Morton's Neuroma Ointment

Topical ointments, gels, and creams should only be used in combination with other systemic medications. The use of ointments alone is inconvenient and ineffective. The list of medications to be used externally is approximately as follows:

A case of practical diagnosis of Morton's neuroma.

We present a clinical case of Morton's neuroma in a 46-year-old female patient. The article describes the technique of ultrasound examination of the foot in the pathology in question. The features of clinical manifestations and ultrasound semiotics of interdigital nerve lesion are described. It is shown that ultrasound examination is currently the optimal and highly informative method of radial diagnosis in the diagnosis of Morton's neuroma.

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To quote:

Volkov GP, Babaev MV. A case of practical diagnosis of Morton's neuroma. Medical Vestnik of Southern Russia. 2019;10(2):55-58. https://doi.org/10.21886/2219-8075-2019-10-2-55-58

To quote:

Volkov GP, Babaev MV. A case of practical diagnosis of Morton's neuroma. Medical Herald of the South of Russia. 2019;10(2):55-58. (In Russian.) https://doi.org/10.21886/2219-8075-2019-10-2-55-58.

In 1876, Morton TG was the first to describe the disease 'with an unusual and painful lesion in the fourth metatarsophalangeal joint' [1]. [1]. To date, most researchers believe that repeated microinjuries and nerve impingements are the cause of this pathological process. The historical chronology of events associated with the comprehensive study of the pathology in question revealed that the disease was called Morton's neuroma. This nosological entity should be considered as peripheral nerve formation, manifested by limited thickening and thickening of the sheath of the injured nerve associated with reactive degeneration of its fibers and peri-neural connective tissue hyperplasia (2). Chronic trauma can lead to the formation of inflammatory infiltrates, which ultimately lead to epineural fusion with the surrounding musculoskeletal structures [1][3].

Morton's neuroma is a manifestation of tunnel syndrome that occurs in the foot. Tunnel syndrome is one of the most common forms of peripheral nervous system damage and accounts for approximately 25 % of the diseases in this group[2]. The disease is relatively rare. It is a compression of the interdigital nerve in the distal interdigital space between the heads of the metatarsal bones. In the vast majority of cases, compression between the heads of the third and fourth metatarsals occurs four times more often in women than in men [4]. The clinical symptoms are characteristic and occur in patients up to 50-60 years of age, but in the presence of triggers and other causes, this pathology can develop at almost any age.

clinical observation

A 46-year-old woman complained of severe pain between the 3rd and 4th toes of the right foot, which worsened with exertion and sometimes shot upward and spread to the other toes. She also reported numbness and walking barefoot on rocks. Visual examination revealed swelling, mild congestion, and soft tissue inflammation on the dorsal surface of the metatarsal bone. She was overweight and had worked as a saleswoman for a long time.

The pain started several years ago. She turned to her doctor. She was treated for osteoarthritis in the small joints of her right foot. She underwent an X-ray examination in two projections, which showed no changes in the bone structure.

The lack of improvement and increasing pain syndrome in the right foot prompted the patient to visit a neurologist, who referred her to the Department of Radiation Diagnostics at Rostov State Medical University. Longitudinal and transverse palpation of the soft tissues and joints of the metatarsal and dorsal surfaces of the right foot was performed. The presence of fluid in the metatarsal sac, which is located in front of the interdigital nerve between the heads of the metatarsal bones, was considered because inflammation of the metatarsal sac is usually accompanied by fluid.

Examination revealed a local fusiform thickening of the interdigital nerve between the heads of the third and fourth metatarsals of the right metatarsal, up to 2 cm long. The thickening was a heterogeneous hypoechoic structure disrupting the normal layered structure of the nerve trunk. The dynamic longitudinal examination showed a clear association of the lesion with the intercostal nerve. The soft tissues on the dorsal surface of this area were slightly thickened due to subcutaneous edema. Localization revealed significant tenderness.

Causes of the development of neuroblastoma

The causes of neuroblastoma development in specific individuals are difficult to determine. The transformation of neuroblasts into neuroblastoma cells may be due to a mutation. In some cases, structural changes in chromosome 1 or familial neuroblastoma are observed. In 10 % patients, neuroblastomas are associated with the presence of neurofibromatosis type 2, which is due to a mutation in the Merlin gene on chromosome 22. It is difficult to say what factors cause neurinomas (especially single neuromas) in other patients. Multiple neuromas are often associated with neurofibromatosis type 1. This disease is caused by a mutation of a suppressor gene in the long arm of chromosome 17.

