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Not sure of Mortons Neuroma

Discussion in 'General Issues and Discussion Forum' started by lucycool, Nov 10, 2010.

  1. lucycool

    lucycool Active Member


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    Hi guys,
    Hoping you can help.. I've just started in private practise and finding it hard to give definite diagnosis without a second opinion!
    I had a pt yesterday who's GP has diagnosed 'mortons neuroma' on 2nd/3rd metatarsal area. But I don't think it is. Pain is more throbbing than tingling or numbness and there's no click or horrific pain when doing squeeze test. She has enlarged EHL tendon at MP jt. Has had unexplained bruising on 3rd digit of same foot. Pt has slight swelling around the area, but more at the met heads.. I think she has a fft equinus.
    I want to supply orthotics with a PMP with U to area to start with.. Am I only totally wrong?!
    From what I've said what do people think?
    Thanks

    Lucy
     
  2. Peter

    Peter Well-Known Member

    based on that, I would get an X-ray in case of an osseous cause.

    As for a FFT equinus, I would get her into a moderate heeled shoe, with a thick out/midsole
     
  3. Lucy think Plantar plate tear - Plantar plate tear thread

    Also if not sure ultrasound or MRI but read the thread there is lots of good info for you including treatment discussions - if not this patient many more to come I promise you.
     
  4. vbpedorthist

    vbpedorthist Member

    srtictly from a Pedorthist point of view. If a Podiatrist sent a patient to me with all the symptoms you are discribing i would try the orthotics with the pmp and u. also ensure that there is sufficient padding and that her footwear has a rounded toe box.
     
  5. Paul Bowles

    Paul Bowles Well-Known Member

    Diagnostic ultrasound is your friend.
     
  6. Not to be picky, but a planter u pad will plantarflex the met relative to it's neighbors. Is that what we want if it IS a pp rupture?

    If you can't get an ultrasound try taping the toe in plantaflexion. If it's a pp that could help. If it's a neuroma it will do nothing.

    Or.


    Roll a joint. Between your fingers. squeezing I m will catch both i m space and joint. Squeezing the joint won't compress the I m space.
     
  7. JAYNES

    JAYNES Active Member

    Hi lucycool,
    ultrasound scan will determine neuroma. have you done sharp touch to 2nd/3rd toes (apical areas)? when doing scan ask them to look at EHL maybe tendonitis.
    Jaynes
     
  8. True. But it won't tell you if thats the problem.

    I had a patient once with a painful foot and a neuroma, confirmed by US. They were considering surgery. They also had a VP. When we got rid of the VP, the pain vanished. The Neuroma was a dead herring. They can be sub clinical.

    Are neuromas the new heel spurs?
     
  9. Ryan McCallum

    Ryan McCallum Active Member

    Hi,
    If suspecting a neuroma, why not just drop a bit of local anaesthetic into the IM space? Quicker, easier and cheaper than an ultrasound scan. If the pain persists, you can rule out neuroma.

    You could alternatively inject local into the MTPJs but obviously that's more than one injection (if you think it's the 2nd and 3rd) and a little trickier if you are not used to injecting joints. Going by the detail you provided, I would hazard a guess that it's not a neuroma but rather MTPJ synovitis.

    I'm not quite sure why more people don't use local anaesthetic as a diagnostic aid. Worth trying in my opinion (unless you already have and I've wrongly assumed!)

    Ryan.
     
  10. This sounds like a much better test to me! Quick, cheap, and tells you if the neuroma is sub clinical or not!

    I've never been taught how to do this one but I'd dearly love to be. Do other people use it routinely?
     
  11. Ryan McCallum

    Ryan McCallum Active Member

    Robert,
    It's not a difficult test to perform and unlike steroid, it doesn't really matter if you aren't completely sure if you are in the right place. When I first starting doing this, I just injected a bit more local than I do now to make sure I 'got' the nerve.

    All I do is palpate the met heads dorsally, insert the needle half way between the two and advance the needle until I am as deep as the plantar surface of the MTPJs and I'll normally angle the needle straight down. I generally inject the local into the one place but a colleague of mine likes to infiltrate it slightly proximal and distal to the met head (at the same level). I'll continue to inject as I withdraw the needle the first 5mm or so.

    At the end of the day, as it is fluid, I don't think it stays in the same place so I don't bother moving the needle too much. I'll normally inject around 1ml-1.5ml of 2% lidocaine and sent the patient for a walk.

