Figura 1 - available via license: Creative Commons Attribution-NonCommercial 4.0 International
Content may be subject to copyright.
Source publication
Pathological abnormality (neuroma) related to the painful foot condition commonly called "Morton's metatarsalgia" was first observed in 1835 by Filippo Civinini (1805-1844) of Pistoia, in course of a cadaverous dissection, and clearly described in the anatomic letter entitled "Su un nervoso gangliare rigonfiamento alla pianta del piede" ("On the ne...
Similar publications
Lipofibromatous hamartoma (LFH) is a rare, benign, tumor-like soft-tissue lesion that affects the peripheral nerves and forms a palpable neurogenic mass. Lipofibromatous hamartoma is associated with pain and sensory and/or motor deficits in the area of innervation of the affected nerve. This report describes a rare case of LFH of the plantar nerve....
Morton's neuroma is a compressive neuropathy resulting in perineural fibrosis rather than a neuroma of the plantar digital nerve. Surgical treatment is indicated for patients with a clear diagnosis of Morton's neuroma and no improvement with nonsurgical treatment. The surgical options include isolated intermetatarsal ligament division, isolated int...
PURPOSE
To describe our initial experience in performing cryoneurolysis in a cohort of patients with peripheral neuralgia. Chronic peripheral nerve pain is a common problem that can arise from numerous causes including surgery, trauma, a neuroma, or it can be idiopathic. Treatment options consist of surgical and various percutaneous procedures such...
Morton’s Neuroma is a common metatarsalgia in athletes created due to the entrapment of the inter-digital nerve inside the transverse inter-metatarsal ligament. The purpose of the present study is to draw the necessary conclusions from the use of a particular surgical treatment to release the digital nerve, accompanied by neurolysis in adults who e...
Citations
... по 1]. В работе "Su di un gangliare rigonfiamento della piñata del piede", датированной сентябрем 1835 г. и обнаруженной только в 1983 г. при реконструкции больничной библио теки, Ф. Чивинини описывает веретенообразную припухлость третьего подошвенного пальцевого нерва [8,9]. ...
... Pasero) и П. Марсон (P. Marson), фамилия Чивинини все же стала больше ассоциироваться с невромой Мортона [9]. ...
Background. The urgency of the problem is explained by a high morbidity rate and the need to verify the diagnosis with related specialists (ultrasound physicians, radiologists, trauma surgeons, pathologists), as well as by significant difficulties in patient routing and high probability of primary referral to neurologists, neurosurgeons, and general practitioners. In modern Russian literature, neuromas of all interdigital spaces are identified with Morton’s neuroma. Aim of the review was to determine the accuracy of modern medical terminology, in particular of the term «Morton’s neuroma», to reveal the spectrum of eponyms unacceptable for communication with related specialists and patients, to fill the historical gap and to attract the scientific medical community to discussion on this topic. Methods. We identified 40 articles on this topic published from 1845 to 2022. The search was performed in PubMed/MEDLINE and eLIBRARY databases. Results. Evolution, history, and etymology of several terms used for intermetatarsal neuroma are covered in the study, based on the analysis of literature sources. It has been found that a number of eponyms used to designate neuromas are historically inaccurate. In addition, we have discovered that the reports of «nerve fibrosis» were encountered prior to the introduction of the term «neuroma». However, most authors have popularized the nominal term «Morton’s neuromas». Conclusions. An obvious contradiction between the etiopathogenesis of neuroma and the term itself can be confusing for clinicians and diagnosticians. In our opinion, the disease known nowadays as «Morton’s neuroma» should be named «fibrosis of the plantar nerve of the third toe», and the name terms denoting the number of the corresponding interdigital space should be replaced by the number of the corresponding common plantar digital nerve.
... It often causes significant pain that limits footwear choice and weightbearing activities. This condition was first described anatomically by Civinini in 1835 [1] and later described clinically by Thomas Morton in 1876 [2]. Therefore, some authors have called this pathology Civinini-Morton syndrome (CMS) [3]. ...
Morton’s neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly affecting the third inter-digital space. The conservative approach is the first recommended treatment option. However, other different approaches have been proposed, offering several options of treatments, where, several degrees of efficacy and safety have been reported. We treated five consecutive patients affected by MN through three indirect ultrasound-guided injections of type I porcine collagen at weekly intervals. All patients were assessed before the treatment, after the treatment and up to 6 months after the last injection via AOFAS and VNS scores for pain, in which the function and pain were evaluated, respectively. In all patients, both analyzed variables progressively ameliorated, with benefits lasting until the last follow-up. The trend of the scores during the follow-up showed significant statistical differences. No side effects occurred. To our knowledge, this is the first study on injections of type I porcine collagen for the treatment of Morton’s neuroma. Future research is needed to confirm the positive trend achieved in this MN mini-series.
