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Neuroma treatments??

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bartypb, Feb 3, 2012.

  1. G Flanagan

    G Flanagan Active Member

    Also in regards of Roberts VP patient. Could it be the case that since the VP had resolved they no longer had an antalgic gait causing increased IM pressure. Just throwing it out there. As I see quite a few patients with secondary 'neuroma' symptoms resolve once the primary pathology has been treated which was causing altered gait i.e. often incidental neuromas become pathological whilst the patient has altered forefoot load
     
  2. Send him a Pm maybe he G Bourke will post p the full text - docbourke

    and probably not done in Sweden Morington - Melbourne I would guess
     
  3. gavw

    gavw Active Member

    http://dx.doi.org/10.1016/j.fas.2011.01.007

    Timely paper for this interesting discussion

    Background
    The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton's neuroma.

    Methods
    Clinical assessments and pre-operative radiological imaging of patients who had excision of a Morton's neuromas were retrospectively compared.

    Results
    43 neuromas were excised from 36 patients over 68 months. The commonest clinical symptoms were tenderness on direct palpation (100%), pain on weight bearing (91%) which was relieved by rest (81%). The most sensitive clinical sign was a Mulder's click. Clinical assessment had a sensitivity of 98% (42/43). Ultrasonography had a sensitivity of 90% (28/31) and magnetic resonance imaging had a sensitivity of 88% (14/16).

    Conclusion
    There is no absolute requirement for imaging patients who clinically have a Morton's neuroma. The two main indications for imaging are (a) an unclear clinical assessment and (b) cases when more than one web space is affected. Ultrasonography should be the investigation of choice.
     
  4. Yep, And if you'd have followed the link I posted in the next paragraph, when I said:
    you'd have seen that was the study I had linked to.
     
  5. Ian Harvey

    Ian Harvey Active Member

    From Simon:

    From:
    Myofascial trigger points: the current evidence. Leesa K. Huguenin.
    Travell and Simons define trigger points as the presence of exquisite tenderness at a nodule in a
    palpable taut band (of muscle). Trigger points are able to produce referred pain, either spontaneously or on digital compression. The clinical definition came to be that trigger points are localised areas of deep tenderness within a taut band of muscle. They exhibit a local twitch response
    (muscle fasciculation) or jump sign (whole body movement) in response to digital pressure or dry needling.

    This paper looks at evidence for Trigger Points (TrPs) and illustrates the inconsistencies between trained , experienced practitioners in identifying TrPs. In fact both inter and intra- reliability was poor.

    The thermographic imaging study you posted Simon appears to show that TrPs can be visualised by this method, but others think that is not at all reliable. The following is a bit old, and perhaps other studies exist which show imaging in a more positive light:

    I think there is also some evidence for ultrasound imaging, but not sure. However, the evidence is a bit patchy for the use of thermographic imaging to diagnose TrPs.

    Regards,
    Ian.
     
  6. And that's what I don't get: if it's palpable why doesn't it show up on any modern imaging?
     
  7. Ian Harvey

    Ian Harvey Active Member

    From Simon:
    Don't know! Maybe someone can shed some light?

    Regards,
    Ian.
     
  8. One reason might be because these "nodules" don't exist. :morning:
     
  9. Ian Harvey

    Ian Harvey Active Member

    Simon says:
    Sounds reasonable, but I suspect that most practitioners would be certain that something is palpable, and that treating the "nodules" or "bands" appears to work and to change how the thing feels under the palpating digit.

    Just because we can't see it yet doesn't mean it doesn't exist.

    Regards,
    Ian.
     
  10. And just because a group of practitioners say they can feel something and sticking a needle into it or rubbing it is efficacious doesn't mean it does exist nor works by anything other than by placebo effect. See: Applied Kinesiology.

    Lets not forget the studies where multiple practitioners couldn't even agree on where the "nodule" was supposed to be. Nor the multiple studies which show dry needling is no more effective than placebo.

    Until someone can show me one, I'll retain a healthy scepticism.
     
  11. Ian Harvey

    Ian Harvey Active Member

     
  12. I'm sceptical because two different clinicians can't say where a trigger point is with any accuracy and sticking a needle in to a so called trigger point or just into the skin has the same clinical outcome... and moreover, because no-one has ever seen a trigger point. Show me the evidence to change my mind because thus far in my opinion the evidence regarding trigger points is highly questionable. Seems to me that someone once made this up and many have followed, ignoring the evidence, along the way... I could be wrong.
     
