MRI of metatarsalgia

NewsBot · Sep 5, 2015

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MRI utility in patients with non-traumatic metatarsalgia: A tertiary musculoskeletal center observational study
Mohamed Ragab Nouh et al
The Egyptian Journal of Radiology and Nuclear Medicine; 1 September 2015

Aim
To assess the utility of MRI of the forefoot in the workup of patients with non-traumatic metatarsalgia and inconclusive initial radiographs.

Patients and methods
The study included 125 patients (46 males and 79 female) with a mean age 38.8 years (age range 7?74 years) presented with forefoot pain. Patients with history of a clear recent forefoot trauma, gross osteo-articular deformities and previous forefoot surgery were excluded. Radiographic evaluations of the fore-foot followed by MRI imaging were performed using 1.5-T scanner. We stratified our patients into 4 groups: (a) stress-related, (b) arthritic-related, (c) infection-related, and (d) neoplastic disorders.

Results
The most common causes of fore-foot pain, in our series, were Morton neuroma in 20 cases (16%), metatarsophalangeal (MTP) instability syndromes in 15 cases (12%) and sesamoid pathologies in 9 cases (7.2%) of the stress-related group. In arthritic group, rheumatoid arthritis and osteo-arthritis were equally the commonest entities (9.6%). Foreign body invasion in 10 patients (8%) was the common cause of infection-related forefoot pain. In the neoplastic category plantar fibromas were the commonest lesion (5.6%) in our series.

Conclusion
MR imaging depicted numerous forefoot soft-tissue and early osteo-articular processes in absence of gross fractures or other remarkable findings on radiographic screening.
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NewsBot · May 25, 2021

Accuracy of Magnetic Resonance Imaging (MRI) and Dynamic Ultrasound for the Diagnosis of Plantar Plate Injuries:

NewsBot · Jun 9, 2021

Should the webspaces be a review area for Mortons neuroma
on computed tomographies performed for metatarsalgia?
Christine Azzopardi et al
Pol J Radiol 2021; 86: e322-e324

Purpose: Morton’s neuroma-bursal complex (MNBC) is a common cause of metatarsalgia which is usually investigated with ultrasound. Patients presenting with metatarsalgia may also have computed tomography (CT) as part of
their investigation to look for alternative causes such as stress fracture. Although CT is considered to be of most use
in assessing the bones in this scenario, the soft tissues can also be reviewed. This study analyses whether MNBC can
reliably be detected on CT in patients presenting with metatarsalgia.
Material and methods: 43 cases were identified on the Radiology Information System where both CT and ultrasound
had been undertaken to assess for metatarsalgia. Two blinded consultant musculoskeletal radiologists retrospectively
reviewed the CTs to determine the presence or absence of MNBC and this was compared to the ultrasound reports.
Results: There was a mean sensitivity of 45.5% and mean specificity of 62.5%. Mean accuracy was 52.3% and Youden’s
index was 0.080. There was fair agreement between the two reviewers with Cohen’s κ of 0.62.
Conclusions: Sensitivity and specificity of CT for MNBC are poor. CT should not be used as an isolated modality to
make a definite diagnosis regarding the presence or absence of a MNBC.
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NewsBot · Feb 7, 2022

Diagnostic Accuracy of MRI in Diagnosing Plantar Plate Tear About Metatarsalgia: Incidental Finding of A Tear on Routine Magnetic Resonance Imaging
Amir R. Kachooei, MD, Rachel J. Shakked, MD, Johannes B. Roedl, ...
Foot & Ankle Orthopaedics January 21, 2022

Introduction/Purpose:
This study aimed to assess the rate of plantar plate tear finding on MRI study of symptomatic versus asymptomatic patients. We secondarily aimed to determine the correlation between PP tear grading and symptoms and to assess the diagnostic accuracy of MRI.

Methods:
Based on the physical examination report, patients were divided into Symptomatic and Asymptomatic groups. Data from the MRI reports were extracted for the second to fifth plantar plates. All MRIs were studied again by a musculoskeletal radiologist to measure the inter-rater agreement and MRI reports' reliability. MRI finding of the plantar plates was categorized as torn vs. intact. We used the anatomical grading system (AGS) to assess the plantar plate tear grading correlation with symptoms

Results:
There was an excellent inter-rater agreement (Kappa=0.92). Calculating the odds ratio reveals that the odds of finding intact PP in a symptomatic patient is 16 times more than finding a tear in the same patient. Diagnostic accuracy of MRI shows that PP tear finding on MRI is highly specific and has a low sensitivity meaning that the chance of incidental finding of a PP tear is extremely low.

