bovie numerous times during one procedure and had no idea what anyone was referring to, in typical stiff upper lip British fashion i didn't ask the attending (consultant) and waited until he left to ask the scrub nurse

 

There are two types of people who think they don't have a problem Dxing neuromas. Those who get it right, and those who THINK they get it right. Trouble is, the two are superficially similar and by their own account, indistinguishable!

There is only one type of person who admits to getting stuck sometimes, one who has an honest and realistic approach to their own practice!

Which is not to say that those who DON'T get stuck DON'T have such an approach of course.

 

One of the benefits of being a surgeon, Robert, is that when I excise the suspected neuroma, I send the specimen to the pathologist for microscopic examination to make sure it was a neuroma. How do you know, Robert, that any of the suspected neuromas that you have treated have actually been neuromas? What is your "gold standard" for diagnosing neuromas....in other words, how do you know what you think is a neuroma is actually a neuroma?

 

Hi Kevin,

Question if by change the report comes back negative to a neuroma from pathology - whats the next step ? As I know you will have ruled out most other likely suspects before you go in for a look see.

PS To Robert - having a bad day the weight of the NHS getting you down ?

 

Taking a chunk out of my finger with a rasp has not noticably sweetened my mood, I will admit. Hence I may take issue with Sensai.

I don't. And that is sort of the point. Allow me to reference the Elephant in the room.

Let me preface this by making it clear that i am not trying to be personally offensive to anyone. I'm sure, Kevin, that you are S*** hot and smoking when it comes to clinically identifying MN's. However.

I've been looking very hard for a paper I read once on the histopathological examination of neuromas. I can't find the wretched thing so I won't talk about it until I do. But it brought up some other interesting stuff.

The literature varies wildly on the success rates for neuroma surgery. Some studies ( Pace & Scammell 2008) report poor results in quite small numbers (8%). Others, like this one by Womack et al (2008) report "poor" outcomes in 40% of cases!

40 %

Thats 32% different!!!

and 40% is a LOT of unhappy patients.

And anecdotally, we have surgeons reporting

But that

And so do I. On this we agree.

And then of course, we have the discrepancies in the data for where neuromas are found, with some reporting 91% in one webspace and others a much more even distribution. Don't have the refs for hand but there is a good bit in Mcglamery on it.

Steve Arbes made a very intelligent comment on another thread.

As another person quoted

So we have literature which disagrees on the success rate of the surgery, literature which disagrees on the distribution on the neuromas, anecdotal agreement that it often fails and a question over why.

I doubt many surgeons would persist with neuroma surgery if they BELIEVED they had a 40% poor outcome rate!

So, the failed surgeries might be down to technique as you suggest, Kevin, or down to misdiagnosis as Steve postulated.

Now I'm open to either as a possibility, but I do know this. It IS possible to have an ultrasound confirmed neuroma which is none the less sub clinical. I've seen it happen. And I've seen clinically diagnosed neuromas waiting for surgery where the pain dissappeared with the removal of a corn.

You've removed a lot of neuromas Kevin. Lee, I'm sure you have too. So answer me this.


How many histopathological reports have you had come back negative for a neuroma?

I'd be willing to bet its between few and none. Now that could mean, as I say, that you are S*** hot at clinical diagnosis and never get it wrong. But lets say you were the surgeon with the 8 % failiure rate, or even the 40% failiure rate. What then can we say? Do they have 40% histo reports come back saying "you done messed up, thats not a neuroma" I seriously doubt it.

It raises the question. Why does neuroma surgery fail? Is it always bad technique? Is it good technique on a sub clinical neuroma? Some and some? And if it is a problem of diagnosis and not of method, does a histopathology report show that the neuroma was causing the pain, or merely that there was one there, heel spur styley.

I think that, with respect Kevin, if you really have a close to 100% success rate, you are the wrong person to ask about whether we need another option for a diagnostic test. You obviously don't need it as you have good results and therefore both good technique AND good diagnostics. But for those with less good results, or who see less good results happening around them, consider the following.

Is it possible that some failed neurectomies are down to misdiagnosis?If so,

Is it possible that an additional, inexpensive and easily available test could spare some people surgical failiure caused by said misdiagnosis?

Remember lots of people have access to neither ultrasound, nor your level of skill and experiance.


Respectfully.

Robert

 

Robert:

One of the jokes we would often make as surgery residents is if we sent a piece of fat to the pathologist and told them it was a neuroma, would they diagnose that piece of fat as a neuroma? Seriously, the gold standard for properly diagnosing most pathologies, including intermetatarsal neuroma, is by microscopic analysis and these pathologists are very good at what they do.

Of course, when you excise a sensory nerve from the interspace, everything in the interspace will feel better since it now has no sensory innervation. For this reason, neuroma surgeries tend to be surgeries which are the least painful of all the types of surgery I perform.

