599032

research-articleXXXX
FASXXX10.1177/1938640015599032Foot <italic>&</italic> Ankle SpecialistMONTH XXXXvol. X no. XFoot & Ankle Specialist

vol. 9 / no. 1 Foot & Ankle Specialist 37

〈 Clinical Research 〉
Excision of Morton’s
Neuroma Using a Longitudinal Hans-Peter Kundert, MD, Christian Plaass,

Plantar Approach
MD, Christina Stukenborg-Colsman, MD,
PhD, and Hazibullah Waizy, MD

A Midterm Follow-up Study

Abstract: Background. Operative and assessing clinical findings. Introduction
procedures are indicated in the Results. The average amount of pain,
treatment of Morton’s neuroma according to VAS, was 8 (range = Different conservative therapeutic
(MN) when conservative therapies 6-9) points preoperatively and 0.4 approaches have been applied for
have been unsuccessful. A dorsal (range = 0-5) points at final follow- treatment of interdigital neuroma
approach for neurolysis or neurectomy up. Complications occurred in 7.1% (Morton’s neuroma, MN), such as shoe
was strongly recommended. The of interventions and scar problems modifications, orthotic use,
aim of this case series study was to in 5.2%, including delayed wound electrotherapy, corticosteroid injections,
prospectively analyze the midterm healing, hypertrophic scar formation, and alcohol sklerosing therapy. Some of

“
clinical outcome and complications and inclusion cyst.
following the excision of a MN using Conclusion. The present
a plantar longitudinal approach. study shows a strong Painful plantar scarring in the weight-
Methods. Between September 2000 relief of pain after
and January 2009, we included MN resection using a bearing area of the forefoot is the most
44 patients (51 feet, 56 neuromas) plantar longitudinal
in a prospective study treated by incision, coupled with
relevant problem when using a plantar
excision of a primary MN using a a low rate of local approach.”
plantar longitudinal approach. The complications. This
MN diagnosis was based on clinical surgical procedure
symptoms, magnetic resonance seems to be a reliable choice for the these may provide temporary pain relief
imaging findings, and pain relief excision of MN, even in cases with MN but can be associated with unwanted
after infiltration of local anesthetics. in adjacent webspaces, because it is complications, such as skin or fat pad
Histological examinations were technically simple and the plantar scar atrophy and altered pigmentation.1-6
performed in all resected specimens. is not bothersome if properly located. Generally, surgical therapy is
The patients returned for final follow- recommended in patients with failed
Levels of Evidence: Therapeutic,
up at a mean of 54 (range = 12 to conservative therapies.2,7,8
Level IV: Prospective, Case series
99) months, comparing preoperative Although the etiology of MN still
and postoperative perception of pain Keywords: neuroma; Morton; remains unclear, most previous studies
on a Visual Analogue Scale (VAS) neurectomy; plantar approach assumed a symptomatic entrapment with

DOI: 10.1177/1938640015599032. From the Foot and Ankle Center, Hirslanden Clinic Zurich, Switzerland (H-PK); Department for Foot and Ankle Surgery, Orthopedic
Clinic, Hannover Medical School, Hannover, Germany (CP, CSC); Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW). Address correspondence
to: Hans-Peter Kundert, MD, Hirslanden Clinic Zurich, Bergstrasse 12, 8044 Zurich, Switzerland; e-mail: hpkundert4foot@bluewin.ch.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2015 The Author(s)
38 Foot & Ankle Specialist
thickening of the interdigital nerve
beneath the transverse metatarsal
ligament (TML) and with an unaltered
appearance proximal to that ligament.9-13
Assuming this entrapment hypothesis,
different surgical options have been
proposed, mostly aiming to decompress
or excise the squeezed nerve. To realize
these requirements, dorsal
longitudinal,14-17 plantar longitudinal,18-21
and plantar transversal22-24 approaches
have been proposed. Alternative
techniques such as endoscopic,25
minimally invasive,26 or open9,27,28 release
of the TML with or without neurolysis
have been described. Painful plantar
scarring in the weight-bearing area of the
forefoot is the most relevant problem
when using a plantar approach.14,17
The purpose of this study was to
evaluate the clinical results of excision of
primary MN using a plantar longitudinal
incision. Our special interest involved
MN in adjacent webspaces. We present a
prospective, single-surgeon case series,
using a standardized diagnostic and
operative procedure, and follow-up
protocol.
