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. 2024 Feb 9;2(2):CD014687.
doi: 10.1002/14651858.CD014687.pub2.

Treatments for Morton's neuroma

Barry G Matthews  1 , Colin E Thomson  2 , Michael P Harding  3 , John C McKinley  4 , Robert S Ware  5
Affiliations

Treatments for Morton's neuroma

Barry G Matthews et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

BM: none known; BM is a podiatrist and manages people with Morton's neuroma. He authored a 2019 systematic review of non‐surgical interventions for Morton's neuroma.

CT: none known; CT is a surgical podiatrist and manages people with Morton's neuroma. He is an author of an RCT funded by the Chief Scientist Office Scottish Government, which is relevant to this systematic review. CT resolved study inclusion, data extraction, risk of bias and GRADE appraisal disagreements except for the included study (Thomson 2013), which he co‐authored.

JM: none known; JM is an orthopaedic surgeon who manages people with Morton's neuroma.

MH: none known; MH is a podiatrist and manages people with Morton's neuroma. He co‐authored a 2019 systematic review of non‐surgical interventions for Morton's neuroma.

RW: none known; RW is an academic biostatistician. He co‐authored a 2019 systematic review of non‐surgical interventions for Morton's neuroma. RW is a Cochrane editor who was not involved in the editorial process for this review.

Figures

1
1
Flow diagram of study selection.
1.1
1.1. Analysis
Comparison 1: Shockwave therapy (SWT) versus sham SWT: short term (up to 1 month), Outcome 1: Pain: VAS (0‐100) (final values): short term (up to 1 month)
1.2
1.2. Analysis
Comparison 1: Shockwave therapy (SWT) versus sham SWT: short term (up to 1 month), Outcome 2: Function: AOFAS (0‐100) (final values): short term (up to 1 month)
1.3
1.3. Analysis
Comparison 1: Shockwave therapy (SWT) versus sham SWT: short term (up to 1 month), Outcome 3: Satisfaction (short term)
2.1
2.1. Analysis
Comparison 2: Shockwave therapy (SWT) versus sham SWT: adverse events, Outcome 1: Adverse events: short term
3.1
3.1. Analysis
Comparison 3: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): pain, Outcome 1: Pain: VAS (0‐100) meta‐analysis (change from baseline and final values) short‐term results
3.2
3.2. Analysis
Comparison 3: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): pain, Outcome 2: Pain: VAS (0‐100) meta‐analysis (change from baseline and final values) intermediate‐term results
3.3
3.3. Analysis
Comparison 3: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): pain, Outcome 3: Pain: VAS (0‐100) (final values) long‐term results
4.1
4.1. Analysis
Comparison 4: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): function, Outcome 1: Function: AOFAS (0‐100) and MFPDS (0‐100) meta‐analysis (final values) short term
4.2
4.2. Analysis
Comparison 4: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): function, Outcome 2: Function: AOFAS (0‐100) and MFPDS (0‐100) meta‐analysis (final values) intermediate term
4.3
4.3. Analysis
Comparison 4: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): function, Outcome 3: Function: MFPDS (0‐100) (final values) long term
5.1
5.1. Analysis
Comparison 5: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): HRQoL, Outcome 1: HRQoL: EQ‐5D (0‐1) (final values) short term
5.2
5.2. Analysis
Comparison 5: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): HRQoL, Outcome 2: HRQoL: EQ‐5D (0‐1) (final values) intermediate term
5.3
5.3. Analysis
Comparison 5: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): HRQoL, Outcome 3: HRQoL: EQ‐5D (0‐1) (final values) long term
6.1
6.1. Analysis
Comparison 6: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): satisfaction, Outcome 1: Satisfaction: intermediate time point (6 months)
7.1
7.1. Analysis
Comparison 7: Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA): adverse events, Outcome 1: Adverse events: intermediate term
8.1
8.1. Analysis
Comparison 8: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): pain, Outcome 1: Pain: VAS (0‐100) (final values) short term
8.2
8.2. Analysis
Comparison 8: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): pain, Outcome 2: Pain: VAS (0‐100) meta‐analysis (final values) intermediate term
8.3
8.3. Analysis
Comparison 8: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): pain, Outcome 3: Pain: VAS (0‐100) meta‐analysis (final values) long term
9.1
9.1. Analysis
Comparison 9: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): function, Outcome 1: Function: MFPDS (17‐51) (final values) short term
9.2
9.2. Analysis
Comparison 9: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): function, Outcome 2: Function: MOXFQ (0‐100) and MFPDS (17‐51) meta‐analysis (final values) intermediate term
9.3
9.3. Analysis
Comparison 9: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): function, Outcome 3: Function: MOXFQ (0‐100) and MFPDS (17‐51) meta‐analysis (final values) long term
10.1
10.1. Analysis
Comparison 10: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): satisfaction, Outcome 1: Satisfaction: short term
10.2
10.2. Analysis
Comparison 10: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): satisfaction, Outcome 2: Satisfaction: meta‐analysis intermediate term
10.3
10.3. Analysis
Comparison 10: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): satisfaction, Outcome 3: Satisfaction: long term
11.1
11.1. Analysis
Comparison 11: Ultrasound guided corticosteroid injection (UG CS+LA) versus non‐ultrasound guided corticosteroid injection (NUG CS+LA): adverse events, Outcome 1: Adverse events: long term
12.1
12.1. Analysis
Comparison 12: Plantar incision neurectomy (PN) versus dorsal incision neurectomy (DN): satisfaction, Outcome 1: Satisfaction: long term
13.1
13.1. Analysis
Comparison 13: Plantar incision neurectomy (PN) versus dorsal incision neurectomy (DN): adverse events, Outcome 1: Adverse events: long term
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD014687

References

References to studies included in this review

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References to other published versions of this review

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