... Morton's neuroma (MN) was first described by Civinini in 1835 as a "neural ganglial swelling of the foot sole" (1) . However, it received its current name years later, in 1876, from Thomas George Morton who reported a "painful affection of the foot" occurring particularly at the fourth metatarsal after wearing high-heeled shoes or without any identifiable cause (2) . ...
Morton’s neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular degeneration, and deregulation of sympathetic innervation. Patients usually present with burning or sharp metatarsalgia at the dorsal or plantar aspect of the foot. The management of Morton’s neuroma starts with conservative measures, usually with limited efficacy, including orthotics and anti-inflammatory medication. When conservative treatment fails, a series of minimally invasive ultrasound-guided procedures can be employed as second-line treatments prior to surgery. Such procedures include infiltration of the area with a corticosteroid and local anesthetic, chemical neurolysis with alcohol or radiofrequency thermal neurolysis. Ultrasound aids in the accurate diagnosis of Morton’s neuroma and guides the aforementioned treatment, so that significant and potentially long-lasting pain reduction can be achieved. In cases of initial treatment failure, the procedure can be repeated, usually leading to the complete remission of symptoms. Current data shows that minimally invasive treatments can significantly reduce the need for subsequent surgery in patients with persistent Morton’s neuroma unresponsive to conservative measures. The purpose of this review is to present current data on the application of ultrasound for the diagnosis and treatment of Morton’s neuroma, with emphasis on the outcomes of ultrasound-guided treatments.
... Pathologic abnormality (neuroma) related to the painful foot condition commonly called ''Morton's metatarsalgia'' was first observed in 1835 by Filippo Civinini (1805-1844). 1 The clinical symptoms of interdigital neuroma were first described by Durlacher in 1845 and later by Morton in 1876. 2 Although Durlacher brought insight to this condition as ''a neurologic affection,'' Morton's name has remained linked to the condition. ...
Background
This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques.
Methods
We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery.
Results
Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1–2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections.
Conclusions
The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.
... Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly occurring in the third web space, followed by the second and then the fourth [1][2][3][4][5][6][7][8][9][10]. The plantar nerve enlargement was first described in 1835 [11], the symptoms in 1845 [12] and the condition was initially called metatarsalgia in 1876 by Thomas Morton whose name is now associated with the condition [13]. Affecting 88 in every 100,000 women and 50 in every 100,000 men presenting for primary care in the United Kingdom, it is the most common compressive neuropathy after carpal tunnel syndrome [14]. ...
Background
Morton’s neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits footwear choices and weight bearing activities. This paper aims to review non-surgical interventions for MN, to evaluate the evidence base for the clinical management of MN.
Methods
Electronic biomedical databases (CINAHL, EMBASE, MEDLINE and Cochrane) were searched to January 2018 for studies evaluating the effectiveness of non-surgical interventions for Morton’s neuroma. Outcome measures of interest were treatment success rate (SR) (binary) and pain as measured using 100-point visual analogue scale (VAS) (continuous). Studies with and without control groups were included and were evaluated for methodological quality using the Downs and Black Quality Index. Results from randomised controlled trials (RCT) were compared between-groups, and case series were compared pre- versus post-treatment. Effect estimates are presented as odds ratios (OR) for binary data or mean differences (MD) for continuous data. Random effects models were used to pool effect estimates across studies where similar treatments were used. Heterogeneity was assessed using the I2 statistic.
Results
A total of 25 studies met the inclusion criteria, seven RCTs and 18 pre/post case series. Eight different interventions were identified, with corticosteroid or sclerosing injections being the most often reported (seven studies each). Results from a meta-analysis of two RCTs found corticosteroid injection decreased pain more than control on VAS (WMD: -5.3, 95%CI: -7.5 to − 3.2). Other RCTs reported efficacy of: manipulation/mobilisation versus control (MD: -15.3, 95%CI: -29.6 to − 1.0); extracorporeal shockwave therapy versus control (MD: -5.9, 95%CI: -21.9 to 10.1). Treatment success was assessed for extracorporeal shockwave therapy versus control (OR: 0.3, 95%CI: 0.0 to 7.1); and corticosteroid injection vs footwear/padding (OR: 6.0, 95%CI: 1.9 to 19.2). Sclerosing and Botox injections, radiofrequency ablation and cryoneurolysis have been investigated by case series studies, however these were of limited methodological quality.