As far as my results with neuroma surgery, I'm sure I am not 100% successful since I have had a neuroma surgery fail and I had to redo. However, I can only remember one of these in 25 years. Now, maybe some of my patients were lying when they told me they were pleased with the surgery or maybe some patients went somewhere else to complain of my neuroma surgery, but I am not aware of these people. And please don't think I do neuroma surgery on a high percentage of patients which I have diagnosed with neuromas. I probably only surgically excise 10-20% of neuromas that I treat since the rest of the patients get better with more conservative means.

Just like doing orthotics, surgery is very technical. Even though I can't speak for someone else's surgical results, I can speak for my surgical results. Intermetatarsal neuroma surgery is highly predictable in my hands and has been a very worthwhile surgical procedure for the vast majority of my patients with a minimum of disability in the 25+ years I have been performing it.

And, as I said earlier, clinical diagnosis is key and this, I believe, takes years of practice and careful observation. When I first started out many years ago in practice, I found it hard to differentiate neuroma pain from MPJ pain due to my weak examination skills. However, with time and continued practice and repetition comes skill in diagnosis and treatment methods. Maybe if you can attend the seminar in Manchester this coming summer, I can take some time to demonstrate how I examine for neuromas vs plantar plate tears and you can hopefully get a better idea of how I perform my clinical exam for these patients.

 

I could not agree more :drinks. And thats the real rub isn't it. The frustration for me is the lack of consistancy across the board. One cannot expect every surgeon to be as experianced every other surgeon, we all start somewhere and evolve. However unlike orthoses where a screw up can usually be rectified by removing the device, a surgical misdiagnosis can have life ruining consequences for the patient.

And THAT is why the idea of the diagnostic LA interests me so much. It sounds pretty straightforward, its instant and readily available to everybody! If it is capable of determining whether a pain is IM or in the joint, I think it has the potential to save a lot of problems!

I am certainly hoping to see you next year Kevin :drinks. I owe you a drink.

Cheers
Robert

 

Looking forward to meeting you and chewing the fat with you also, Robert.

I think it is about time you moved toward getting a paper published in a peer-reviewed journal. Don't you?:drinks

 

Yeah, Simon and I have a plan on that.

 

Came across this thread when Looking for something else.

Injection V´s ultrasound for neuroma diagnosis

 

If anyone is interested, I have the full electronic copy of this short article posted by Michael.

With regards to this study, I am not entirely sure why the seroid was added to the "cocktail" for diagnostic purposes. I frequently inject neuromas with seroid for therapeutic effect but I am not sure if there was a query over diagnosis, why local anaesthetic was not administered alone.

Interesting to see such a split opinion on this topic and I wonder if anyones opinion has changed from reading the thread.

Regards,
Ryan

 

Hello Ryan,

They're probably using a mix of LA and corticosteroid as part diagnostic/ part therapuetic injections. If they're fairly sure it's a neuroma they might put the two together - this saves the patient 2 injections, the clinician time and has a potential negative impact on the results of their study in that the population they are investigating would be skewed towards patients they believe have a high chance of having a neuroma. This would be at odds with your post regarding differential diagnoses of 2nd MTPJ pain and localised neuromas where you are not as sure of the chief complaint.

And to Kevin - somehow all the neuromas in Norfolk have evaded me this week (for once) so I haven't had a chance to do a free-bleeding neurectomy yet. I did amputate a toe free bleeding the other day and thought of you all though. Gotta go, patients to see and all that.

Lee

 

Lee:

Just did another 3rd intermetarsal neurectomy this morning. Tourniquet time was 11 minutes. I Bovied bleeders for about 4 minutes after ankle tourniquet was let down. The surgical field was bloodless when I was sewing up the wound. This was another large neuroma in a small female foot which had little room for the neuoma to "rest comfortably" between the 3rd and 4th metatarsals without being "pinched" on each step.

Most neuromas I treat, however, respond well to orthoses, a change in shoes, metatarsal pads and cortisone injections, without surgery. The large ones, like the one I excised this morning, seem to be the ones that fail conservative care and need to be surgically excised. Maybe that is the reason I have the opinions I do about my neuroma surgeries...I only perform surgery on those patients who I know, in my hands, will have a very good chance of having a happy and successful outcome. The ones who I don't want to do surgery on, I send on to someone else.

 

I move that this thread be promoted to the "hall of fame".

Its not in the higher flights of biomechanical theory, not academic excellance, but it contains a LOT of really good, practical information about a very common and troublesome condition.

 

I feel very privileged to have such interesting answers to my question. I would like to thank you all again for giving up your time so that I - and lots of other pods can really understand what to do!!
As a newly qualified pod going straight into private practice, your answers and suggestions have been a wonderful way for me to gain confidence!

Hopefully this confidence will earn me enough money so I can save up to go to boot camp next year!!

Thank you very very much!!

Lucy

 

Why has no one mentioned looking at the muscles in the area? ie. interossei and lumbricals.
A lot of forefoot pain (especially if it is an ache) that i see is associated with muscle stiffness. Check intermetatarsal movement and palpate the trigger points between the metatarsals. If this causes twitch respose or redness then there are probably active trigger points and massage will restore movement and relieve pain.
But dont massage until your rule bone injury! ie. xray first.