  13. musmed

    musmed Active Member

    Dear Simon et al
    I ahve posted many a time that in 75 odd percent of PF patients the abd hall has a trigger point or more precisely a tenderpoint present.
    If you U/S the muscle at the level of the med.calc and nav. bone and measure the cross sectional area.
    Also look at the colour.
    Stick an acupuncture needle in
    come back in 10 mins and remeasure the cross sectional area. Also look for colour change.
    If this does not change your mind as to something happening, I do not know what will.
    Regards
    Paul Conneely
    www.musmed.com.au

    PS re trigger points. In lectures some years back there were presentations of electron micrographs of sections of dog muscle where the actin and myosin fillaments were bunched to gether amonst normal muscle patterning.
     
  14. Paul, it's very simple: if you want people to take you and your statements seriously, you need to start evidencing them. Show us the evidence...

    The moons a balloon and if you stick a needle in it it will pop (just like a neuroma). I'm sure y'all believe me; not.
     
  15. musmed

    musmed Active Member

    Simon
    When I can afford the 600,00 dollars for the ultrasound I will retire.
    You ahve a go at what I found and get back to me.
    Regards
    Paul C
     
  16. Peter

    Peter Well-Known Member

    Paul,

    The machine I use only costs £30k, including colour and power doppler, tissue harmonics, and 2 probes!

    Further, you say you can see colour change, is that power or colour doppler signal change?
     
  17. Ryan McCallum

    Ryan McCallum Active Member

    I excised a fairly lare neuroma from a foo tyestrday and stuck a needle into it. Nothing happened except for the needle passing through the other side.

    I am a little dubious about actually whether or not people stick their needle right into a neuroma. I inject neuromas with steroids on an almost daily basis and on numerous occassions, I suspect I have pranged the nerve with the needle tip and the patient has nearly jumped off the couch. Also, I remember a couple of months ago, I was excising a neuroma under general anaesthesia and had given an ankle block to the patient once they had been put to sleep. When I clamped onto the nerve, the anaethetist kindly told me that my tibial block hadn't gone off as they noticed an increase on the patients respiratory rate as soon as the nerve was interfered with (I suspect my block just hadn''t time to go off!). I jimagine it must be incredibly painful for a needle to be inserted into a nerve (an already painful one at that) and the patient's tolerate it. Am I missing something?

    Regards,
    Ryan
     
  18. PMSL.

    Well, you'd have paniced if it hadn't!!
     
  19. Ryan McCallum

    Ryan McCallum Active Member

    Haha, indeed I would, and even more so if it passed through and straight into my finger!!

    What I should clarify is that I didn't actually expect anything else to happen!! And the more I think about it, I'm not actually sure why I even bothered!

    Ryan
     
  20. Peter, as someone who is obviously familiar with these techniques and equipment, do you ever see the changes Paul Conneely stated that he has observed?

    P.S. Can you explain the differences between a colour and power signal change? What reasons in terms of the muscle might account for a change in either of these following the introduction of a needle?

    Paul, do you think the cross-sectional area of the muscle gets bigger or smaller after you stick a needle into it?
     
  21. Peter

    Peter Well-Known Member

    Until Paul clarifies what colour changes he sees, I can't be sure what he is referring to. You can't see clolour change on a grey scale image, thats for sure. Colour doppler refers to pattern and speed of moving tissue to and from the probe, ie vascular components, and power doppler refers to an "averaged" tissue flow, thus inflammatory tissue and hyperaemia/neovascularisation can be visualised. I do not undertake guided injections using superimposed doppler (yet) so Mart in Canada might be able to answer that.

    Otto Chan et al have done some work on hyperaemia/neovascularisation in achilles tendinosis in athletes, injecting dextrose ( i think) and have reduced the doppler signal, as have some Scandinavian workers injecting other injectates, not a needle in isolation.

    If the refs are needed, I can post them a bit later.
     
  22. Peter

    Peter Well-Known Member

    All the following papers undertook US guided interventions which reported on doppler changes as a result of the procedure. nb, all used some intervention, not a needle in isolation.

    Boesen, M. Torp-Pedersen, S. Koenig, M. Christensen, R. Langberg, H. Holmich, P. Nielsen, M. Bliddal, H (2006) Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study, Br J Sports Med; 40:761-766


    Chan, O. O’Dowd, D. Padhiar, N. Morrissey, D. King, J. Jalan, R. Maffulli, N. Crisp, T (2008) High volume image guided injections in chronic Achilles tendinopathy, Disability and Rehabilitation; 30:1697-1708

    Fredberg, U. Ostgaard, R (2008) Effect of ultrasound-guided, peritendinous injections of adalimumab and Anakinra in chronic Achilles tendinopathy: a pilot study, Scand J Med Sci Sports; 18:1-7