Conclusions
Corticosteroid injections and manipulation/mobilisation are the two interventions with the strongest evidence for pain reduction, however high-quality evidence for a gold standard intervention was not found. Although the evidence base is expanding, further high quality RCTs are needed.
... It acquired its eponym after Thomas George Morton who reported this condition in 1876 [2]. In fact, Civinini and Durlacher preceded Morton in describing such a condition in 1835 and 1845, respectively [3,4]. Later on, many synonyms were suggested to describe Morton's neuroma such as: Morton neuralgia, Morton metatarsalgia, interdigital neuroma and intermetatarsal neuroma. ...
Morton’s neuroma is a common cause of metatarsalgia which characterized by enlargement of interdigital nerve possibly due to nerve entrapment. Morton’s neuroma is usually common among middle age population with female gender predominance. Diagnosis of Morton’s neuroma is essentially clinical. Imaging modalities may help to delineate and localize the nerve lesion. Prone position foot MRI is associated with higher visibility of Morton’s neuroma. Identification of Morton’s neuroma, as a cause of metatarsalgia, tends to be missed by clinicians. Hence, high index of suspicion should be invested for this purpose. Proper footwear awareness should be emphasized among athletes. The cross-training shoes are discouraged for long distance running. Local steroid injection may provide temporary relief. Ultrasound-guided injection can improve the localization of injection. Neurectomy of the thickened nerve is considered the standard surgical treatment to date. Majority of surgeons prefer dorsal approach for first-time excision of Morton’s neuroma despite of its limited exposure reserving the plantar approach to the revision cases. Plantar surgical approach provides direct anatomical access and allows wide exploration of the area of neuroma. Recurrent neuroma is a major concern after neurectomy. Deep burial of nerve stump within the intermetatarsal soft tissues might minimize the risk of recurrent neuroma formation.
... Since the first publication by Civinini (1835) [2,3], several authors have provided their scientific contribution in the attempt to identify the etiopathogenesis of this condition, which still nowadays remains not entirely clear. In 1876, Thomas G. Morton described this condition by publishing an article in the American Journal of the Medical Science and reporting the results of 12 cases of severe metatarsalgia affecting the 4th metatarsal head treated with the complete resection of the metatarsophalangeal articulation of the 4th toe and all the surrounding neurovascular structures [4]. ...
The authors, while analyzing the nosologic framework of Civinini-Morton metatarsalgias, present their surgery case-study of 31 patients treated with a minimally invasive percutaneous technique. In particular, the neurolysis of the neuroma was performed through the percutaneous incision of the transverse intermetatarsal ligament (TIML) and through the distal metaphyseal osteotomy of the metatarsals contiguous to the involved intermetatarsal space, all of them being anatomical elements which identify the arch of the involved metatarsal canal. Of pivotal importance are the results of radiographic tests showing, in all the cases, a macroscopic reduction of the diameter of the nerve affected by nerve compression neuropathy. Furthermore, a remarkable percentage of the patients (70%) were exclusively treated with the osteotomy of the 3rd metatarsal. Such unusual procedure proved to further facilitate the postoperative course of the patient and the overcoming of some complications. The encouraging results obtained in this kind of surgical treatment place, in the authors’ opinion, this technique among the most effective minimally invasive surgical treatments.
... Morton neuroma is named after Thomas G. Morton [7] who described it in 1876, though earlier descriptions exist [8]. The symptoms are characterized by plantar pain of neuropathic characteristics in the forefoot, typically between the third and fourth toes. ...
Background and Objective
Morton neuroma is a common cause of metatarsalgia of neuropathic origin. Systematic reviews suggest that insufficient studies have been performed on the efficacy of the different treatments available. OnabotulinumtoxinA has shown a degree of usefulness in other conditions associated with neuropathic pain. The aim of this study was to investigate the therapeutic potential of onabotulinumtoxinA in Morton neuroma.