    Hope this helps,
    Ryan
     
  12. Right! Next time you and I are in the same room, bel, we do IMs!
     
  13. blinda

    blinda MVP

    You know what, Robert? This obsession with needles is worrying ;)


    But...actually, yeah. Why not. Shall I wear stilettos every day to induce an MN? Might look a little odd with my scrubs.
     
  14. Oh I don't know. THats always a good look ;)
     
  15. If your going to then Isaacs would have to as well to make the test worth while.

    Just a thought.
     
  16. Controlled trial style of thing.

    I could do that. Though I say so myself they DO shape my legs pleasingly.
     
  17. Paul Bowles

    Paul Bowles Well-Known Member

    You are injecting local anaesthetic around a SENSORY NERVE? See the irony of your test?
     
  18. Ryan McCallum

    Ryan McCallum Active Member

    Paul, I don't get you...
     
  19. Paul Bowles

    Paul Bowles Well-Known Member

    So lets say the issue is anything distal to that block - the pain vanishes? So how can you say it was the "neuroma" from that block alone? If I had MTPJ effusion, synovitis, capsulitis, plantar plate tear, neuroma, burisitis, stress fracture etc... Your diagnostic block would be effective to some degree and reduce symptoms.

    ...and you wouldn't be the first to "not get me" I am sure my wife would agree!!!
     
  20. Ryan McCallum

    Ryan McCallum Active Member

    I don't base my diagnosis on the "block alone".

    I see neuromas on a daily basis so am pretty confident on my diagnostic skills but will happily perform the test if I have any doubt. The use of local anesthetic as a diagnostic aid for neuroma is well documented in literature.

    If a patient is unsure of any benefit from the injection after a walk then I will request an ultrasound scan.

    I think any effect of the local on any other pathology is negligible. On numerous occassions, I have wrongly queried the presence of a neuroma in cases of MTPJ synovitis and this test has provided no relief of symptoms.
    It is of course possible that a patient may have concurrent MTPJ pathology in addition to the neuroma and of course in these cases, the test is not particularly helpful.

    I have no problems doing this test and am happy that I am not misdiagnosing based on the outcomes.

    Regards,
    Ryan
     
  21. Rich Blake

    Rich Blake Active Member

    Dear Lucycool, Yes probably not a neuroma. Never had neuroma throb or produce bruising. See what xrays show and think accom (guess what you mean as U). Good luck> Rich Blake
     
  22. Paul Bowles

    Paul Bowles Well-Known Member

    Ryan my point is that it is a sensory nerve which supplies anatomical regions distal to the block - how can the effect to those regions be negligible?

    For example: If I have heel pain as well as a corn on the plantar aspect of my heel causing pain, and I give a posterior tibial nerve block all pain goes away.

    How do you issue a regional nerve block and expect it to "not" give you relief? How many of your patients do not get any relief from the block? Do you put them in the "other" basket and say its not a neuroma? What if it was simply a failed block?

    A sensory nerve block is exactly that. In this case I don't see how it is diagnostic in any way shape or form. Now the only way your diagnostic block may work is that sensation may still be supplied by the opposing digital nerve - in any case the patient would still report an improvement in symptoms of either a neuroma OR joint synovitis (as an example), so do you base your decision on complete pain eradication of any pain relief will suffice?

    Would love you to change my mind though! :D
     
  23. lucycool

    lucycool Active Member

    Thank you so much for all your suggestions.
    I'm in a small pp (ie just me) in a sports centre and she's waiting 10 weeks for NHS appt to get it seen by hospital after GPs diagnosis of neuroma, so unlikely to get an Xray or any other diagnostic tool before then.
    How do I strap down the 2nd toe into a plantarflexed position? I'm seeing her tomorrow again so getting prepared!!

    Thanks again,

    Lucy
     
  24. I'm enjoying the debate between Paul and Ryan. Please, gentlemen, continue! This is an area I'm both fairly ignorant of and very interested in. So don't divert on my account.

    But Is not the capsule (for eg) supplied by planter nerves either side of it? Thus even if the nerve is blocked and the sensory infilration has the effect of saturating the area, would not the unaffected nerve maintain some effective innervation of the joint?

    As in, if the whole capsule is inflamed, and we inject the medial side, it surely cannot infiltrate to the lateral side of the joint. Thus, will still hurt?

    But like I say, I'm ignorint. Please school me!
     
  25. Lucy this is how I do it, In fact just said goodbye to a patient who´s toes I taped -

    Take some size 12 tubegauze 5-6 cm long 2cm * 3 cm strips pre cut Fixamull * 2

    Put the tubegauze around toes 2-3 in your case - splint the 2nd to the 3rd toe

    Put one strip of fixamull on the dorsal surface to hold the tubegauze, then gently put the tubegauze under tension and plantarflex the toes slightly and fix the tubegauze on the plantar surface of the foot . Try and keep the toes from abducting or adducting , then test - there should be resistance to the Dorsiflexion of the toes. Show the patient how to do this and retape their toes the same everyday. I usually see them again after 3 weeks.

