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Hydrodilation injections for mortons neuroma

Discussion in 'General Issues and Discussion Forum' started by MelbPod, Oct 24, 2009.

  1. MelbPod

    MelbPod Active Member


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    Hi all,

    I am interested in the opinions and experience of those who have used hydrodilation injection for a mortons neuroma.

    I have a patients with a intermetatarsal neuroma of the 2nd webspace that is persistent despite conservative approaches to footwear and orthotics.
    She does not want to have surgical removal. I have discussed hydrodilation as an option and would appreciate hearing others techniques and results.

    Thanks,

    Sally
     
  2. Mart

    Mart Well-Known Member

    please could you explain what this is or give us a citation

    thanks

    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
     
  3. MelbPod

    MelbPod Active Member

    Hi Matt,

    Maybe I am using poor terminology to describe what I mean.
    I am referring to a technique I have heard other practitioners refer to but have not previously used before myself (I have yet to search the literature, a bit lazy really).

    The technique is used for intermetatarsal neuromas, usually before taking a surgical approach.
    It involves (from what I understand, but requesting further guidance on), the local injection of an amount of local anaesthetic near the site of symptoms with the aim to:
    1) provide temporary pain releif and hopefully break/ reset the neural pain cycle.
    2) stretch and distend local tissues and adhesions and release any impingement.

    Hopefully this provides a little more info into what I meant and i hope to get some feedback.

    Thanks Again
     
  4. W J Liggins

    W J Liggins Well-Known Member

    Hi

    I published some time ago on the use of this technique in the treatment of Plantar Fasciits (1), although I have never heard it referred to as 'hydrodilation'. I think it far more likely that the mechanism of action is a localised hyperaemia resulting in a reduction in inflammatory response.

    The possibility of the procedure breaking and re-setting the pain cycle is speculative but may possibly be involved (2). Personally, I have not found the use of L.A. alone rewarding, although I admit to low numbers since I now always start with methylprednisolone and bupivacaine in appropriate cases of neuroma. Again, I have not researched, so the comment is anecdotal only.

    I suspect that like so many pathologies, it really depends on clinical presentation. I have found injectables useless in the case of large neuromata (circa 20mm +) identified by U/sound.

    (1) Pavier J.C.S., Liggins W J. "The Use of 0.5% Bupivacaine Husdrochloride Plain Solution Injections in the Treatment of Chronic Plantar Fasciitis". British Journal of Podiatry , 2001, 4(3) 90-94

    (2) Melzack ., Wall P. "The Challenge of Pain" pps 188-193. Penguin, London.

    I'll be interested to see your results if you would kindly post them here.

    All the best

    Bill Liggins
     
    Last edited: Oct 25, 2009
  5. Mart

    Mart Well-Known Member

    I would normally just call this a diagnostic injection.

    I routinely inject a very small volume, 0.3 mls of buffered 2% plain lidocaine, into inter-metatarsal space at metatarsal head/ prox phallanx level as confirmation for DDx for metatarsalgia.

    This is helpful if there is suspicion of multiple causes eg, synovitis of metatarsophalangeal joint, plantar plate tear, or plantar digital neuritis with one of more than one inter-metatarsal space.

    Like Bill I have never found any therapeutic value in doing this, infact I usually warn patients that there will be possible temporary aggrevation of symptoms which often seems to be case.



    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





    I find
     
  6. Having done quite a number of Morton's neuroma excision surgeries over the past quarter century, I would tend to doubt that injecting a fluid around the neuroma would "distend local tissues and adhesions and release any impingement". The neuroma is not in a compartment of the foot that you can somehow distend without causing increased pressure on the nerve by the fluid and/or without the fluid leaking out elsewhere.