Patients and Methods
We present an open-label, pilot study with 17 consecutive patients with Morton neuroma and pain of more than 3 months’ duration that had not responded to conservative treatment with physical measures or corticosteroid injection. Patients received one onabotulinumtoxinA injection in the area of the neuroma. The main outcome measure was the variation in the pain on walking evaluated using a visual analogue scale (VAS) before treatment and at 1 and 3 months after treatment. The secondary outcome was the change in foot function, which was assessed using the Foot Health Status Questionnaire.
Results
In the overall group, the mean initial VAS score on walking was 7. This mean score had fallen to 4.8 at 1 month after treatment and to 3.7 at 3 months. Twelve patients (70.6 %) reported an improvement in their pain and five patients (29.4 %) reported no change; exacerbation of the pain did not occur in any patient. Improvements were also observed in two of the dimensions of the Foot Health Status Questionnaire: foot pain, which improved from a mean of 38.88 before treatment to 57 at 3 months, and foot function, which improved from a mean of 42.27 before treatment to 59.9 at 3 months. Clinical variables including age, sex, site and size of the lesion, standing activity, weekly duration of walking, footwear, foot type and footprint had no influence on the outcome. No adverse effects were reported.
Conclusions
In this pilot study, injection with onabotulinumtoxinA was shown to be of possible usefulness to relieve the pain and improve function in Morton neuroma. This finding opens the door to further clinical research.
Abstract
Purpose The interdigital nerve neuroma of the forefoot is commonly known as Morton’s Neuroma. Many authors have described and treated this condition before and after Morton. This study aims to investigate the past scientific literature to better understand what comprehension and treatments have been used to master this pathology.
Methods Historical and modern scientific accounts were searched for descriptions of interdigital nerve neuroma or metatarsalgia (as some authors described it) to have a thorough overview of the subject. The scientific literature was searched to highlight the evolution of the nomenclature and to summarise historical and current treatments, especially conservative ones.
Results Influential authors described the interdigital nerve neuroma and its symptoms. Durlacher, the King’s podiatrist in England in the 1800s, was the first to understand that this was a neuralgic affection; with his practical approach, he treated the Neuroma using pressure-relieving footwear. The first anatomical description should be credited to the Italian anatomist Civinini. Morton, the American Civil War surgeon, was the first to understand the aetiology of pain better and the first to propose a surgical treatment to relieve symptoms. Tubby, the British alpine climber, linguist, archaeologist and orthopaedic surgeon, observed a nodular mass on the third common digital nerve and proposed surgical treatment with resection of the metatarso-phalangeal joint.
Conclusion the use of a term widely accepted and recognised by all its users with a precise meaning and symbolisation makes it easily understandable and lasting. Also, if it is known that what is called Morton’s neuroma is not a neuroma but a benign perineural fibrosis of a common plantar digital nerve, the use of the terminology Morton’s neuroma is still universally accepted and recognised.
Background:
Morton's neuroma (MN) is a painful neuropathy resulting from a benign enlargement of the common plantar digital nerve that occurs commonly in the third webspace and, less often, in the second webspace of the foot. Symptoms include burning or shooting pain in the webspace that extends to the toes, or the sensation of walking on a pebble. These impact on weight-bearing activities and quality of life.
Objectives:
To assess the benefits and harms of interventions for MN.
Search methods:
On 11 July 2022, we searched CENTRAL, CINAHL Plus EBSCOhost, ClinicalTrials.gov, Cochrane Neuromuscular Specialised Register, Embase Ovid, MEDLINE Ovid, and WHO ICTRP. We checked the bibliographies of identified randomised trials and systematic reviews and contacted trial authors as needed.
Selection criteria:
We included all randomised, parallel-group trials (RCTs) of any intervention compared with placebo, control, or another intervention for MN. We included trials where allocation occurred at the level of the individual or the foot (clustered data). We included trials that confirmed MN through symptoms, a clinical test, and an ultrasound scan (USS) or magnetic resonance imaging (MRI).
Data collection and analysis:
We used standard Cochrane methodological procedures. We assessed bias using Cochrane's risk of bias 2 tool (RoB 2) and assessed the certainty of the evidence using the GRADE framework.
