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Mortons neuroma and splayed toes

Discussion in 'General Issues and Discussion Forum' started by John McShane, Apr 1, 2016.

  1. John McShane

    John McShane Member

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    I observe that many clients with Mortons neuroma symptoms also have the adjacent toes laterally splayed apart. I presume that "splaying" (or spreading) of the toes apart is due to the inter-metatarsal swelling of the the nerve or bursa.

    Would Ethanol ablation (injection) reduce the splaying of the toes?

    One particular patient is just as concerned about the splaying of her 2nd and 3rd toes as the pain from the neuroma. What is the best best intervention in her case?
  2. Craig Payne

    Craig Payne Moderator

    consider ruling out rheumatoid arthritis.

    I recall a really old paper that did a very long term follow up on people who had a neuroma removed ... a very high percent were eventually diagnosed with RA
  3. Ina

    Ina Active Member

    Laterally splayed toes are sometimes mentioned as the daylight sign in a rheumatoid arthritis context, e.g.:

    "On examination, swelling in the synovium and soft tissues of the metatarsal-phalangeal joints may cause patients toes to splay laterally so that you could see light shining between their toes (the "daylight sign")".

    Rheumatoid Arthritis, Marc C. Hochberg, Alan J. Silman, Josef S. Smolen, Michael E. Weinblatt, Michael H. Weisman


    "Inflammation of the synovium may produce separation of the toes known as the daylight sign (Figure 2-2). This results from the stretching and weakening of the joint capsule and loss of integrity of the collateral ligaments and plantar plate (Jaakkola and Mann 2004; Keenan et al. 1991)".

    Management of Chronic Musculoskeletal Conditions in the Foot and Lower Leg, Keith Rome, Peter McNair
  4. John McShane

    John McShane Member

    Thanks for your detailed reply.
    I will look-up these references.
  5. Ina

    Ina Active Member

    You are welcome, this is a burning issue for many of our clients as well. I just have come across the following book which looks like a very interesting reading on splayed toes of a rheumatoid etiology:

    The Foot and Ankle in Rheumatoid Arthritis: A Comprehensive Guide, Philip Helliwell

    "Daylight sign (when daylight can be observed between the toes, Fig.3.4) is a clinical indicator of synovitis or inter-metatarsal mass at the relevant MTP joint. However, sensitivity and specificity data for this clinical sign is lacking."

    "Occasionally, the 'daylight sign' is seen (see Clinical Features in Chapter 4) and this is reported as an early sign of RA due to inflammation of the inter-metatarsal bursa (Dedrick et al. 1990)."

    "In the metatarsophalangeal joints early inflammatory change may cause, through disruption of the joint capsule, widening of adjacent toes (daylight sign: see Fig. 2.15) and pressure on the inter-digital nerve (Morton?s ?neuroma? ? see below). These clinical pointers are unique to this area, possibly as a result of the anatomy of the metatarsophalangeal joint and the surrounding structures in the web space. Extension of synovial pannus into the contiguous ligamentous structures, such as the deep transverse metatarsal ligament, will cause disruption of this structure and thus widening of the forefoot at this point. The subsequent development of the typical changes seen in RA are a consequence both of synovitis, attenuation of joint capsule and ligaments, altered mechanical forces and unequal pull of the long and intrinsic tendons crossing the joints (see Fig. 2.24).

    Morton?s ?neuroma? is a misnomer in this situation. Although Morton originally described the syndrome in association with a swelling of the inter-digital nerve adjacent to the metatarsophalangeal joint, it seems likely that in RA it is synovitis in the joint that is causing compression of the nerve (Awerbuch et al. 1982). The presentation is the same: a sharp pain radiating into the ipsilateral digit, worse on weight bearing and reproduced by pressure across the metatarsophalangeal joints."

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