Conclusion:
MRI is specific for diagnosing plantar plate tear and is suggested to confirm the diagnosis and plan for the surgery when the diagnosis is highly probable concerning the clinical examination.
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NewsBot · Aug 30, 2022

Incidental Finding of Plantar Plate Pathology on Routine Magnetic Resonance Imaging of the Foot and Ankle
Amir R Kachooei et al
Foot Ankle Spec. 2022 Aug 29

Background: We hypothesized that there would be a comparable and high incidence of an incidental torn plantar plate on routine magnetic resonance imaging (MRI) in asymptomatic patients.

Methods: We included adult patients undergoing a foot MRI from 2019 to 2020. Based on the documented reason for MRI, patients were divided into symptomatic and asymptomatic. A separate musculoskeletal radiologist re-evaluated MRI images. Findings were categorized as "torn vs intact." We also used the anatomical grading system (AGS).

Results: We reviewed 218 records, including 165 asymptomatic and 53 symptomatic patients. The chance of finding a plantar plate (PP) tear on MRI of symptomatic patients was 28% (21% in PP2, 5.7% in PP3, 5.7% in PP4, and 2% in PP5), while PP tear in asymptomatic patients was only apparent in 2% of MRIs (1.5% in PP2, 0 in PP3, 0 in PP4, and 0.6% in PP5). Cohen's kappa coefficient was 0.92, showing excellent agreement between the radiologists. Odds calculation revealed that the chance of finding a torn PP in an asymptomatic patient is 2.5%. In comparison, the chance of finding an intact PP in a symptomatic patient is 72%, showing 2.5 times more likely to find an intact PP than a torn PP in symptomatic individuals.

Conclusion: Interestingly, there was a low rate of abnormal PP appearance on MRI in both symptomatic and asymptomatic patients, which suggests that the chance of finding a false-positive PP tear in an asymptomatic patient is minimal and probably negligible.
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NewsBot · Jan 13, 2023

This trial was just registered:
US and MRI of the Forefoot: Intermetatarsal Bursitis or Morton's Neuroma

The aim of this study is to investigate the incidence of intermetatarsal bursitis and Morton's neuroma in patients with metatarsalgia (i.e. pain in the forefoot) and control subjects by diagnostic imaging with ultrasound and MRI.
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NewsBot · Jan 31, 2023

Lesser Metatarsophalangeal Joint Plantar Plate Degeneration and Tear and Acute First Metatarsophalangeal Joint Capsuloligamentous Injury: What the Surgeon Wants to Know
AshtonReeve et al
Seminars in Ultrasound, CT and MRI; 28 January 2023

Injuries to the plantar plate complex of the first toe and the lesser toes, although closely related anatomically, differ significantly in their pathogenesis. Lesser metatarsophalangeal (MTP) joint plantar plate degeneration and tear typically presents as an attritional pattern of capsuloligamentous deficiency in middle-aged patients, whereas first MTP joint capsuloligamentous injury is typically acute and occurs in younger adult athletes engaged in sports involving repetitive running and jumping. Consequently, considerations regarding surgical decision-making also differ. Knowledge of the anatomy, pathophysiological basis, common patterns, grading and classification of these injuries, and indications for surgery, will aid imaging interpretation in the pre-operative setting. The acuity and extent of injury, tissue quality and functional requirements of the patient (such as timely return to sport) influence clinical decision-making with respect to conservative versus surgical management and are informed by the use of optimized multi-modal imaging. This section will provide an overview of these injuries in two parts, separated into those affecting the first toe and the lesser toes, and will highlight imaging findings relevant to surgical decision-making.
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NewsBot · Mar 16, 2023

Evaluating the features of interdigital
neuroma using 3-Tesla magnetic resonance
imaging
Tugrul Ormeci et al
Eur J Anat, 27 (2): 171-180 (2023)

