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Ist I/M space lesion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Singleton, Mar 31, 2011.

  1. David Singleton

    David Singleton Active Member

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    Hi All,

    I had a patient referred via GP with an Ultra sound report which stated " A 6mm mortons neuroma between the 1st and 2nd Metatarsal heads".

    Should I take this as gospel? Given the rarity of Neuroma in this space, is U/S conclusive for these lesions?

    Could it be a Bursa?

    The patients reports intermittent pain, not exacerbated by shoes. The pain is located to the dorsal I/M space, I was able to palpate a tender point in the area identified by the scan.

    Anyone any ideas regarding treatment?

    If it is a Neuroma, a recent paper I read found nerve lesions 6mm or greater failed to respond to injection therapy. Would surgical removal be the treatment of choice?

    By the way I tried an over the counter orthotic.

    Thanks in advance for any pearls!

  2. Ian Drakard

    Ian Drakard Active Member

    Hi David
    I'm certainly not an expert in US but developing an interest.
    My experience is that the operator is key to effective dx in US. So is it conclusive in these lesions? depends who did the scan.

    Morton's neuromas can look like other lesions on US. However if it's the right shape and you are able to track the nerve entering the lesion and leaving chances are it's a neuroma. If not it's not a conclusive dx.

    Be interested to know what the paper was if you have it? Was it including guided injections?
  3. Lee

    Lee Active Member

    Hello David,

    There is a neuroma of the 1st ID space described in the literature by Heuter (Heuter's neuroma as opposed to Morton's in the 3rd webspace). See the following article for further information:


    In my time operating on my share of neuromas I have only seen one confirmed neuroma of the 1st webspace and that was iatrogenic following surgery for hallux valgus where the previous surgeon had performed an aggressive lateral release through a separate incision at the dorsal aspect of the 1st webspace. I have seen a few bursae in the 1st webspace giving typical neuroma-like symptoms. These all responded to conservative care - footwear advice, orthoses and corticosteroid injections where necessary. Personally, I'm not keen to offer surgery based on the size of the lesion as diagnosed on imaging. Exhaust conservative care first, size isn't important (so I keep telling everyone :D) - I don't know what the intra or inter-rater repeatability of measuring neuromas on USS is, but I'm guessing it's pretty poor, certainly not good enough to jump in with my knife from the off.

    As Ian has already said, successful diagnosis on USS is user dependent. It might be worth trying an image guided injection if this is available and the sonographer is reliable? You could try an MR scan for a differential diagnosis as Michael has said if you are questioning the diagnosis too.
  4. David Singleton

    David Singleton Active Member

    Thanks Ian, Mike and Lee for you reply's!
    Ian I am struggling to find the paper re the size of the lesion and response to treatment, could have been after a long day. This might be the paper I thought I read that in?

    The role of MRI and ultrasound imaging in
    Morton’s neuroma and the effect of size of
    lesion on symptoms
    R. J. Sharp, C. M. Wade, M. S. Hennessy, T. S. Saxby
    From The Brisbane Foot and Ankle Centre, Australia.

    Thanks again guys! :drinks
  5. Peter

    Peter Well-Known Member

    I think you might be referring to Redd et als paper who was probably the 1st sonographer to evaluate Morton's neuroma under US. for what its worth, any intermet neuroma/bursitis is worth treating with the usual battery of conservative RX, inc corticosteroid injection(s). The proposal that lesions >5mm don't respond has been contested, so don't pass the buck on the strength of that alone.

    to my recollection, only Markovic, Sofka et al, and Hassouna have evaluated US guided corticosteroid injection of Morton's neuroma. This stuff is part of my Masters (in progress), so you might want to PM me.

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