Materials and Method
From September 2000 to January 2009,
44 patients with 56 neuromas in 51 feet
were included in this prospective study.
Inclusion criteria were excision of a MN
by a plantar approach after ineffective
conservative treatment of MN; absence of
associated foot problems to be surgically
treated simultaneously, such as hallux
valgus, forefoot or midfoot arthritis, and
lesser-toe deformities; and a follow-up of
at least 12 months. The study was
approved by the local review board. All
patients gave written informed consent.
All operations and follow-up evaluations
were performed by the corresponding
author.
There were 38 (86%) women and 6
(14%) men. The average age of the
patients at surgery was 53 (range =
30-84) years. The mean follow-up time
was 54 (range = 12-99) months. In all
patients, a MN was diagnosed through
clinical findings, magnetic resonance
imaging (MRI) examination, and a
diagnostic infiltration with local
anesthetic. The clinical examination was
judged conclusive for MN when pressing
the webspace plantarly with one finger
without simultaneous dorsal pressure
provoked the patient’s typical pain
localized to the plantar aspect of the foot
between the metatarsal heads and when
the digital nerve stretch test was
positive.29 A clicking feeling while
squeezing the foot mediolaterally
without concomitant reproduction of the
patient’s pain was not indicative for
MN.30 The diagnostic infiltration of the
neurovascular bundle of the suspicious
webspace was done with 1 to 1.5 mL
lidocaine hydrochloride 1% without
epinephrine from the dorsal side,
perforating the transverse intermetatarsal
ligament. Preoperative weight-bearing
X-rays and MRI scans of the foot were
done routinely in all patients to exclude
other pathologies such as stress fractures,
true neoplasms, intermetatarsal bursitis,
ganglia, plantar plate rupture, and
synovial cysts.31
Pain during daily activities was
evaluated by means of a 10-cm Visual
Analogue Scale (VAS; 0 = no pain, 10 =
severe pain) preoperatively and at final
follow-up by the operating surgeon.
Likewise, clinical findings, any wound
healing problems, and other
complications were recorded. The
patients’ satisfaction with the procedure
was evaluated using a 4-step ordinal
scale with the categories excellent, good,
fair, and poor. Subjective discomfort and
numbness were measured using a 4-step
Likert scale, including none, slight,
moderate, and severe.
Operative Technique
In our in-house session, the patient was
positioned prone if reasonable, which
provided the surgeon a good overview
and a comfortable position. With the use
of spinal anesthesia and after
unwrapping the foot and setting up a
supramalleolar tourniquet control, a
longitudinal plantar incision of about 2.5
cm was positioned exactly between the
corresponding adjacent metatarsal heads
(Figure 1A). In cases of a double MN, an
Feb 2016
additional incision was placed, with a
distance of at least 1 cm between the
incisions (Figure 1B). With careful sharp
and blunt dissection, the interdigital
nerve was identified. Special anatomical
findings such as accessory nerves or
communicating or plantarly directed
nerve branches were assessed and
guarded against damage. The nerve was
resected both 2 cm proximal to the
neuroma and distally beyond its splitting
into the digital nerves (Figures 2A and
2B). The TML remained intact. The
proximal end of the transected nerve
was cauterized and allowed to retract
into surrounding muscle tissue with or
without discretely engraving the plantar
fascia longitudinally. The tourniquet was
removed, and meticulous hemostasis was
done if necessary. No suction drains and
no subcutaneous sutures were used. The
skin was sutured using nonabsorbable
single 2-0 stitches, avoiding inversion of
the skin edges. Sutures were removed 2
weeks postoperatively.
Patients were encouraged to elevate
their feet for 24 hours. Weight bearing
was allowed as tolerated after 1 to 2 days
postoperatively, in a forefoot relief shoe
for 4 weeks. A sport shoe with a
semirigid sole was recommended for
another 2 weeks.
Results
In all, 44 patients (51 feet, 56
neuromas) had a final clinical follow-up
evaluation at an average of 54 (range =
12-99) months.