• With tumors in the abdominal cavity – increased abdominal circumference, abdominal pain, weight loss, abnormal urination and bowel movements.
• Neuroblastoma in the spine area, which can compress the spinal cord - decreased muscle tone, back pain, loss of sensation and mobility of the limbs, muscle wasting, hypersensitivity, urination and bowel movements.
• Pelvic tumor – problems with urination and bowel movements.
• Neuroblastoma in the mediastinum – cough, difficulty breathing, dyspnea, dysphagia.
• Neuroblastoma in the neck area – Gorner syndrome, ghostly hematomas, squint, swelling of the eyelids.

The symptoms of neuroma of the eighth cranial nerve are related to the abnormal function of this nerve. The vestibulocochlear nerve is responsible for hearing and balance. A tumor arising from the sheath of this nerve causes: hearing impairment, tinnitus, balance disorders, dizziness, nausea, vomiting, headaches, disorders associated with compression of other cranial nerves, a significant growth of the tumor can lead to herniation of the cerebellar tonsils, a significant Increase in intracranial pressure and hydrocephalus, which can be life-threatening for the patient.

Intervertebral neuromas arising from spinal nerve roots can produce characteristic symptoms of nerve compression depending on the spinal level at which they occur. The most common symptoms include numbness, loss of sensation in the limbs and limited mobility of the limbs.

Neuroblastoma – diagnosis

Diagnosis of a neuroma depends on the type of neuroma. Based on the more or less characteristic symptoms and the physical examination, the doctor suspects neuroblastoma, which is confirmed by appropriate imaging studies. Histopathological examination is necessary to determine the exact type of neuroblastoma.

The treatment of neuroblastoma, like the diagnosis, depends on the location of the lesion and its type. In the case of neuroblastoma, the entire tumor is removed, while in more advanced lesions additional chemotherapy and radiation therapy are carried out. Treatment of neuroblastoma of the lumbar or thoracic spine usually involves neurosurgical removal of the lesion.

For neuroblastoma of nerve VIII, neurosurgery, radiation therapy or stereotactic radiosurgery are used - each of these techniques has its own specific indications and is associated with certain advantages and disadvantages. Neurofibromas, on the other hand, are treated surgically, but due to the superficial location of the lesions, these are simple procedures with a very low risk of complications.

Alexander Gennadievich Kurmanov

Alexander Gennadievich Kurmanov is the chief physician of the Elena Malysheva Medical Center. He is an orthopedist and trauma surgeon.

Sahakyan Artur Abelovich

Artur Abelovich Sahakyan is an expert in the modern treatment of joint, bone, tendon and muscle injuries as well as diseases of the musculoskeletal system.

Danila Sergeyevich Kovalenko

Experienced doctor, traumatologist and orthopedic surgeon deals with the diagnosis and treatment of diseases of the musculoskeletal system, orthopedic pathologies and injuries.

Caused

Morton's disease is a polyetiological disease in which both genetic predisposition and exogenous/endogenous factors play an important role. The main etiological factors responsible for tunnel neuropathy include loading/overloading of the forefoot, most commonly caused by wearing tight or high-heeled shoes, transverse flatfoot, and various foot deformities including, flat feet, hematoma Acute trauma to the foot (e.g. spinal injuries, bruises, contusions) at the nerve fiber site and in the foot.bruisesAcute trauma to the foot (bruises, fractures, dislocations), inward gait, obesity, long walking, obliterative vascular diseases, autoimmune/infectious diseases, fat deposits of various types on the foot, changes in nerve structure, etc.

At risk are people whose professions involve long walking, standing, weight lifting, weightlifters, jumpers, runners and patients with flat feet and various types of foot deformities. The existence of this problem is also evident in the athlete forum. Important triggers include: Bunions/ tendovaginitisdesolation Endarteritis Leg/obliterating atherosclerosisthe presence of a benign tumor (plexiform neuroma).

Symptoms of Morton's Neuroma

The symptoms of a neuroma on the foot depend largely on the size of the neuroma: a neuroma with a diameter of less than 5 mm is often asymptomatic. As the disease progresses, it initially manifests itself as an excruciating, stabbing pain in the area of the 3-4 toes against or after exertion. The above symptoms of Morton's neuroma can be combined with paresthesias and other sensory disorders. Over time, the intensity/frequency of the pain increases and the time interval between the start of exercise and the onset of pain becomes shorter.

Eventually the pain becomes sharp, acute, and occurs at rest without changing the configuration of the foot. Sometimes the patient feels as if there is a foreign body in the shoe. When palpating the foot (clinical examination with pressure in the frontal plane), the pain syndrome increases and radiates to the toes, which suggests innervation of the affected nerve. As the pain syndrome progresses, there may be a parallel increase in sensory disturbances (before anesthesia). Motor disorders are not uncommon.

risk factors

The development of Morton's neuroma is influenced by a number of internal and external factors. These factors may include:

• Excessive body weight, which puts undue stress on the lower limbs and causes constant compression of the nerve fibers in the foot area.
• Injuries to the soft tissues and osteoarticular mechanisms of the distal part of the limbs.
• Infections (especially chronic infections) of the musculoskeletal system.
• Curvature of the foot, flat feet.
• Frequently wearing uncomfortable shoes (tight, crooked, high heels).
• Tumors in the distal parts of the lower limbs.
• Excessive strain on the limbs (sports, occupational overload, regular long periods of standing or walking).