    Morton's neurectomy procedures, if done with a more proximal transection of the intermetarsal nerve, is a very predictable surgery that rouitinely works very well for patients. Most of the failures that I have seen from Morton's neuroma surgery is when the nerve is transected too distally so that the cut end of the nerve is close to the metatarsal neck in a more weigthbearing area of the foot, rather than deep within the foot at the midshaft level of the metatarsal.
     
  7. Mart

    Mart Well-Known Member

    Hi Bill

    I think this is an interesting issue.
    Diagnostic ultrasound exam of the inter-metatarsal space is tricky do well. There can be a very limited opportunity in patients with significant metatarso-phalangeal joint subluxation to get an unrestricted plane to focus the beam without hitting joint margins either bone or capsule. The presence and size of the inter-metatarsal bursa also seems somewhat contentious in the literature. I do inter-metatarsal space US exams daily and what I have noticed is that the size of the bursa generally but not always seems related to pain associated with plantar digital neuritis. I often see what I interpret as larger bursa in inter-metatarsal spaces with no associated symptoms in the same patient. I think this is why diagnostic injection is important adjunct to imaging, ie the image derived sign may be incidental to pain.
    Measuring the size of the bursa is tricky. The margins are most often ambiguous and deciding where to put the callipers is quite subjective. It will depend on;
    how the machine is set up in terms of gain, frequency and focus,
    the impedance of surrounding and overlying fat,
    the amount of compression applied by probe
    the actual plane of the slice at instant of measurement
    there are occasionaly very defined lesions where there are very defined borders. My suspicion is that they represent bursal transformation where the synovial fluid has become thickened as is does with synovial cysts and the appearance is very similar.
    As a generalisation what I find important is evidence of lesion which extends superficial to the NVB. This is regarded as evidence of bursal transformation, the tissue, whatever that is, has a permanent encapsulation of the NVB rather than transient weight-bearing motion. This seems to correlate with symptoms and may well prove to be a good prognostic sign.
    I am hoping to do some US cadaver studies on this issue over the next year or so and will post anything which might result from this

    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
     
  8. W J Liggins

    W J Liggins Well-Known Member

    Hi Mart

    I agree that u/s is tricky for neuromata. I don't carry out the investigation myself, but have noted that using the same radiologist time and again has resulted in more accuracy based on histopathology following surgery. The specimen always seems larger than suggested by u/s examination. In fairness, they do seem to pick up bursae pretty well and I have had some success treating these with L.A. Maybe rupturing the bursa? I've never carried this out under u/sound guidance so do not know if this is the case.

    Look forward to your future postings on the subject.

    All the best

    Bill
     
  9. Mart

    Mart Well-Known Member

    I am really curious about what kind of information the histopathology generates from your surgeries.

    How are the specimens prepared? Are you able to post some generalisations, particularly with regard to cell types and morphology.

    One of the issues which interests me is how closely US appearance might correlate with histology of these lesions and I have no opportunity so far in my own work investigate this.

    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
     
  10. G Flanagan

    G Flanagan Active Member

    Hi Martin,

    Our path lab normally reports something along the lines of.....

    Macro: a soft yellowish white peice of tissue

    Micro: Fibrofatty tissue contaning nerve bundles with concentric fibrosis and pacinian corpuscles. Consistent with neuroma.
     
  11. drsarbes

    drsarbes Well-Known Member

    "She does not want to have surgical removal....."

    No one WANTS surgery. If she has a recalcitrant neuroma excision is the treatment of choice. Sometimes we do our patients an injustice by bending to their wishes even when our training and experience tells us different.

    Steve
     
  12. Mart

    Mart Well-Known Member

    Thanks George and interesting!

    I guess the concentic fibrosis fits our expection of what a neuroma is.

    I wonder about the pacinian corpuscles, I guess they would be expected to be found in this region, but perhaps not.

    Could it be possible that the concentric fibrosis noted is a feature of increased corpuscle density? Bit of a long shot and then so what anyway?

    It would have potential as pain generator, it could have modified pain threshold and possible feature of symptoms modified by steroid shot, I guess if there is radiating toe pain this is mute anyway.