Of 56 neuromas, 25 (44.6%) were
located in the second webspace, and 31
(55.4 %) in the third webspace. In 6
(13.4%) patients, both the second and
third intermetatarsal webspace were
involved in the same foot and were
treated surgically at the same time in 5
patients. Of the 6 (13.6%) patients with
bilateral MN, simultaneous surgery was
performed in 2 (5%). In all 6 patients
with bilateral MN, the same webspace
was involved in both feet. In 4 of these 6
patients, the third webspace was
involved.
The surgically verified accuracy of the
MRIs taken beforehand was 100%. All the
vol. 9 / no. 1
Figure 1.
The plantar incision is placed exactly between the adjacent metatarsal heads (A); in
patients with double neuromas, a distance of 1 cm is maintained (B).
Figure 2.
Plantar incision, preparation of the nerve.
resected specimens were
histopathologically consistent with MN.
According to the VAS, the average pain
was 8 (range = 6 to 9) points
preoperatively, and the average
postoperative VAS score was 0.4 (range =
0 to 5) points at the final follow-up.
There were 2 patients who reported
some residual pain. One patient had scar
pain when practicing high-impact sports
and scored 3 points. One patient suffered
from a painful hypertrophic scar
formation (Figure 3) and had a score of
5 points.
Sensory reduction to the concerned
toes was checked using tactile self-
assessment by all the patients at final
follow-up. It was either absent or was
only slightly noticed, even in the 5 cases
with simultaneous operations for the
occurrence of 2 neuromas in adjacent
interspaces.
In our series, at the time of final
follow-up, 42 (95.5%) patients rated their
Foot & Ankle Specialist 39
Figure 3.
Hypertrophic scar formation, 3
months postoperatively.
results as excellent or good, with no pain
or subjective discomfort in daily activities
(VAS score of 2 or less), and 2 (4.5%)
patients reported that they were slightly
limited, with some discomfort in walking.
In terms of absence of preoperative
symptoms and subjective satisfaction, we
found no difference with respect to the
location of MN in the different webspaces.
Overall, complications were noted in
4/56 (7.1%) interventions and scar
problems in 3/56 (5.3%). Three
complications developed in the third,
and one in the second webspace.
Delayed wound healing occurred in one
case with forced weight bearing because
of a near fall during the first
postoperative day. The other
complications were a painful
hypertrophic scar formation in one
(Figure 3); a mild keloid scar formation,
presumably as a result of a surgically
activated superficial plantar fibromatosis,
in one patient presenting with a
concomitant Dupuytren’s contracture in
the palm of his hand; and an inclusion
cyst in 1 foot (Figure 4), which was
punched out relapse free. All the other
complications were treated with
40 Foot & Ankle Specialist
Figure 4.
Local wound problem: inclusion cyst
in scar.
individually adapted insoles where
required. There were no occurrences of
plantar fat pad atrophy, skin necrosis,
and functional problems to the toes.
No wound slough or other
complications were observed in the 6
patients with simultaneous or consecutive
excision of MN in adjacent webspaces
using 2 parallel plantar incisions.
Discussion
The purpose of this single-surgeon case
series study was to evaluate the outcome
of MN excision using a plantar
longitudinal approach. Our special
interest was in cases with MN in adjacent
webspaces because Friscia et al32
reported a much higher dissatisfaction
rate with a simultaneous dorsal operative
exploration. Coughlin and Pinsonneault15
found a more extensive area of
numbness and a somewhat lower
satisfaction rate performing a staged
dorsal procedure in such cases, whereas
Benedetti et al33 reported significant pain
relief similar to that with resection of a
single neuroma, using 3 different dorsal
and plantar approaches in 15 patients.