Development of disease

The pathogenetic mechanisms of Morton's neuroma are only partially understood, but experts have put forward some of the most likely assumptions. Thus, the morphological examination has shown that at some point a thickening forms on the interdigital branch of the tibial nerve, which is not a neuroblastoma in the true sense, but a false neuroblastoma, similar to that found in the median nerve trunk above the compression site found in carpal tunnel syndrome. The pathological process is probably of ischemic origin.

Another triggering factor may be repeated or multiple microtrauma or compression of the nerve between the third and fourth metatarsals. As a result of these pathological processes, the transverse intertarsal ligament of the foot becomes permanently compressed, delaminated and swollen. This results in displacement of the median nerve of the sole of the foot and the neighboring vessels as well as ischemia.

According to studies, Morton's neuroma is on average 0.95-1.45 cm long and 0.15-0.65 cm wide. The configuration of the pathological element is elongated and fusiform. [4]

Symptoms of Morton's Neuroma

As a rule, there are no external symptoms that would indicate that a patient has a neuroma on the foot and not something else. The most common symptom of the disease is a burning pain in the foot at the base of the toes, which increases with weight on the foot, when walking and when wearing tight shoes. The pain occurs mainly during the day and extremely rarely at night. Morton's neuroma can also cause numbness and discomfort in the toes, most commonly the second, third, and fourth toes. A very unpleasant foreign body sensation can occur when walking and trying to move your toes, especially if you have spent the whole day in tight shoes.

Athletic runners feel the pain of coming off the instep while running, fashionistas in tight high heels feel the same pain with every step. In short, the tighter and more uncomfortable the shoes, the more the feet deteriorate.

diagnosis

After determining the nature of the patient's pain and discomfort, the doctor conducts an external examination of the feet. He first presses the soles of his feet with his palms, trying to imitate the pressure of tight shoes on the foot. If no other obvious causes of pain are found, such as calluses, inflammation of the small ankle joints, or bone fractures, Morton's neuroma is suspected.

MRI image of the foot. The arrows indicate swelling of the interdigital nerve.

In some cases, x-rays may be used to rule out other foot problems that may also cause pain by determining whether the patient has arthritis or a broken bone in the foot. MRI is another imaging test that can be used to diagnose Morton neuroma.

Methods for diagnosing neuroma

The list of examinations is selected by the neurosurgeon or neurologist. Diagnosis begins with the exclusion of diseases with similar symptoms and a physical examination in which the patient is examined and asked about his complaints.

The following examinations can then be recommended:

• For intracranial schwannoma – MRI or CT scan of the brain. A CT scan is less informative because it does not 'see' tumors smaller than 2 cm. If an MRI is not possible, a CT scan with contrast is performed.
• MRI or CT scan of the spine. It can reveal tumors that are pressing on the spinal cord and nerve roots.
• Audiometry. It is part of the comprehensive diagnosis of an auditory nerve schwannoma. It allows us to determine the extent of the hearing loss and its cause.
• Ultrasound or magnetic resonance imaging if the tumor is on the peripheral nerves. The former can be used to detect thickening of the nerve. Magnetic resonance imaging determines the exact location of the tumor, its structure and the degree of involvement of the nerve fibers.
• Electroneuromyography. This examination assesses the permeability of electrical impulses along the nerve. It is used in almost any type of pathology and assesses the degree of impairment of nerve function.
• Biopsy. A biopsy is the removal of an in vivo biomaterial sample followed by cytological analysis. This determines whether the tumor is malignant or benign.

Treatment and removal of schwannomas

This tumor cannot be treated conservatively. It is therefore surgically removed or irradiated. Sometimes a wait-and-see attitude is adopted:

Surgical removal of the neuroma

• Rapid enlargement of the tumor;
• Further tumor growth after partial removal;
• tumor growth after radiosurgical treatment;
• worsening of symptoms;
• Occurrence of new symptoms in patients under 45 years of age.

During neurosurgery, the tumor is completely removed as long as it has not spread to the surrounding tissue. In this case, the risk of tumor recurrence is reduced to an absolute minimum. However, surgery is contraindicated in people over 65 years of age, in poor general health and with decompensated somatic diseases.

If the tumor has grown together with the nerves, it should be incompletely removed and radiosurgery (gamma knife or cybernetic knife) performed.

