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It is generally accepted that an interdigital neuroma (Morton's neuroma) is a clinical diagnosis. If the diagnosis is equivocal, other investigations such as ultrasound (US), MRI Scan, a local anaesthetic with or without hydrocortisone or electromyographic nerve conduction studies can be used.
The aim of this retrospective study is to compare the accuracy of ultrasound versus a “cocktail” of hydrocortisone (HCI)/local anaesthetic injection (LAI), as an adjuvant investigation in the diagnosis of interdigital neuroma. The results showed that both these investigations are excellent in confirming an interdigital neuroma.
I know radiologists use a "push" technique (very technical term I made up-not sure if it does have a name) whereby they push on the area that is hypoechoic whilst performing diagnostic ultrasound to differentiate neuroma from bursa. This puts beyond doubt (if there was any) that it is indeed a neuroma or bursa. I wonder how the injection would differentiate this when considering that it should alleviate pain in both conditions.
I have only read the abstract so I am not priviledge to further info.
By the way, what do people find the most effective treatment for morton's neuroma and in what order from conservative to less conservative would you go. I have had a recent large amount of cases of neuroma's. Could be cold weather and closed shoes. Not sure why.
Any experience would be helpful
Cheers
Con
Last edited by conp : 15th August 2006 at 05:51 PM.
I know radiologists use a "push" technique (very technical term I made up-not sure if it does have a name) whereby they push on the area that is hypoechoic whilst performing diagnostic ultrasound to differentiate neuroma from bursa. This puts beyond doubt (if there was any) that it is indeed a neuroma or bursa. I wonder how the injection would differentiate this when considering that it should alleviate pain in both conditions.
Cheers
Con
I am curious about how this works. Could you please elaborate on the manouver and interpretation if you are familiar with it.
I have been looking at inter-metatarsal spaces for several months with Diagnostic ultrasound.
I have yet to make unequivocal judgement on my interpretation.
The difficulty I am having is noticing any clear demarcation of tissue echogenicity whilst noticing definite nebulous interspace motion which is coincident either with sudden palpable clicking or sudden tissue displacement.
My assumption is that if a bursa is present, it will be clearly anechoic and compressibe (provided it is not within a high pressure space) wheas a neuroma will be less differentiated and non compressible.
My suspicion is that the neuroma is poorly or subtly differentiated from surrounding fatty tissue, and may be impossible to differentiate from mucoid degeneration.
I am also curious to to know if anyone has tried to visualise a neuroma by surrounding it with volume of local anaestheic forming a vissible anechoic margin. I alos cannot see how a nerve block would be capable to differentiate between bursa or neuroma.
Any ultrasound examiners out there going/gone through same process?
this "push" test is called a positive mulders click.
you hold the foot at both sides by the metatarsals firmly so that your squeezing the metatarsals together, then you push up where the patient is experiencing pain, usually between the third and fourth metatarsals.
if you feel - and rarely if you have good hearing! - hear a click, then it is a postitive mulders click, and you can almost be sure the patient has a neuroma.
apparently it is the neuroma slipping between the mets that produces the click
A retrospective study was carried out on 48 patients to correlate preoperative ultrasound findings with postoperative histopathology findings and to assess the sensitivity, specificity, positive predictive values, and negative predictive values of ultrasound in the diagnosis of Morton's interdigital neuroma. All case sheets of 48 patients operated on between 1997 and 2005 were reviewed in the medical record section of Ninewells Hospital, Dundee, Scotland, so that preoperative ultrasound reports were compared with the postoperative histopathological reports. A statistical analysis of the results was performed. Ultrasonography showed 43 true-positive cases, 1 true-negative case, and 4 false-negative cases out of 48 cases. Histopathology showed 47 true-positive cases and 1 true-negative case; statistical analysis performed on the results showed a sensitivity of 91.48%, a specificity of 100%, and 100% positive and 20% negative predictive values, respectively. In our analysis, the probability that ultrasound will confirm the presence of plantar intermetatarsal neuroma is 91.67%.
I know radiologists use a "push" technique (very technical term I made up-not sure if it does have a name) whereby they push on the area that is hypoechoic whilst performing diagnostic ultrasound to differentiate neuroma from bursa. This puts beyond doubt (if there was any) that it is indeed a neuroma or bursa. I wonder how the injection would differentiate this when considering that it should alleviate pain in both conditions.
Cheers
Con
I agree that injection would be unhelpful to differentiate conditions.
I saw a patient today with the most unequivocal US exam I have done for inter-metatarsal neurofibroma. As I mentioned previously, this exam for me has been difficult to me to gain confidence with. The attatched frozen images are pretty easy to interpret but the video are really nice. If you read this Craig and are amenable they would be useful additions as attachments but several MBs. Not sure if this is possible but please drop me a line if so and I’ll prepare something.
53 year old female;
Chronic unrelenting weight-bearing right foot metatarsalgia of increasing pain over past two years. She has obvious clinical signs of a space filing lesion in distal right foot3/4 inter-metatarsal space which with slight dorsiflexion of 4th metatarsal head will migrate plantarly or dorsally according to angle of applied force. Patient reports clicking sensation when walking but interestingly no pain in digits, I wonder if this might be because it doesn’t appear to surround the nerve but seems clearly plantar to it and perhaps experiencing less compressive stress than if being surrounded on all sides.. Diagnostic ultrasound exam is fairly unequivocal for neuroma rather than bursa (lesion incompressible and complex rather than uniform hypo-echoicity).
A clearly differentiated incompressible inhomogeneous hypoechoic mass was seen lying plantar to proper digital nerve, the mass could be clearly seen to displace dorsally and compress against nerve with lateral compression of forefoot. Measurement of mass was 7.4mm deep, 6.1mm wide, 16.8mm long.
Cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918 www.winnipegfootclinic.com
Last edited by Mart : 6th May 2008 at 05:03 PM.
Reason: error
Injection vs ultrasound for neuroma diagnosis
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