Historically, the dorsal approach has
been advocated as the safer method
because of lower complication rates
when compared with studies using a
plantar approach.14,17 Akermark et al,18 in
their well-designed prospective study,
showed the absence of significant
differences in regard to subjective and
clinical findings between the dorsal and
plantar approaches. In our study with 56
neuromas in 44 patients, using a
longitudinal plantar approach for
excision of MN, we noticed a high
subjective satisfaction and a good clinical
outcome, with a low rate of
interventional complications (7.1%). At
the time of final follow-up, 42/44 (95.5%)
patients reported that they were satisfied
with the operation and had no pain or
discomfort in daily activities. We found
no relevant differences in outcome
between patients with neurectomy in
one isolated webspace or in adjacent
webspaces operated simultaneously. In
terms of VAS scores, our results are
consistent with previous midterm studies
dealing with MN excision through a
plantar approach.19,20,22,23,34
Diagnosing a MN based on the patient’s
history and on physical examination
(notably the dorsal stretch test and
Mulder’s click, when linked with the
patient’s typical pain) had shown a
diagnostic accuracy of 72%.31,35 The 100%
detection rate in our study seems to be
connected to our applied technique of
placing the patient in a prone position in
the MR scanner.36
In our study, the female to male ratio
was 6.3:1 (38/6), comparable to 7:1 in
Nery’s cohort.22 The mean age at the
time of operation (53 years) confirms the
suspicion that middle-aged women are
mainly affected by MN.14,15,17,37,38 The
reason for this is yet unknown, but
repeated dorsiflexion of the toes when
walking habitually in shoes with narrow
toe boxes and high heels could expose
the intermetatarsal nerve underneath the
sharp-edged anterior boarder of the TML
to increased biomechanical stress and
trapping.9,13,39
In the present study, we found a
moderate predominance of the third over
the second webspace at a proportion of
55.4% and 44.6%, respectively. More
differing data were reported by Karges19
Feb 2016
(second webspace 8%, third 91%) and
Mann and Reynolds17 (equally located in
second and third interspaces). Thompson
and Deland40 reported the occurrence of
2 interdigital neuromas in one foot to be
less than 4%, in contrast to 16.6%, as
reported by Beskin and Baxter.23 We
found this constellation in 13.4% of our
patients, possibly explainable by the
consequent use of preoperative MR
imaging and awareness of the senior
surgeon in our series. Histological
examination was routinely obtained in all
our cases, not least to meet legal
standards, and all resected specimens
were consistent with MN criteria.
The best operative approach for
resection of MN is still under debate.
Many authors prefer the dorsal approach,
basically pointing out the diminished
potential for scarring problems.2,14,15,17,32
The supporters of the plantar approach
highlight the excellent exposure of the
interdigital nerve and the possibility of
resecting the nerve well proximal to the
MTL.19-22,24 Beskin and Baxter23 and
Johnson et al41 strictly recommended the
plantar approach for revision surgery.
To our knowledge, there are at least 4
studies that directly compare the
outcomes of dorsal and plantar
approaches. Nashi et al42 showed faster
weight bearing and return to work for
patients in the dorsal group, whereas in
the plantar group, more painful scars
occurred (5 vs 2). Wilson and Kuwada24
pointed out the improved access to the
neuroma and lack of amputation
neuromas using a transverse plantar
incision. In a prospective study, Faraj and
Hosur43 stated that good clinical outcome
is obtainable with both approaches, but
faster rehabilitation and fewer scar
problems were aspects in favor of the
dorsal approach.
In the only level-1 prospective
randomized controlled trial of plantar
versus dorsal incision groups, Akermark
et al18 could not identify any significant
differences regarding clinical outcome,
restrictions in daily activities, and scar
tenderness between the plantar and the
dorsal approaches. Although the
complication rate was comparable, the
type of complications was different:
vol. 9 / no. 1
scar-related complications in the plantar
group (14%) and missed nerves, wound
healing problems, and amputation
neuromas in the dorsal group (12%).
Furthermore, we believe that the
plantar approach has several potential
benefits. The TML is responsible for
stabilizing the forefoot. With the dorsal
approach, the dissection of the TML is
essential to completely address a MN,
whereas with the plantar approach, the
MN can be reached without injuring the
TML. Whether or not the transection of
the TML favors the formation of a
splaying forefoot deformity has been up
for discussion but has not been proved,
to our knowledge.7
The plantar incision facilitates detection
and reliable preservation of anatomical
variations and special findings.44-46 This
approach allows a safe and complete
neurectomy, thus minimizing the risk of
resecting a metatarsal head bursa,
vascular structures, or perineural fat
tissue instead of a neuroma.
Some authors using the plantar
approach reported a rate of scar-related
symptoms of 5% with transverse
incisions22 and 15% to 27% with
longitudinal incisions.18,47 These findings
do not quite correlate with the low rate
of scar-related problems (5.3%) in our
series. In agreement with Karges,19 the
authors believe that hypertrophic scar
formation may be avoided by slightly
everting wound closure.
