The effectiveness of non‐surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta‐analysis

Abstract

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 I 2 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. Electronic supplementary material The online version of this article (10.1186/s13047-019-0320-7) contains supplementary material, which is available to authorized users.

Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review

“…More recently, one randomized study indicated that though both treatments improved outcomes for 18 months, corticosteroids had a greater improvement than PRP within 1 month of injection, and PRP had a more positive effect than ICS at 6-, 12-, and 18-month follow-ups [38]. Conversely, two other studies found that ICS and PRP both improved outcomes up to 16 weeks and 6 months, respectively, with no difference between level of improvement due to the two treatments [8,9].…”

“…Diagnosis of MN can also be confirmed with the Mulder maneuver, where pressure and tightening is exerted on the metatarsals, resulting in pain and a distinct clicking or the Silfverskiöld test to assess gastrocnemius muscle tightness are useful in diagnosing MN [5][6][7]. Surgical treatment of MN is traditionally a neurectomy; however, non-surgical treatments first are now becoming more recommended [5,8]. A non-surgical option is preferred due to the large spectrum of potential causes of MN, patients declining surgical options, or not being suitable for surgery due to contraindications [5,8].…”

“…Surgical treatment of MN is traditionally a neurectomy; however, non-surgical treatments first are now becoming more recommended [5,8]. A non-surgical option is preferred due to the large spectrum of potential causes of MN, patients declining surgical options, or not being suitable for surgery due to contraindications [5,8].…”

A service review of the patient focused outcomes of neuroma excision at a mean follow-up of 8 years and 10 months

“…Bennett et al 1995 noted that 85% of 115 patients found that they had improvement from non-surgical treatment and just 21% required surgical excision [4]. However, in a systematic review of non-surgical interventions Matthews et al 2019 found only limited evidence for non-surgical treatment though it was still recommended that non-surgical treatment should always be attempted prior to surgery [11,12,13,14].…”

Disorders of the Peripheral Nervous System

“…Conservative measures such as steroid injection and mobilization have shown some benefit. [20] Surgical resection is often necessary. [21].…”