Dynamic sonography of the forefoot in Morton’s syndrome: correlation with magnetic resonance and surgery

Perini, Luciano; Borrello, Mario Del; Cipriano, R; Cavallo, A; Volpe, Antonio

doi:10.1007/s11547-006-0088-2

Cited by 21 publications

(10 citation statements)

References 11 publications

(27 reference statements)

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“…Perini et al . published an interesting study using dynamic US to confirm the clinical suspicion of Morton's neuroma 25. The main advantages of US were related to its high availability and the low cost.…”

Section: Discussionmentioning

confidence: 99%

MRI and ultrasonography in Morton’s neuroma: Diagnostic accuracy and correlation

Torres-Claramunt

Ginès

Pidemunt

et al. 2012

IJOO

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Background:The diagnosis of Morton's neuroma is based primarily on clinical findings. Ultrasonography (US) and magnetic resonance image (MRI) studies are considered complementary diagnostic techniques. The aim of this study was to establish the correlation and sensitivity of both techniques used to diagnose Morton's neuroma.Materials and Methods:Thirty seven patients (43 intermetatarsal spaces) with Morton's neuroma operated were retrospectively reviewed. In all cases MRI or ultrasound was performed to complement clinical diagnosis of Morton's neuroma. In all cases, a histopathological examination confirmed the diagnosis. Estimates of sensitivity were made and correlation (kappa statistics) was assessed for both techniques.Results:Twenty seven women and 10 men participated with a mean age of 60 years. Double lesions presented in six patients. The second intermetatarsal space was affected in 10 patients and the third in 33 patients. An MRI was performed in 41 cases and a US in 23 cases. In 21 patients, both an MRI and a US were performed. With regard to the 41 MRIs performed, 34 were positive for Morton's neuroma and 7 were negative. MRI sensitivity was 82.9% [95% confidence interval (CI): 0.679–0.929]. Thirteen out of 23 US performed were positive and 10 US were negative. US sensitivity was 56.5% (95% CI: 0.345–0.768). Relative to the 21 patients on whom both techniques were carried out, the agreement between both techniques was poor (kappa statistics 0.31).Conclusion:Although ancillary studies may be required to confirm the clinical diagnosis in some cases, they are probably not necessary for the diagnosis of Morton's neuroma. MRI had a higher sensitivity than US and should be considered the technique of choice in those cases. However, a negative result does not exclude the diagnosis (false negative 17%).

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Section: Discussionmentioning

confidence: 99%

MRI and ultrasonography in Morton’s neuroma: Diagnostic accuracy and correlation

Torres-Claramunt

Ginès

Pidemunt

et al. 2012

IJOO

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“…); local ischemia leading to nerve scarring (Nissen, ); bursitis (Bossley & Cairney, ); entrapment neuropathy (Jones & Tubby, ; Mulder, ; Graham & Graham, ; Viladot, ; Perini et al. ); increased tension in the foot fasciae (Stecco, ). Because the pathogenesis of this condition is doubtful (Hassouna & Singh, ), there is no ‘gold standard' for treatment either (Thomson et al.…”

Section: Introductionmentioning

confidence: 99%

The role of fasciae in Civinini–Morton's syndrome

et al. 2015

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This study evaluates the pathogenetic role of the perineural connective tissue and foot fasciae in Civinini-Morton's neuroma. Eleven feet (seven male, four female; mean age: 70.9 years) were dissected to analyse the anatomy of inter-metatarsal space, particularly the dorsal and plantar fasciae and metatarsal transverse ligament (DMTL). The macrosections were prepared for microscopic analysis. Ten Civinini-Morton neuromas obtained from surgery were also analysed. Magnetic resonance images (MRIs) from 40 patients and 29 controls were compared. Dissections showed that the width of the inter-metatarsal space is established by two fibrous structures: the dorsal foot fascia and the DMTL, which, together, connect the metatarsal bones and resist their splaying. Interosseous muscles spread out into the dorsal fascia of the foot, defining its basal tension. The common digital plantar nerve (CDPN) is encased in concentric layers of fibrous and loose connective tissue, continuous with the vascular sheath and deep foot fascia. Outside this sheath, fibroelastic septa, from DMTL to plantar fascia, and little fat lobules are present, further protecting the nerve against compressive stress. The MRI study revealed high inter-individual variability in the forefoot structures, although only the thickness of the dorsal fascia represented a statistically significant difference between cases and controls. It was hypothesized that alterations in foot support and altered biomechanics act on the interosseous muscles, increasing the stiffness of the dorsal fascia, particularly at the points where these muscles are inserted. Chronic rigidity of this fascia increases the stiffness of the inter-metatarsal space, leading to entrapment of the CDPN.