We could not confirm the findings of
Womack et al48 in a long-term study with
the dorsal approach, identifying MN
location in the second webspace as a
possible prognostic indicator of poor
outcome. In our series, in terms of
absence of postoperative pain and
satisfaction, we found no difference
between the locations of MN in the
different webspaces. In terms of
interventional complications in our
series, 3/4 (75%) developed after
neurectomies in the third and 1/4 (25%)
in the second webspace. In cases with
MN in adjacent webspaces of the same
foot, there was no difference whether the
excisions were simultaneous or staged.
The recurrence rate of neuromas has
been reported by many authors and
varies from 3.8% to 21%.6,15,41 Coughlin
and Pinsonneault15 showed that
postoperative recurrent neuralgia in the
weight-bearing area may be interpreted
as a missed neuroma or a stump
neuroma. Amis et al46 assumed that
multiple plantarly directed nerve
branches may prevent retraction of the
resected nerve stump out of the
weight-bearing area of the forefoot and,
therefore, advised resection of the nerve
at least 3 cm proximal to the TML. The
absence of stump neuroma in the
present study indicates that our practice
of resecting the nerve at least 2 cm
proximal to the TML seems to be
adequate to position the proximal nerve
stump safely in the intrinsic foot muscles.
Our study, based on the use of a
longitudinal plantar approach, as well as
the recent study by Nery et al22 using a
transverse plantar approach,1-5,49 indicate
that a rate of local complications <10%
could be achieved by MN excision
through a plantar approach. This does
not match with previous studies, where
the rate of scar-related problems was
15% to 27%.18,42,47
This single-surgeon case series using a
longitudinal plantar approach with
standardized diagnostic examination,
operative procedure, postoperative
schedule, follow-up protocol, and
histological confirmation in all cases may
have the limitation of lacking a control
group with dorsal approach.
Furthermore, there could be a bias
because the treating surgeon also did the
follow-up examination. Nevertheless, the
complete cohort of operated patients had
a personal final follow-up. The
observation period represents a short- to
midterm follow-up, but the main
complications of any surgical MN therapy
would have been assumed to be
clinically present at the time of the final
follow-up in all cases, even though Lee
et al50 reported that long-term results of
neurectomy clinical outcomes in MN
were slightly worse than short- and
midterm results. One of the perceptions
of this study is that patients with MN in
adjacent webspaces of the same foot
showed the same favorable results as
patients with one isolated MN,
Foot & Ankle Specialist 41
irrespective of simultaneous or staged
surgery.
Summary
The present study shows that there is
considerable relief of pain after MN
resection using a plantar longitudinal
incision, coupled with a low rate of local
complications. This surgical procedure
seems to be a reliable choice for the
excision of MN, even in patients with MN
in adjacent webspaces of the same foot,
because it is technically simple, and the
plantar scar not bothersome if properly
located.
Authors’ Note
H-PK and CP are equally contributing authors.
References
1. Basadonna PT, Rucco V, Gasparini D,
Onorato A. Plantar fat pad atrophy after
corticosteroid injection for an interdigital
neuroma: a case report. Am J Phys Med
Rehabil. 1999;78:283-285.
2. Bennett GL, Graham CE, Mauldin
DM. Morton’s interdigital neuroma: a
comprehensive treatment protocol. Foot
Ankle Int. 1995;16:760-763.
3. Espinosa N, Seybold JD, Jankauskas
L, Erschbamer M. Alcohol sclerosing
therapy is not an effective treatment
for interdigital neuroma. Foot Ankle Int.
2011;32:576-580.
4. Kay D, Bennett GL. Morton’s neuroma.
Foot Ankle Clin. 2003;8:49-59.
5. Makki D, Haddad BZ, Mahmood Z,
Shahid MS, Pathak S, Garnham I. Efficacy
of corticosteroid injection versus size of
plantar interdigital neuroma. Foot Ankle Int.
2012;33:722-726.
6. Pace A, Scammell B, Dhar S. The
outcome of Morton’s neurectomy in the
treatment of metatarsalgia. Int Orthop.
2010;34:511-515.
7. Jain S, Mannan K. The diagnosis and
management of Morton’s neuroma:
a literature review. Foot Ankle Spec.