    I did not recall much about them other than being mechano/pain sensors found in skin. I have posted an referenced wikopedia cut and paste as a refresher blow.

    Do you have access to US images of the patients you see before and after excision exision? I would love to see what they look like on US with this kind of pathology feedback, even better if it was possible also to US to examin the removed specimins covered in US gel before pathology. If you do or might I'd love to chat to you about how this might be usefully documented

    This would be very helpful in thinking about what the US images might represent and possibly improve diagnostic specificity and prognosis using US.



    cheers

    Martin



    Pacinian corpuscles are one of the four major types of mechanoreceptor. They are nerve endings in the skin, responsible for sensitivity to pain and pressure.
    Contents

    Structure

    Similar in physiology to the Meissner's corpuscle, Pacinian corpuscles are larger and fewer in number than both Merkel cells and Meissner's corpuscles[1] .
    The Pacinian corpuscle is oval shaped and approximately 1 mm in length. The entire corpuscle is wrapped by a layer of connective tissue. It has 20 to 60 concentric lamellae composed of fibrous connective tissue and fibroblasts, separated by gelatinous material. The lamellae are very thin, flat, modified Schwann cells. In the center of the corpuscle is the inner bulb, a fluid-filled cavity with a single afferent unmyelinated nerve ending.
    Function

    Pacinian corpuscles detect gross pressure changes and vibrations and are rapidly adapting (phasic) receptors. Any deformation in the corpuscle causes action potentials to be generated, by opening pressure-sensitive sodium ion channels in the axon membrane. This allows sodium ions to influx in, creating a receptor potential.
    These corpuscles are especially susceptible to vibrations, which they can sense even centimeters away. [1] Their optimal sensitivity is 250 Hz and this is the frequency range generated upon finger tips by textures made of features smaller than 200 µms.[2] Pacinian corpuscles cause action potentials when the skin is rapidly indented but not when the pressure is steady, due to the layers of connective tissue that cover the nerve ending [1]. It is thought that they respond to high velocity changes in joint position.
    Pacinian corpuscles have a large receptive field on the skin's surface with an especially sensitive center [1]. They only sense stimuli that occur within this field.
    How it works

    Pacinian corpuscles sense stimuli due to the deformation of their rings of lamellae which press on the top of the sensory neuron. When the lamellae are deformed, either due to pressure or release of pressure, a generator potential is created as it physically deforms the plasma membrane of the tip of the neuron making it “leak” Na+ ions. If this potential reaches a certain threshold nerve impulses or action potentials are formed by pressure sensitive sodium channels at the first node of Ranvier, the first node of the myleinated sensory neuron. This impulse is now transferred along the axon with the use of sodium channels and sodium/potassium pumps in the axon membrane. As long as the top of the neuron is depolarized it will continue to depolarize the first node of Ranvier. It is a graded response meaning the greater the deformation the greater the generator potential. This information is encoded in the frequency of impulses as a bigger or faster deformation induces a higher impulse frequency. Action potentials are formed when the skin is rapidly distorted but not when pressure is continuous. The frequencies of the impulses decrease quickly and soon stop due to the layers of connective tissue that cover the nerve ending. This adaption is useful as it stops the nervous system from being overloaded with unnecessary information such as the pressure exerted by clothing.
     
  13. Mart

    Mart Well-Known Member

    Hi Steve
    I used to have thoughts like this until recently reading a life changing book called
    “Critical thinking: a concise guide” by Tracy Bowell, Gary Kemp.
    In trying to improve the ability at getting at the truth of a statement they talk about the role of “charity” which examines the notion of restructuring an argument in a way which although not what was “said” was most likely to reflect what was “meant”.
    As obvious as it seems now I realize that people who annoy me often stop having that effect when I think for a second and about what they meant and then challenge that with them. It has improved my patient communication no end and my blood pressure is down a bit to boot.
    respectfully

    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
     
  14. drsarbes

    drsarbes Well-Known Member

    "not what was “said” was most likely to reflect what was “meant”."