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“…Secondo Shapiro [13] e poi Quinn [14], ci si può attendere una affidabilità diagnostica intorno al 95% per masserelle superiori a 5 mm, essendo di 2 mm il limite massimo del nervo normale. Attualmente si esegue l'US con tecnica dinamica (ecografia dinamica), come proposto da Torriani [15] e poi da Perini [16], ricreando durante l'esame il cosiddetto "click" descritto da Mulder [17]. Con questa manovra si lussa manualmente dal lato plantare la masserella neuromatosa, che poi scatta di nuovo verso la pianta del piede nella manovra di avvicinamento delle dita.…”

Section: Diagnosiunclassified

“…Con questa manovra si lussa manualmente dal lato plantare la masserella neuromatosa, che poi scatta di nuovo verso la pianta del piede nella manovra di avvicinamento delle dita. Secondo Perini, che preferisce utilizzare una sonda lineare da 10 MHz, con questa tecnica è più facile identificare la masserella, che si riconosce più agevolmente nel suo spostamento, risulta dolente se compressa e si può più facilmente misurare nelle sue dimensioni; l'esame diventa così significativo per masserelle da 3,5 mm in su [16] (Fig. 3).…”

Section: Diagnosiunclassified

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La sindrome di Morton

Volpe

2011

LO SCAL

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MORTON'S SYNDROME Morton's syndrome (MS) is a typical metatarsalgia, due to an intermetatarsal neuroma. Patients complain of burning pain in the lateral metatarsal region, extending into the third, fourth or both toes. Patients typically experience pain relief by sitting down, removing the shoe, and massaging the foot. The diagnosis is primarily clinical, producing pain by compression with the fingers in the second or third web-space and moving the neuroma up and down between metatarsal bones according to the Mulder's manouvre. Other sources of forefoot pain can be misdiagnosed as an interdigital neuroma, like metatarsal stress fractures, early rheumatoid arthritis, Freiberg's infraction, biomechanical disorders of the Mp joint. Therefore, diagnosis needs a confirmation with advanced imaging. Ultrasound (US) intermetatarsal exploration of forefoot, reproducing local pain and Mulder's click with dynamic manoeuvres, is today, if performed by a well-experienced examinator, an easy and economical test to confirm clinical suspect, with an accuracy of about 90% for intermetatarsal masses greater than 4 mm. There are differing reports about the accuracy of diagnosis with magnetic resonance imaging (MRI), more indicated as a second level examination fot doubtful cases. As for treatment of MS, alcohol injection under sonographic guidance is today a preferred method for intermetatarsal masses greater than 4 mm. Two or three injections of 1 cc of medical alcohol 30% diluted with 70% of xylocaine 2%, injected directly in the mass, are required. In our experience of 150 published cases, success rate is about 80%, without any hindrance to surgery in case of persistent pain. Surgery is indicated in refractory cases and can be done in a formal operative suite in outpatient surgery. The dorsal intermetatarsal approach is preferred, isolating the neuroma from distal to proximal, after transverse intermetatarsal ligament transection. After careful isolation of the third common digital nerve from the thin plantarly directed branches and, if present, the accessory branch of the lateral plantar nerve, the nerve is resected with a new fifteen blade and passed through the fibers of the transverse adductor muscle (neurectomy/relocation technique) to prevent mechanical irritation in case of a stump neuroma. According to literature, results of surgery have been favorable, with 90% of success, when MS was localized in a third web space, but with a worse outcome in cases with second web space (60%) or multiple web space intervention.

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Dynamic sonography of the forefoot in Morton’s syndrome: correlation with magnetic resonance and surgery

Cited by 21 publications

References 11 publications

MRI and ultrasonography in Morton’s neuroma: Diagnostic accuracy and correlation

MRI and ultrasonography in Morton’s neuroma: Diagnostic accuracy and correlation

The role of fasciae in Civinini–Morton's syndrome

La sindrome di Morton

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