Interdigital neuroma is an entrapment neuropathy of the interdigital nerve. Previously, studies
on interdigital neuroma were done with 1 Tesla
Magnetic Resonance Imaging and more often 1.5
Tesla Magnetic Resonance Imaging. We used 3
Tesla Magnetic Resonance Imaging in our study
and we did not encounter as much as we know
about the study with 3 Tesla Magnetic Resonance
Imaging in the literature. Between 2013 and 2019,
the 3 Tesla Magnetic Resonance Imaging results
of 39 consecutive surgically-confirmed interdigital neuromas and patients’ files were retrospectively evaluated. The soft tissue surrounding the
prominent interdigital nerve “target sign” were
assessed. Spearman’s rho, Pearson’s correlation
tests, and Mann-Whitney U-tests were used. Of
the 39 cases (mean transverse dimension = 4.64
mm), 35 (89.7%) were hypointense on T1-weight
ed sequencing, 34 were intermediate (87.1%) on
short tau inversion recovery sequencing, and 29
(74.3%) had slightly-moderately enhanced neuromas on post-contrast spectral presaturation with
inversion recovery sequences. A statistically significant negative relationship was found between
contrast enhancement and disease duration (p =
0.020). On short tau inversion recovery or spectral presaturation with inversion recovery series,
the intralesional nerve view “target sign” was observed in 23 (58.98 %) of 39 neuromas. This is the
first study in the literature with 3 Tesla Magnetic
Resonance Imaging that shows the visual characteristics of interdigital neuroma and its possible
contribution to the diagnosis of the disease.
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NewsBot · Jun 15, 2023

Differential Diagnosis of Metatarsalgia
P. Diana Afonso , Sabrina Veras Britto , Charles E. Spritzer , Patrícia Martins e Souza
Semin Musculoskelet Radiol 2023; 27(03): 337-350

Lesser (or central) metatarsalgia is defined as pain in the forefoot under or around the lesser metatarsals and their respective metatarsophalangeal joints. Two common causes of central metatarsalgia are Morton's neuroma (MN) and plantar plate (PP) injury. Because both clinical and imaging features overlap, establishing the correct differential diagnosis may be challenging. Imaging has a pivotal role in the detection and characterization of metatarsalgia. Different radiologic modalities are available to assess the common causes of forefoot pain, so the strengths and weakness of these imaging tools should be kept in mind. It is crucial to be aware of the pitfalls that can be encountered in daily clinical practice when dealing with these disorders. This review describes two main causes of lesser metatarsalgia, MN and PP injury, and their differential diagnoses.
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NewsBot · Jun 21, 2023

Comparing clinical examination and radiological evaluation in the preoperative diagnosis and location of symptomatic Interdigital (Morton's) Neuroma
Helena FRANCO, MD et al
June 20, 2023

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma.
A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected pre-operative clinical findings, radiological investigations and post-operative outcomes. Sensitivity and positive predictive value were calculated and Z-score for two populations proportions was performed.
114 consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common pre-operative clinical feature was pain (99.2%).
The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (P-value: <0.001 and P-value: <0.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (P-value: 0.005).
Pre-operative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Pre-operative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.
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NewsBot · Jul 31, 2023

Are MR imaging and pathologic tissue sizes compatible in morton neuroma?
Guler, Yasin; Hakyemez, Omer Serdar; Seker, Mehmet; Cakir, Asli; Kara, Adnan; Ayanoglu, Semih
Medicine Science . Jun2023, Vol. 12 Issue 2, p475-478. 4p.

It is claimed that Morton Neuroma (MN) is symptomatic if it is greater than 5mm. In contrast, significant amounts of Morton neuroma that do not reach this critical level may become symptomatic. Therefore, it is thought that MN size and intensity of symptoms do not show a positive correlation. Twenty patients who were operated at Medipol University School of Medicine between 2015-2019 for the diagnosis of Morton neuroma and whose disease was diagnosed as Morton Neuroma by MRI and pathological evaluation and were evaluated retrospectively. Pathological tissue size measurements and MRI measurements were compared. The mean age of the operated patients was 47, 14 were female and 6 were male. The average of the pathological tissue dimensions after the measurements was 16,6 mm. The average of the radiological image dimensions after the measurements was 8,5 mm. The pathologic dimension was significantly higher (p<0.05) than the radiological dimension. After comparative measurements of MR images and pathological dimensions of Morton Neuroma, it was determined that there was a difference between them. Therefore, the surgical treatment option should not be determined according to the severity of clinical symptoms rather than size.
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NewsBot · Jan 8, 2024

Sonographic anatomy and technique to image the plantar digital nerves and aid identification of a Morton’s neuroma
Michelle Fenech
Source

Introduction:
The anatomy of the forefoot is complex, and the sonographic assessment to image the plantar digital nerves and exclude, diagnose or discriminate between a Morton’s neuroma and intermetatarsal bursitis can be challenging.
Topic description and discussion:
A good appreciation of the sonographic anatomy, technique, normal and abnormal appearances is required to undertake a sonographic assessment of the forefoot and its interspaces, particularly the plantar digital nerves. This is unpacked in this paper with associated pictorial aids. Muscles, tendons, and ligaments of the interspaces and the nearby metatarsophalangeal joints and their associated soft-tissue structures are helpful sonographic landmarks to guide imaging and assessment of the common and proper plantar digital nerves and the intermetatarsal bursa. These need to be appreciated from both dorsal and plantar sonographic approaches, in both short- and long-axis imaging planes.
Conclusion:
Improved understanding of the anatomy and sonographic appearances of the interspace structures can enhance the sonographic assessment of the forefoot and improve diagnosis of a Morton’s neuroma and/or intermetatarsal bursitis when present to guide patient management.
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NewsBot · Feb 29, 2024