    Hi Martin:

    I agree completely.

    Listening is an art form.

    The problem (if you want to call it that) with the office setting is that frequently we don't have time nor are we inclined (towards the end of the day) to be compassionate with each and every patient. We like to think we are but I doubt we all haven't had our "bad" days.

    The other side of the coin is that communication is an art form. It's also important for the patient (in this case) to be able to describe why they are against having surgery.

    Afraid of infection, poor outcomes, hospitals, bad previous experience, low pain threshold........ some deep seeded childhood fear stemming from an interaction with Uncle Adolph who was a General Surgeon and always yelled at the patient when she and her family visited??????? What?

    Is it really OUR job to find out why a patient may not want surgery or is it enough to diagnose and suggest Tx then carry out that treatment as best as we can. Certainly you don't want to TALK anyone INTO surgery.

    IF they are over 18 it's their decision, isn't it?


    Steve
     
  15. MelbPod

    MelbPod Active Member

    Hi Steve,

    I agree, I dont think anybody comes in saying ooohh wow surgery....gimme gimme...

    But at the same time, there is importance in discussing all the treatment options available for the patient, the pros and cons and expected outcomes of each.

    Then, with this knowledge the patient can make a more educated decision as to what treatment path they want to take.

    There is a multitude of reasons that patients may not choose the surgical option and in this case the main factor is that she plain and simply can not afford it.

    The right to choose after educated on expected outcomes is an important step in avoiding liability issues. Even though surgical excision is the gold standard and probably most effective treatment option, it is just not the path for this patient at this time. So I need to try and work with this.

    Kind Regards,

    Sally
     
  16. drsarbes

    drsarbes Well-Known Member

    "it is just not the path for this patient at this time."

    Fair enough. When it hurts enough or interferes in her life style enough she may reconsider. Until then, maybe you will come up with an alternative treatment. Stranger things have happened.

    Good luck.

    Steve
     
  17. Rick K.

    Rick K. Active Member

    I have done a ton of neuroma excisions over the years, but have done none over the last 5 years since starting neural sclerosis injections with alcohol. I noted about a 10% recurrence rate post excision - and I transected the nerve sufficiently proximal to the intermetatarsal ligament.

    I inject 1cc of 4% ethyl alcohol proximal to the neuroma and inject 7 times at 7 day intervals (at 7:07 starting on the 7th) and have tended to only note failures due to adjoining interspace neuromata.

    And over the years, post neurectomy, it only takes a couple CRPS/RSD complications to make you a little leery. I have seen none of those with the sclerosis therapy.
     
  18. drsarbes

    drsarbes Well-Known Member

    Hi Rick:
    Do you mix your own solution or have it made up for you?

    Why 7 times in 7 weeks. Had you tried other time frames?

    What complications had you had with the injections?

    Any contraindications?

    Thanks

    Steve
     
  19. Mart

    Mart Well-Known Member

    Curious to know if you can add anything to this thread

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=36428&highlight=ethanol

    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
     
  20. MR NAKE

    MR NAKE Active Member


    thanks martin

    i think this is the most interesting part i gather with this thread!:good:, allow me to ask?is the action potential being generated by the the pressure that is acting as a stimulus enough to cause depolarisation that is picked up by the pecinian corpuscles and then either translated/transfered/shared with the common proper digitigal nerve? hence the neuritis resulting in end stage neuroma tissue .......confirmed by histology as micro(flanagan):confused: could some of the symptoms be from the pacinian corpuscles alone then.....in cases where U/S is unrermakable of a hypoechoic mass?
     