2013;6:307-317.
8. Stamatis ED, Karabalis C. Interdigital
neuromas: current state of the art—surgical.
Foot Ankle Clin. 2004;9:287-296.
9. Gauthier G. Thomas Morton’s disease:
a nerve entrapment syndrome: a new
surgical technique. Clin Orthop Relat Res.
1979;(142):90-92.
42 Foot & Ankle Specialist
10. Graham CE, Johnson KA, Ilstrup DM.
The intermetatarsal nerve: a microscopic
evaluation. Foot Ankle. 1981;2:150-152.
11. Shereff MJ, Grande DA. Electron
microscopic analysis of the interdigital
neuroma. Clin Orthop Relat Res.
1991;(271):296-299.
12. Morscher E, Ulrich J, Dick W. Morton’s
intermetatarsal neuroma: morphology
and histological substrate. Foot Ankle Int.
2000;21:558-562.
13. Wu KK. Morton’s interdigital neuroma: a
clinical review of its etiology, treatment,
and results. J Foot Ankle Surg. 1996;35:112-
119, discussion 187-188.
14. McKeever DC. Surgical approach for
neuroma of plantar digital nerve (Morton’s
metatarsalgia). J Bone Joint Surg Am.
1952;34-A:490.
15. Coughlin MJ, Pinsonneault T. Operative
treatment of interdigital neuroma: a long-
term follow-up study. J Bone Joint Surg Am.
2001;83-A:1321-1328.
16. Dereymaeker G, Schroven I, Steenwerckx
A, Stuer P. Results of excision of the
interdigital nerve in the treatment of
Morton’s metatarsalgia. Acta Orthop Belg.
1996;62:22-25.
17. Mann RA, Reynolds JC. Interdigital
neuroma: a critical clinical analysis. Foot
Ankle. 1983;3:238-243.
18. Akermark C, Crone H, Skoog A,
Weidenhielm L. A prospective
randomized controlled trial of plantar
versus dorsal incisions for operative
treatment of primary Morton’s neuroma.
Foot Ankle Int. 2013;34:1198-1204.
19. Karges DE. Plantar excision of primary
interdigital neuromas. Foot Ankle.
1988;9:120-124.
20. Richardson EG, Brotzman SB, Graves
SC. The plantar incision for procedures
involving the forefoot: an evaluation of one
hundred and fifty incisions in one hundred
and fifteen patients. J Bone Joint Surg Am.
1993;75:726-731.
21. Nissen KI. Plantar digital neuritis; Morton’s
metatarsalgia. J Bone Joint Surg Br.
1948;30B:84-94.
22. Nery C, Raduan F, Del Buono A, Asaumi
ID, Maffulli N. Plantar approach for
excision of a Morton neuroma: a long-term
follow-up study. J Bone Joint Surg Am.
2012;94:654-658.
23. Beskin JL, Baxter DE. Recurrent pain
following interdigital neurectomy: a
plantar approach. Foot Ankle. 1988;9:
34-39.
24. Wilson S, Kuwada GT. Retrospective study
of the use of a plantar transverse incision
versus a dorsal incision for excision of
neuroma. J Foot Ankle Surg. 1995;34:537-540.
25. Shapiro SL. Endoscopic decompression
of the intermetatarsal nerve for Morton’s
neuroma. Foot Ankle Clin. 2004;9:297-304.
26. Zelent ME, Kane RM, Neese DJ, Lockner
WB. Minimally invasive Morton’s
intermetatarsal neuroma decompression.
Foot Ankle Int. 2007;28:263-265.
27. Diebold PF, Daum B, Dang-Vu V, Litchinko
M. True epineural neurolysis in Morton’s
neuroma: a 5-year follow up. Orthopedics.
1996;19:397-400.
28. Dellon AL. Treatment of Morton’s neuroma
as a nerve compression: the role for
neurolysis. J Am Podiatr Med Assoc.
1992;82:399-402.
29. Cloke D, Greiss M. The digital nerve stretch
test: a sensitive indicator of Morton’s
neuroma and neuritis. Foot Ankle Surg.
2006;12:201-203.
30. Mulder J. The causative mechanism in
Morton’s metatarsalgia. J Bone Joint Surg
Br. 1951;33-B:94-95.