    Humphrey, J. Chan, O. Crisp, T. Padhiar, N. Morrissey, D. Twycross-Lewis, R. King, J. Maffulli, N (2010) The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy, Journal of Science and Medicine in Sport; 13:295-298


    Koening, M. Torp-Pedersen, S. Qvistgaard, E. Terslev, L. Bliddal, H (2004) Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients, Scand J Med Sci Sports; 14:100-106

    Maxwell, N. Ryan, M. Taunton, J. Gillies, J. Wong, A (2007) Sonographically Guided Intratendinous Injection of Hyperosmolar Dextrose to Treat Chronic Tendinosis of the Achilles Tendon: A Pilot Study, AJR; 189: W215-220

    Ohberg, L. Alfredson, A (2002) Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment, Br J Sports Med; 36: 173-177

    Ryan, M. Wong, A. Taunton, J (2010) Favourable Outcomes After Sonographically Guided Intratendinous Injection of Hyperosmolar Dextrose for Chronic Insertional and Midportion Achilles Tendinosis, AJR; 194:1047-1053
     
  23. Griff

    Griff Moderator

  24. Mart

    Mart Well-Known Member

    I only just noticed this thread today and just trying to assimilate all the points so far.

    Peter is correct - power Doppler imaging is an index of motion, apart from motion artifact, what it detected and displaced is motion of RBCs. It is extremely sensitive and useful in MSK because it allow discrimination of small vessel changes associated with inflammation. For this reason it increasingly investigated as most sensitive indicator for early rheumatoid arthritis and other arthritides. It is also very useful when trying to identify small vessels such as those associated with inter-metatarsal space neurovascular bundle when ambiguous in simple B Mode.

    Attempts to quantify power Doppler imaging signal are problematic compared to using conventional colour Doppler which is a different process which allows quantification of velocity etc using Doppler shift characteristics of reflected beam. Colour Doppler is not as sensitive as power Doppler imaging.

    I wanted to throw this following idea into the mix.

    Has anyone thought about why ethanol injection for plantar digital neuritis doesn't seem to cause any sensory change to digits?

    The most plausible explanation I can concoct goes like this;

    Plantar digital neuritis may be present in absence of significant mass causing compression of neurovascular bundle.

    We don't have any understanding of the histologic progression of "Mortons neuroma" (MN)

    The importance of the presence of high density of pacinian corpuscles (PCs) within MN biopsy is unclear.

    If normal sensory nerve is subject to injury it may "sprout" nerve tissue AKA problematic stump neuroma

    It may be possible that the fine meshwork of sensory nerves within the plantar fibro-fatty pad "sprout" increasing sensitivity/density of PCs as part of MN progression.

    This might explain symptoms in absence of identifiable mass through imaging early in process.

    This might be reasonable explanation for biomechanical effect of offloading (reducing peak pressure and force time integrals) of sensitive tissue

    It may explain why poor fitting shoes are not problematic in some and associated with pain in others (need to have histologic change + foot-wear compression)

    This might explain effect of ethanol injection - destruction of sprouts vs entire nerve

    Gold standard to explore this would be biopsy but clearly unethical.

    Another idea I have toyed with is to use vibration perception thresholds (VPT) to infer change.

    The idea is to see if there is a normal predictable ratio between dorsal / plantar foot ie a VPT ratio index. If this is true (easy to evaluate) then this might be used as a tool to compare normal to plantar digital neuritis cohort.

    Perhaps it is a bit of a stretch to infer that VPN might be an index of PC density?

    If these indices seemed well correlated to symptoms though then a comparison of VPT index pre and post ethanol might test the idea for consistency of premise of "sprouting"? ie if there was no effect then it would be unlikely that effect of ethanol was to degrade theoretical presence of "sprouts".


    Lots of potential pitfalls but curious to hear any criticism/modification regarding flaws in the methodology/validity of this approach?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  25. Mart

    Mart Well-Known Member

    For those interested in inter-metatarsal space masses other than MN this may be of interest.

    Cheers

    Martin
     
  26. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    I figured you'd show up eventually!
    The variations of location of a MN may answer some of your questions. I have seen these "all over the place" from deep to distal to proximal to more superficial. Many times I feel it depends on the foot type.

    BTW" Our reimbursement rates for MSK US has just about dried up! Our decimal point has moved quite a bit to the left!!!!

    Steve
     
  27. Mart

    Mart Well-Known Member

    Hi Steve

    I have been rationing my PA participation to catch up with other stuff for a while.

    Anyhow I was wondering if you use US prior to your surgeries and if so do you find a useful correlation between the shape of what you dig out surgically and its appearance sonographically. My impression is there is actually the correlation is poor which if true I find curious.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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