4/8/2017 Ovid:OperativeTechniquesinFootandAnkleSurgery

Editors: Easley, Mark E.; Wiesel, Sam W.

Title: Operative Techniques in Foot and Ankle Surgery, 1st Edition

Copyright 2011 Lippincott Williams & Wilkins

> Table of Contents > Section I Forefoot > Chapter 37 Morton's Neuroma and Revision Morton's Neuroma Excision

Chapter 37
Morton's Neuroma and Revision Morton's Neuroma Excision

David R. Richardson

DEFINITION
A primary interdigital (Morton's) neuroma is in fact not a neuroma as it does not involve the haphazard
proliferation of axons seen in a traumatic nerve injury.

Instead, this condition is best described as an interdigital perineural fibrosis.

It was first described in 1845 by Lewis Durlacher, a chiropodist to the Queen of England.

Recurrent neuromas are true histopathologic (haphazard proliferation of axons) amputation stump neuromas.

Eightyfive to 90% of nontraumatic neuromas are found in the third web space. The rest are found in the second
web space.

ANATOMY
The medial plantar nerve supplies sensation to the first, second, and third digits and the medial aspect of the
fourth digit. It emerges plantar and medial to the flexor digitorum brevis, coursing obliquely across the plantar
surface of the muscle.

The lateral plantar nerve supplies sensation to the lateral half of the fourth and the fifth digit.

Both are branches of the tibial nerve and terminate with digital branches that course plantarly deep to the
transverse metatarsal ligament (FIG 1).

The lumbrical tendon appears lateral and superficial to the digital nerve as it attaches to the medial aspect of
the extensor expansion of the digit and may be mistaken for nerve.

In a cadaveric study, Levitsky et al 12 found that 27% of specimens had a communicating branch connecting the
medial and lateral plantar nerves. They also noted that the second and third interspaces were significantly
narrower than the first and fourth.

Changes in the nerve itself involve perineural fibrosis, demyelinization and degeneration of nerve fibers,
endoneural edema, and the absence of inflammatory changes.

Plantardirected nerve branches may tether the common digital nerve to the plantar skin.

Theses nerve branches are present up to 4 cm proximal to the transverse metatarsal ligament.

PATHOGENESIS
All histologic changes in a primary interdigital neuroma occur distal to the transverse metatarsal ligament, as
shown in studies by Lassmann 11 and Graham et al.7

The cause is unclear but is thought to evolve as an entrapment neuropathy.

The second and third intermetatarsal spaces are narrower than the first and fourth.
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Mobility between the medial three rays and the lateral two rays may contribute to the high number of primary
neuromas in the third interspace.

In a limited number of patients (about 27%) the common digital nerve to the third interspace consists of branches
from the medial and lateral plantar nerves, which perhaps increases the size of the nerve and predisposes it to
entrapment (Fig 1).

A recurrent interdigital neuroma may be due to several factors, including failure to make the correct diagnosis
originally.

Neurogenic pain may be due to causes other than perineural fibrosis, such as neuropathy and radiculopathy. Also,
neuromalike symptoms may be due to nerve irritation from local synovitis or bursitis.

Beskin and Baxter3 found that in patients with recurrent symptoms of interdigital neuroma, about two thirds
presented within 12 months and one third had recurrence 1 to 4 years after primary surgery.

Those with recurrence within the first 12 months probably represent patients who were originally
misdiagnosed.

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FIG 1 Course of medial and lateral plantar nerve. A communicating branch of the lateral plantar nerve
occurs in about 27% of patients.

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FIG 2 A. Standing palpation of the web space. B. Metatarsophalangeal joint plantarflexion stress test. C.
Mulder test: The examiner places the thumb on the dorsal surface and the index finger on the plantar
surface in the affected web space and applies gentle pressure. D. With the opposite hand the examiner
applies a gentle squeeze to the forefoot in a mediolateral direction. A clicking sensation that reproduces the
patient's pain will often be appreciated.

Those presenting after 12 months probably represent patients with a true bulb neuroma at the cut end of the
common digital nerve. It probably requires at least this length of time for a neuroma to grow big enough to cause
symptoms.

Formation of a recurrent neuroma after primary surgery is usually due to inadequate resection.

Plantardirected nerve branches may tether the common digital nerve to the plantar skin and not allow for
retraction of the nerve after it is cut. These nerve branches may occur up to 4 cm proximal to the transverse
metatarsal ligament.

NATURAL HISTORY
Interdigital neuromas occur more commonly in females.

The primary symptom of an interdigital neuroma is pain, most often described as burning, aching, or cramping.

The pain often radiates to the toes or proximally along the plantar aspect of the foot.

Relief usually occurs with removing narrow toebox shoes.

Walking barefoot on soft surfaces often produces no symptoms.

PATIENT HISTORY AND PHYSICAL FINDINGS

In patients with an interdigital neuroma, the most common complaint is plantar pain, which is often increased by
walking.

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Pain is often relieved by resting and removing shoes.