    Ice is very important 20 25 min at night as is shoes that don´t flex to much under the Metatarsal heads and reduce barefoot.

    Hope that helps.
     
  26. I use one of these.

    [​IMG]

    Both pics are mid construction so you can see whats inside. The top is 3mm poron with lycra cover. There is a 1mm polyprop "rib" under the mpjs. The rib has two slots cut into it (4 for the 2 toe version). A strap, which can be the 3mm lycra/poron or just doubled up lycra if the poron is too thick, is posted into one slot and glued to the underside. The other is posted into the other slot where friction keeps it put. Thin eva on the base to cover the rib and reinforce the adhesion of the strap. Similar on the top of the strap to reinforce the poron.

    Stick the toe in, pull the strap through to bring it down and tuck it under the pad and bobs your mothers brother. Use a bit of tape to hold the big flat bit to the foot it can also be used as a night splint.
     
  27. lucycool

    lucycool Active Member

    Hi
    Thanks for that! Is fixamull a stretchy or non stretchy tape? I have a variety of tapes but none with that name!
    Should I be supplying an orthotic at the same time? I was going to do that tomorrow as well.. Without any ff prescription?
    Thanks again!
    Lucy
     
  28. Maybe you have Hyperfix ?

    If not heres some info for you


    Fixamull

    Hypafix

    EDIT : Lucy its a bit hard to say if you should be issuing an orthotic or even taping the toes as we have not seen the patient.

    What I would suggest is tape ( or Roberts device), ice, rest, stiff shoes for a period of time review in 2-3 weeks and then see if the patient symptoms have improved.

    the key to treatment is diagnosis once we know what tissue is under stress then reduce the loads on the stressed tissue. At the moment we have a conflict in diagnosis. We have Morton´s neuroma v´s it seems Plantar plate issues but nothing concrete and as you have said there is a limit to the diagnostic tools you have available.

    So I would suggest 1 step at a time and if ice,tape etc works then a longer term treatment plan can be discussed. If no symptom relief you will need to look at the differential diagnosis list again.
     
  29. G Flanagan

    G Flanagan Active Member

    Hi all, sorry for joining the debate late. I agree with Ryan, very easy to do. The main point is ruling out soft tissue mass ie the perineural fibroma from adjacent MTPj capsultis. I do this all the time.

    Paul i really do understand what your saying, however, firstly the main advice when giving this block is to only use a small amount of LA, as Ryan said, extend the needle plantarly until you see the plantar skin blanche then withdraw slightly. Here (hopefully) you will only pay attention to the plantar nerve. The dorsal nerve (and as Robert said) the lateral portion of the capsule will still be inervated and thus produce pain if capsulitis. If you flood the area, its not really diagnostic, more pain relief!

    The other point where i tend to differ in technique is going slightly distal to the met heads, when seeing the neuroma it is often extending beyond the met heads, contrary to the text books which notes its presence directly between the met heads. Thus the only analgesic effect will be on the digits which i'm not worried about.

    I've just this weekend spent a day teaching LA and its techniques to the Lancashire branch SCP, including briefly IM diagnostic injection. With aid from pigs feet, very fun! Hopefully will see more diagnostic blocks in general PP.

    George
     
  30. lucycool

    lucycool Active Member

    Brilliant!
    Now I have a short term plan and a longer term one! Now to see if this works!
    I'm not going to do an IM LA as I've only just left uni (in June) and work by myself so don't have the confidence..
    George - any plans to teach it up in Edinburgh? Or know anyone i could go and see?
    Thanks
    Lucy
     
  31. neilmalc

    neilmalc Member

    Hi Lucy,

    For future reference, toe loops that can be obtained from rx labs are generally quite effective when splinting lesser toes.

    All the best,

    Neil.
     
  32. Thanks Neil. I might look into that myself (always keen to save myself time!)

    This Has turned into something of a gem of a thread!!

    The lucky swines!

    I too would like to see more diagnostic blocks. It sounds to me like a superior test to the untrasound. The ultrasound, after all, can only tell you whether a neuroma is there. The DLA can tell you if its the cause of the pain.