  21. Mart

    Mart Well-Known Member

    Those are the some of the questions that have been floating around in my mind too. I am not aware that they have been studied but here's my thoughts:

    The general assumptions seem to be that;

    whatever the mechanism for modifying the tissue around the nerve, the symptoms are caused by mechanical compression against it.

    that corticosteroids when injected for treating these lesions do so by reducing inflamation ie size of space filling lesion

    and that ethanol scleroses the lesion also shinking the dimensions.

    These seem good plausible explainations and I think in most peoples minds are true, however all lack strong evidence.

    Being the contrarian that I am I love exploring alternatives and recently have started filling some of my knowledge gaps regarding what is known about how corticosteroids work and how they affect pain and inflammation.

    This is still a work in progress for me but what I seem to be discovering is that the an effect of corticosteroids amoungst many things could be to modify nociception action potential thresholds.

    It could be important because currently, when dealing with this and other conditions (eg, chronic plantar fasciosis) what we are really treating is pain (in terms of outcome measures at least).

    The measured outcome then (since it is almost exclusively pain VAS) may be less to do with ongoing stress related damage (as measured by imaging) and more to do with reducing threshold of nociceptive responce and/or nociceptive stimulation.

    One of the reasons I think this may be true is that in my observations so far with diagnostic ultrasound there seems to be a lengthy lag period between dimentional change in degenerated plantar fascia and earlier symptom resolution. My obervations for this have been casual and not close to research grade in terms of measurement error. There are other possible reasons but if there is pain resolution in absence reduction of lesion size, a shift in nociceptive threshold seems a plausible notion.

    I think a counter argument against this idea for plantar digital neuritis at least is how that might explain the characteristic radiating toe pain. Logically compression must be a primary feature when radiating toe pain is present.

    Metatarsalgia (even without radiating pain into toes) can sometimes be eradicated with small vol inter-metatarsal space nerve blocks which do NOT render painful zone insensate. This suggests in those cases refered pain generation from injection site. I use this and other diagnostic blocks frequently to work up DDx for generalised metatarsalgia.

    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
     
  22. Funkster

    Funkster Member

    Has anybody read this.

    Treatment of Morton's Neuroma with Alcohol Injection Under Sonographic Guidance: Follow-Up of 101 Cases Richard J. Hughes; Kaline Ali; Hugh Jones; Sue Kendall; David A. Connell. http://www.medscape.com/viewarticle/557978.

    This treatment is offered by Radiologists at Stanmore Orthopaedic hospital UK. From what I can gather the results are as good a surgery but obvioulsy less invasive with quicker recovery etc.

    If anybody knows where I can get free access to the full paper I would be grateful.
     
  23. Mart

    Mart Well-Known Member

    View attachment Treatment of Morton’s Neuroma with alcohol.pdf

    Does anyone have any evidence or ideas about what the alcohol actually does?

    Studies seem to variably consider either neurolysis or sclerosis/dehydration of bursa tissue.

    Anyone care to comment from their own experience if patients treated with ethanol develop or sustain sensory loss of digits subsequent to pain resolution?

    My assumption would be if neurolysis was action then this would occur.

    What about concentration and volumes, any comments regarding this, 4% and 20%
    seemed to have been tried, I am curious about if this is entirely arbitary or if based on rational or precident.

    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
     
  24. Mart

    Mart Well-Known Member

    attached to previous post
     
  25. Funkster

    Funkster Member


    Thanks for the pdf. I am told it ablates the nerve by neurolysis though this is just verbally from a Radiologist who is looking in to performing this technique. I have no real evidence.
     
  26. numlymud

    numlymud Welcome New Poster

    Anyone care to comment from their own experience if patients treated with ethanol develop or sustain sensory loss of digits subsequent to pain resolution?
     
  27. drsarbes

    drsarbes Well-Known Member

    Reading this study from '07 / I don't see a substantial difference between reported resolution of neuroma symptoms following cortisone injection compared to etoh injections. If 80% are going to be asymptomatic at 2 years following cortisone injections why take the risk of post etoh injection associated symptoms? The injection failures will go on to surgery just the same.