Analysis of Nonweightbearing MRI Fat Pad Thickness Under Central Metatarsals in Patients With and Without Metatarsalgia
Chase Gauthier et al
Source

Background:
Metatarsalgia is a common diagnosis for patients with forefoot pain. Many have proposed metatarsal fat pad atrophy is a cause of metatarsalgia and therefore have suggested fat grafting instead of distal metatarsal osteotomies to treat metatarsalgia. For fat grafting to be a viable treatment, fat pad atrophy should correlate with metatarsalgia. This study looked to determine the relationship between metatarsal fat pad thickness and metatarsalgia and the correlation between metatarsal fat pad thickness and patient-reported outcomes.
Methods:
We conducted a retrospective review of patients with metatarsalgia and those with foot or ankle osteoarthritis who had a nonweightbearing MRI performed between February 1, 2021, and March 1, 2023. Data collected included demographics, PROMIS scores, metatarsal fat pad thickness in the second and third rays of the affected foot, and thinnest area on coronal section, measured on MRI. Student t test was used to compare continuous variables, whereas the χ2 test was used to compare categorical variables. Multivariable linear regression models were used to control for potential confounding factors.
Results:
A total of 112 patients were included in this study. Patients with metatarsalgia were significantly more likely to have a lower body mass index (29.3 vs 32.0, P = .03) than patients with osteoarthritis, but this finding was not present when controlling for confounding variables. We found no significant difference in fat pad thickness between patients with metatarsalgia vs patients with foot or ankle osteoarthritis (P = .43). We found no correlation between metatarsal fat pad thickness and pain interference (P = .59), physical function (P = .64), or mobility (P = .94) PROMIS scores.
Conclusion:
In this retrospective comparative study of a relatively small cohort we found no significant difference in metatarsal fat pad thickness for patients with metatarsalgia vs patients with foot and ankle osteoarthritis based on nonweightbearing MRI, and no association between metatarsal fat pad thickness and patient-reported outcomes.
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NewsBot · Mar 5, 2024

MRI in the Evaluation of Plantar Plate Disease: Diagnostic Value of the “Stress Test”.
GIULIANI, L.; Ottonello, C.; Ronconi, P.; Bondì, L.; Giuliani, A.; Pacini, P.; Cantisani, V.
Preprints 2024

Introduction: PP, also called plantar ligament, is a fibrocartilaginous structure found in the metatarsophalangeal (MP) and interphalangeal (IP) joints. The aim of our study is to evaluate the role of MRI, both in standard position and with joint hyperextension, “stress test” (ST), in the study of the plantar plate (PP) disease that involves metatarsophalangeal joints. Material and methods: 25 patients were recruited into our study over a two-year period, 15 positive for metatarsal pain and 10 controls. All symptomatic patients were evaluated before treatment (surgery). Hence, the imaging features were reflective of the natural and true state of the lesions. Results:25 patients were recruited into our study over a two-year period, 15 positive for metatarsal pain and 10 controls. In symptomatic patients: 11/15 demonstrated plantar plate tear/dysfunction on both standard position and stress test, 2/15 had plantar plate tear on stress test (tear not showed on standard position), and 2/12 had no plantar plate tear on both standard position and stress test. The latter two patients showed dorsal subluxation on stress test due to micro-instability for plantar plate failure. In asymptomatic patients, 9/10 were negative for plantar plate dysfunction, and 1/10 was positive for plantar plate dysfunction (dorsal subluxation demonstrated only on stress test), without plantar plate tear. Conclusion:Standard MRI reported, in asymptomatic patients, a specificity of 100% and high NPV (90%), incremented by the ST (NPV and specificity 100%). In symptomatic patients, PP evaluation on standard MRI reported sensitivity of 80%, while stress test increased sensitivity to 100%; in the evaluation of dorsal subluxation of the metatarsophalangeal joint, the sensitivity was 60% (standard MRI) but reached 100% with ST. "Stress test" is an easy task to perform and even affordable in terms of time-consuming (requiring only one additional T2-weighted MRI sequence) for both patients and operators.
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