    I have long been suspicious of the methods used to identify Neuromas, pre and post surgery. Clinical examination can seem awfully hit at miss. Its a very "busy" area anatomically with a lot that can go wrong. Ultrasound will tell you if there is one there, but then as I said I've seen at least one patient with an ultrasound diagnosed neuroma which turned out not to be the cause of the pain. There is histology of course, but I've seen a study (name escapes me) which showed pretty much identical microscopical features in symptomatic and asymptomatic nerves.

    This test looks very much "to the point" to me. I have a good friend, not my patient, who had a Neurectomy. 18 months and 2 or 3 steroid injections later, the area is considerably more painful now than pre surgery. The whole area is "hot" with pain specifically on full extension of the toe (hmmmm) and any kind of local palpation. The theory from the surgical team (sans imaging) is that it is probably a regrowth / stump neuroma and they are keen to go in again and have a rummage. My friend is naturally suspicious of further surgery after the spectacular failiure of the initial operation. I'm thinking stump neuroma is possible, as is plantar plate damage or indeed simply fiberous adhesions within the wound. I'm very open to suggestions.

    I wonder what would happen to her foot if I stuck a bit of lidocaine in the space...
     
  33. I guess the best combo would be ultrasound guided injection.

    ie see if Neuroma is present
    if so then inject using the ultrasound to guide your injection

    wait for results.
     
  34. Lol. I work for the NHS. I might as well ask for some unicorn pelts to sit the patient on while I do it the injection.

    But yeah, that sounds ideal.
     
  35. lucycool

    lucycool Active Member

    You could try asking for some caviar as well?! I'm sure you could come up with some research into fish oils helping cognitive/motor skills..?!
     
  36. Ryan McCallum

    Ryan McCallum Active Member

    Thanks to Robert and George, I think one of the main questions has already been answered- i.e that the joint is innervated by more than just the single nerve we are injecting.

    I think another good point made by George which I had forgotton to mention is that often the neuroma is actually more distal than most think and in so in reality, the neuroma is at best adjacent to the joint not proximal to it so even if this single nerve innervated the joint, it would be unrealistic to expect full anaesthesia anywhere other than distally.

    As for my previous post, the use of the word "negligible" was perhaps innapropriate. What I should have said was that the effects in my opinion are mimial enough to not effect the patient's perception of pain/relief of pain for the reasons mentioned above- the njoint would not be completely anaethetised.

    How many do not get relief? I'm not entirely sure to be honest but a reasonable proportion have report that they do not notice much of a change. I personally don't put my patients into baskets but yes, I suppose it is fair to say that I would conclude that they don't have a neuroma.
    As for a failed block, I haven't had too many of these I think as the nerve is really quite easy to anaesthetise. If for arguement's sake the block did fail, it would be easy to tell as the patient would not have any interdigital anaesthesia.

    I think another useful way to expain this would be to assume the nerve block mimics nerve resection in that the patient should be left with no pain but permanent numbness between the two toes. However, I have seen on numerous occassions cases where a misdiagnosis of neuroma has been made and patient has been rereferred to us due to continued pain. The original diagnosis infact was MTPJ synovitis (and still is). However, if this nerve alone innervates the joint then surely the symptoms should have resolved following the nerve resection? They don't unfortunately!

    Is this local aneasthetic diagnostic block 100% sensitive and specific? No. But then again, neither are ultrasound or MR.
    I personally consider it a bit like a d-dimer (for completely different pathologies obviously!) in that a negative reponse rules out neuroma and a positive result along with clinical suspicion and judgement is suggestive of neuroma.

    Hope this answers the questions, if not, let me know and I'll have another crack at it!

    Regards,
    Ryan
     
  37. Peter

    Peter Well-Known Member

    Lucy,

    have you given any consideration to an X-ray?
    cheap, quick and rules out some frank bony causes, and shows you are practising defensively, just in case the pt doesn't have the condition you are embarking on a treatment plan for.
     
  38. G Flanagan

    G Flanagan Active Member

    Ryan,

    i presume you meant myself when referring to the mystical Gareth;)

    I must say i am rather dissapointed you don't remember my name following the drunken argument dodging we did together at Osteotec, but i'll let you off. :D

    Cheers,

    George
     
  39. lucycool

    lucycool Active Member

    Hi Peter,
    Yes I'd love to get an XRay, but pt is having to wait 10 weeks for any NHS treatment and I work in a wee room with just minimal utensils!!
    Lucy
     
  40. Peter

    Peter Well-Known Member

    Is it feasible to ring her GP and request he/her write an X-ray request form out for the pt to go to X-ray? seems bizarre a potential stress #/bony pathology should wait so long.

    Failing that, tell her to go to A+E, citing some minor insult to her foot.
     
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