    Also: The study showed a minimum of 4 injections; one patient developed an RSD (1 in 100) several had increased pain up to 3 weeks post injection!

    I still think "do no harm" is a creed to live by. If 8 out of 10 neuroma patients will obtain relief from Orthotic and or cortisone injections, and the rest undergo successful neuroma resection surgery (which I would consider minor surgery) why perform a treatment that takes longer to perform, has higher risks and is arguably only minimally more successful?

    Steve
     
  28. Mart

    Mart Well-Known Member

    Hi Steve

    I think that the problem with your arguement is that it doesn't consider the following:

    Treatment of Mortons ... . .. .. Hughes et Al 2007 is using 20% vs Docherty 4%. Concerns regarding frequency of post injection pain may be associated with etoh concentration being higher but possibly with better pain measured outcome compared to 4%. They also attempted dimentional outcome measurement (although I am curious to know more about the methodology for this which is very (acking in the paper) which showed diminution of lesions.

    There are risks associated with steroids for this injection which this paper cites, notably plantar fibro-fatty pad atrophy which I would estimate important.

    The evidence for steroid injections (many more papers) shows great variation in outcomes and overal evidence for injection therapy is low quality evidence.


    In my own experience some patients get severe agrevation of symptoms following a diagnostic block with nothing but LA so post injection pain may be mechanical rather than from agent.

    Interesting Hughes et all do not mention outcome of digital sensory loss, non of the paper s seem to mention this.







    As an outcome measure surely this is vital information since it MUST be an indicator of etoh action ie neurolysis or something else.


    PLEASE could a member experinced with this technique make some comments on this since it is important info in thinking about this further.


    Steve what do you think about these points beore you rule this option out?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT 668)
    fax [204] 774 9918
    www.winnipegfootclinic.com










    .
     
    Last edited: Nov 4, 2009
  29. drsarbes

    drsarbes Well-Known Member

    Hey Mart:
    Well the study sites the selection of 20% due to previous studies siting 20% as the minimum for neurolysis. I'm admittedly not familiar with these injections at any concentration so I cannot speak from experience. It appears that "leakage" of solution to areas outside the neuroma was blamed for these reactions.

    Better outcomes at 4%! Well, this is the whole point of selecting a treatment option - success vs complications (vs cost!)

    As far as complications of cortisone injections - I think we can minimize these by proper selection of drug and frequency of injections. In my experience I only inject twice for morton's neuromas. If 2 doesn't do it 6 aren't going to either!

    I'm certainly open to new and improved treatments - however I think they need to meet certain criteria before we replace other time tested treatments.

    I never want my patients leaving my office in more pain than they entered with!

    Gotta run

    Thanks

    Steve
     
  30. Mart

    Mart Well-Known Member

    George

    Do you think this represents pacinian corpuscle hyperplasia, just a bunch of PCs that are normally lurking around or dunno?

    I am asking because there is a bit in the lit (example attached) regarding this but is regarded as rare. Just thinking rare or under detected? Just thinkin!!

    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
     

    Attached Files:

  31. Funkster

    Funkster Member


    I have made further enquiries about this technique which created a lot of interest from patients mainly because of editorials in the national newspapers.

    I have heard that if it fails there can be extensive fibrosis which can be a nightmare mess for the surgeons to sort out. When it works it is great but when it fails it fails badly. Incidently I think hydrodilatation is a technique used for frozen shoulder where the joint capsule is inflated with saline to break adhesions. Dont think it would work for neuromata !
     
    Last edited: Nov 25, 2009
  32. Mart

    Mart Well-Known Member

    Is this based on comments from

    HUGHES, R. J., ALI, K., JONES, H., KENDALL, S. & CONNELL, D. A. (2007) Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol, 188, 1535-9.

    or something else?


    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
     
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