Main results:
We included six RCTs involving 373 participants with MN. We judged risk of bias as having 'some concerns' across most outcomes. No studies had a low risk of bias across all domains. Post-intervention time points reported were: three months to less than 12 months from baseline (nonsurgical outcomes), and 12 months or longer from baseline (surgical outcomes). The primary outcome was pain, and secondary outcomes were function, satisfaction or health-related quality of life (HRQoL), and adverse events (AE). Nonsurgical treatments Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA) Two RCTs compared CS+LA versus LA. At three to six months: • CS+LA may result in little to no difference in pain (mean difference (MD) -6.31 mm, 95% confidence interval (CI) -14.23 to 1.61; P = 0.12, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Assessed via a pain visual analogue scale (VAS; 0 to 100 mm); a lower score indicated less pain.) • CS+LA may result in little to no difference in function when compared with LA (standardised mean difference (SMD) -0.30, 95% CI -0.61 to 0.02; P = 0.06, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Function was measured using: the American Orthopaedic Foot and Ankle Society Lesser Toe Metatarsophalangeal-lnterphalangeal Scale (AOFAS; 0 to 100 points) - we transformed the scale so that a lower score indicated improved function - and the Manchester Foot Pain and Disability Schedule (MFPDS; 0 to 100 points), where a lower score indicated improved function.) • CS+LA probably results in little to no difference in HRQoL when compared to LA (MD 0.07, 95% CI -0.03 to 0.17; P = 0.19; 1 study, 122 participants; moderate-certainty evidence), and CS+LA may not increase satisfaction (risk ratio (RR) 1.08, 95% CI 0.63 to 1.85; P = 0.78; 1 study, 35 participants; low-certainty evidence). (Assessed using the EuroQol five dimension instrument (EQ-5D; 0-1 point); a higher score indicated improved HRQoL.) • The evidence is very uncertain about the effects of CS+LA on AE when compared with LA (RR 9.84, 95% CI 1.28 to 75.56; P = 0.03, I2 = 0%; 2 studies, 157 participants; very low-certainty evidence). Adverse events for CS+LA included mild skin atrophy (3.9%), hypopigmentation of the skin (3.9%) and plantar fat pad atrophy (2.6%); no adverse events were observed with LA. Ultrasound-guided (UG) CS+LA versus non-ultrasound-guided (NUG) CS+LA Two RCTs compared UG CS+LA versus NUG CS+LA. At six months: • UG CS+LA probably reduces pain when compared with NUG CS+LA (MD -15.01 mm, 95% CI -27.88 to -2.14; P = 0.02, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). (Assessed with a pain VAS.) • UG CS+LA probably increases function when compared with NUG CS+LA (SMD -0.47, 95% CI -0.84 to -0.10; P = 0.01, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). We do not know of any established minimum clinical important difference (MCID) for the scales that assessed function, specifically, the MFPDS and the Manchester-Oxford Foot Questionnaire (MOXFQ; 0 to 100 points; a lower score indicated improved function.) • UG CS+LA may increase satisfaction compared with NUG CS+LA (risk ratio (RR) 1.71, 95% CI 1.19 to 2.44; P = 0.003, I2 = 15%; 2 studies, 114 feet; low-certainty evidence). • HRQoL was not measured. • UG CS+LA may result in little to no difference in AE when compared with NUG CS+LA (RR 0.42, 95% CI 0.12 to 1.39; P = 0.15, I2 = 0%; 2 studies, 116 feet; low-certainty evidence). AE included depigmentation or fat atrophy for UG CS+LA (4.9%) and NUG CS+LA (12.7%). Surgical treatments Plantar incision neurectomy (PN) versus dorsal incision neurectomy (DN) One study compared PN versus DN. At 34 months (mean; range 28 to 42 months), PN may result in little to no difference for satisfaction (RR 1.06, 95% CI 0.87 to 1.28; P = 0.58; 1 study, 73 participants; low-certainty evidence), or for AE (RR 0.95, 95% CI 0.32 to 2.85; P = 0.93; 1 study, 75 participants; low-certainty evidence) compared with DN. AE for PN included hypertrophic scaring (11.4%), foreign body reaction (2.9%); AE for DN included missed nerve (2.5%), artery resected (2.5%), wound infection (2.5%), postoperative dehiscence (2.5%), deep vein thrombosis (2.5%) and reoperation with plantar incision due to intolerable pain (5%). The data reported for pain and function were not suitable for analysis. HRQoL was not measured.
Authors' conclusions:
Although there are many interventions for MN, few have been assessed in RCTs. There is low-certainty evidence that CS+LA may result in little to no difference in pain or function, and moderate-certainty evidence that UG CS+LA probably reduces pain and increases function for people with MN. Future trials should improve methodology to increase certainty of the evidence, and use optimal sample sizes to decrease imprecision.