31. Zanetti M, Weishaupt D. MR imaging of the
forefoot: Morton neuroma and differential
diagnoses. Semin Musculoskelet Radiol.
2005;9:175-186.
32. Friscia DA, Strom DE, Parr JW, Saltzman
CL, Johnson KA. Surgical treatment for
primary interdigital neuroma. Orthopedics.
1991;14:669-672.
33. Benedetti RS, Baxter DE, Davis PF. Clinical
results of simultaneous adjacent interdigital
neurectomy in the foot. Foot Ankle Int.
1996;17:264-268.
34. Akermark C, Saartok T, Zuber Z. A
prospective 2-year follow-up study of
plantar incisions in the treatment of
primary intermetatarsal neuromas (Morton’s
neuroma). Foot Ankle Surg. 2008;14:67-73.
35. Zanetti M, Strehle JK, Kundert HP,
Zollinger H, Hodler J. Morton neuroma:
effect of MR imaging findings on diagnostic
thinking and therapeutic decisions.
Radiology. 1999;213:583-588.
36. Weishaupt D, Treiber K, Kundert H-P, et
al. Morton neuroma: MR imaging in prone,
supine, and upright weight-bearing body
positions. Radiology. 2003;226:849-856.
doi:10.1148/radiol.2263011925.
37. Nery C, Coughlin MJ, Baumfeld D,
Ballerini FJ, Kobata S. Hallux valgus in
males: part 1. Demographics, etiology,
and comparative radiology. Foot Ankle Int.
2013;34:629-635.
Feb 2016
38. Giannini S, Bacchini P, Ceccarelli F,
Vannini F. Interdigital neuroma: clinical
examination and histopathologic results in
63 cases treated with excision. Foot Ankle
Int. 2004;25:79-84.
39. Goud A, Khurana B, Chiodo C, Weissman
BN. Women’s musculoskeletal foot
conditions exacerbated by shoe wear:
an imaging perspective. Am J Orthop.
2011;40:183-191.
40. Thompson FM, Deland JT. Occurrence of
two interdigital neuromas in one foot. Foot
Ankle. 1993;14:15-17.
41. Johnson JE, Johnson KA, Unni KK.
Persistent pain after excision of an
interdigital neuroma: results of reoperation.
J Bone Joint Surg Am. 1988;70:651-657.
42. Nashi M, Venkatachalam AK, Muddu BN.
Surgery of Morton’s neuroma: dorsal or
plantar approach? J R Coll Surg Edinb.
1997;42:36-37.
43. Faraj AA, Hosur A. The outcome after
using two different approaches for
excision of Morton’s neuroma. Chin Med J.
2010;123:2195-2198.
44. Levitsky KA, Alman BA, Jevsevar DS,
Morehead J. Digital nerves of the foot:
anatomic variations and implications
regarding the pathogenesis of interdigital
neuroma. Foot Ankle. 1993;14:208-214.
45. Govsa F, Bilge O, Ozer MA. Anatomical
study of the communicating branches
between the medial and lateral plantar
nerves. Surg Radiol Anat. 2005;27:377-381.
46. Amis JA, Siverhus SW, Liwnicz BH.
An anatomic basis for recurrence after
Morton’s neuroma excision. Foot Ankle.
1992;13:153-156.
47. Jardé O, Trinquier JL, Pleyber A, Meire P,
Vives P. Treatment of Morton neuroma
by neurectomy. Apropos of 43 cases [in
French]. Rev Chir Orthop Reparatrice Appar
Mot. 1995;81:142-146.
48. Womack JW, Richardson DR, Murphy GA,
Richardson EG, Ishikawa SN. Long-term
evaluation of interdigital neuroma treated
by surgical excision. Foot Ankle Int.
2008;29:574-577.
49. Rasmussen MR, Kitaoka HB, Patzer
GL. Nonoperative treatment of plantar
interdigital neuroma with a single
corticosteroid injection. Clin Orthop Relat
Res. 1996;(326):188-193.
50. Lee KT, Kim JB, Young KW, Park YU,
Kim JS, Jegal H. Long-term results of
neurectomy in the treatment of Morton’s
neuroma: more than 10 years’ follow-up.
Foot Ankle Spec. 2011;4:349-353.