If surgery is not technically possible, the patient is prescribed radiation therapy - irradiation of the tumor with a beam of elementary particles. A linear accelerator is used for this treatment.

symptoms

The foot balances on the second metatarsal bone like on a knife edge. This leads to increased fatigue in the foot, lower leg, and back, weakness in the ankle, and stabbing, shooting pain when walking. A foreign body sensation may occur between the toes. The pain usually subsides when shoes are removed and the toes are kneaded. If you have these symptoms, you should not put pressure on your foot with a narrow or high heel.

• Women. This can be caused by women wearing tight, narrow shoes and high heels. Wearing such shoes promotes movement of the bones of the foot in a way that increases the risk of Morton's neuroma.
• people who are overweight, the pressure can cause displacement of the metatarsal bones.

diagnosis

The diagnosis of Morton's neuroma is based on the characteristic symptoms and the location of the pain in the foot. An important part of diagnosis is knowing the type of footwear the patient is wearing. To identify a possible cause in the foot area, the doctor will interview the patient and ask about a medical history such as arthritis, muscle or nerve disease, or past trauma.
To clarify the diagnosis, the doctor examines the foot. The doctor presses the soles of the feet with his fingers to find painful spots that are characteristic of Morton's neuroma. In some cases, the doctor may notice a numb area on the sole of the foot between the toes. Pain in multiple places on the same foot, e.g. B. between the second and third toes and the third and fourth toes are more characteristic of arthritis than Morton's neuroma.

A radiological examination is performed to rule out other causes of peak pain, such as: B. a fracture or arthritis. In some cases that are difficult to diagnose, an MRI is performed.

symptoms

When supported on the second metatarsal bone, the foot balances as if on a knife edge. This leads to increased fatigue in the foot, lower leg, and back, weakness in the ankle, and a burning, stabbing pain when walking. A foreign body sensation may occur between the toes. The pain usually subsides when shoes are removed and the toes are kneaded. If you have these symptoms, you should not put pressure on your foot with a narrow or high heel.

• Women. This can be caused by women wearing tight, narrow shoes and high heels. Wearing such shoes promotes movement of the bones of the foot in a way that increases the risk of Morton's neuroma.
• people who are overweight, The pressure can cause the metatarsals to shift.

diagnosis

The diagnosis of Morton's neuroma is based on the characteristic symptoms and the location of the pain in the foot. An important part of diagnosis is knowing the type of footwear the patient is wearing. To identify a possible cause in the foot area, the doctor will interview the patient and ask about a medical history such as arthritis, muscle or nerve disease, or past trauma.
To clarify the diagnosis, the doctor examines the foot. The doctor presses the soles of the feet with his fingers to find painful spots that are characteristic of Morton's neuroma. In some cases, the doctor may notice a numb area on the sole of the foot between the toes. Pain in multiple places on the same foot, e.g. B. between the second and third toes and the third and fourth toes are more characteristic of arthritis than Morton's neuroma.

A radiological examination is performed to rule out other causes of peak pain, such as: B. a fracture or arthritis. In some cases that are difficult to diagnose, an MRI scan is performed.

Radiofrequency current ablation

During radiofrequency current ablation (RFA), the affected area of the nerve is irradiated with high-frequency currents that destroy the Morton's neuroma. This blocks the transmission of the pain impulse, the inflammatory reaction subsides and the affected foot completely regains its function.

The operation is performed under local anesthesia. The procedure involves a single puncture through which an electrode for RFA is attached to the affected area. This technique prevents postoperative pain and does not leave gross scars.

The duration of radiofrequency current ablation for Morton's neuroma in the Neurospine clinic is only 20 minutes. There is practically no recovery period. As a result, the pain syndrome characteristic of the pathology gradually disappears within 3-5 days.

Removal of Morton's neuroma

Surgical removal of Morton's neuroma in the Neurospine clinic (Kiev) is carried out using microsurgical instruments and a microscope from Carl Zeiss. Above all, this approach guarantees a high success rate of the operation and minimizes the risk of complications.

As a result, hospitalization is no longer required. The minimally invasive techniques shorten the recovery time to 10-12 days. During these days, the operated leg should be rested as postoperative pain of the same magnitude as the discomfort may occur.

A small scar remains at the site of the procedure. This method offers an almost 100 percent guarantee that the pain characteristic of Morton's neuroma will never occur again.

It is impossible to go into all the nuances of treatment in a short article. If you have any questions, please contact us and we will address your concerns.

• Morton shoe inserts.
• metatarsal bones.
• metatarsalgia.
• Treatment of metatarsalgia of the foot.
• hindfoot.
• Syndrome of the tibial nerve.
• heel nerve.
• Treatment of plantar fasciitis ointment.