Often there are no symptoms with barefoot walking on a soft surface.

About half of patients describe pain radiating to the toes.

The duration of pain varies from a few weeks to many years.

Plantar tenderness in the web space is the most common physical examination finding.

The examiner should inspect for deviation or subluxation of the toes or fullness of the web space. This is best
done with the patient standing (FIG 2A).

Palpating the web space proximal to the metatarsal heads and proceeding distally will usually reproduce the
patient's symptoms.

It is often difficult to differentiate adjacent metatarsophalangeal (MTP) joint synovitis from a neuroma.

Plantarflexion of the corresponding MTP joint may help with the diagnosis (FIG 2B). This maneuver often causes
little increased pain in those with an interdigital neuroma but is quite painful in those with MTP joint synovitis.

Difficulty in making a diagnosis may arise when primary synovitis causes secondary neuritic symptoms.

The Mulder test is also useful.

Pain may be present on the asymptomatic contralateral side but is usually not as painful and the click not as
striking.

This test is best performed with the patient lying prone and the knee flexed 90 degrees. The examiner places
the thumb on the dorsal surface and the index finger on the plantar surface in the affected web space and
applies gentle pressure (FIG 2C). With the opposite hand the examiner applies a gentle squeeze to the forefoot
in a mediolateral direction (FIG 2D). A clicking sensation that reproduces the patient's pain will often be
appreciated.

IMAGING AND OTHER DIAGNOSTIC STUDIES

The diagnosis of an interdigital neuroma is most often made solely on the basis of the history and physical
examination.

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Standing AP, lateral, and oblique radiographs are necessary to exclude osseous pathology and to assess the MTP
joint.

The use of nerve conduction testing has not been shown to be beneficial, as findings often are abnormal in
patients without symptoms of an interdigital neuroma.

Studies differ as to the benefit of ultrasonography or MRI. If necessary, ultrasonography appears to be more useful
than MRI in cases with a questionable diagnosis.

A diagnostic injection may be helpful, although other pathology in the area may improve with this local
anesthetic.

2 cc of lidocaine is placed in the symptomatic web space through a dorsal approach.

The needle must be plantar to the transverse metatarsal ligament.

DIFFERENTIAL DIAGNOSIS
Adjacent web space neuroma

MTP joint synovitis

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Freiberg osteochondrosis

Stress fracture of the metatarsal neck

Tarsal tunnel syndrome

Peripheral neuropathy

Lumbar radiculopathy

Unrelated soft tissue tumor (eg, ganglion, synovial cyst, lipoma)

NONOPERATIVE MANAGEMENT
Although reported results of conservative treatment vary, it is still worthwhile to try, as 30% to 40% of patients
may avoid surgery.

The patient should be fitted with a wide, soft, laced shoe with a low heel.

A soft metatarsal support should be added just proximal to the metatarsal heads (FIG 3A).

An injection of steroids with anesthetic may be both diagnostic and therapeutic. For there to be diagnostic value,
however, the anesthetic must be directed to the common digital nerve in the affected web space and not into the
MTP joint. A combination of 40 mg DepoMedrol and 1 cc 0.25% Marcaine is used for the injection (FIG 3B). Thirty
percent of patients may have relief for 2 years or longer. Steroids should be used with caution as fat pad atrophy,
skin discoloration, or MTP joint capsule laxity may result and create a new problem for the patient.

FIG 3 A. Soft inserts and metatarsal support should be the first line of treatment. B. Steroid injection may
improve symptoms and help with diagnosis.

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FIG 4 A neuroma retractor may help with exposure during surgery.

SURGICAL MANAGEMENT
The indication for surgery is failure of conservative treatment in a patient who is healthy enough to undergo
forefoot surgery and who has appropriate vascular status.

Preoperative Planning
A forefoot or ankle block may be used. Twenty to 30 cc of a 50% mixture of a short and longacting anesthetic (eg,
lidocaine and Marcaine) without epinephrine is recommended.

An examination under anesthesia allows for better appreciation of an interspace mass and often will produce a
more striking Mulder click.

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Instruments needed include a Weitlaner or neuroma retractor (FIG 4), small tenotomy scissors, a Senn retractor,
and a Freer elevator.

An ankle tourniquet is used with cast padding and an Esmarch bandage.

If a plantar approach is being used (recurrent neuroma), the surgeon should palpate and outline with a sterile
marker the metatarsal heads corresponding to the web space being explored.

Positioning
The patient is placed supine with a 3inch bump under the distal leg just proximal to the heel. The heel should
be floating just off the bed.

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FIG 5 A. Surgeon position for primary neuroma excision. Magnifying loupes are beneficial. B. Surgeon
position for revision neuroma excision.

For a primary interdigital neuroma the surgeon should sit proximal to the foot with the assistant positioned at the
end of the table to assist with retraction (FIG 5A).

A plantar approach is used for recurrent neuromas. The surgeon sits at the end of the table facing the plantar
aspect of the foot (FIG 5B).

Approach

Primary Interdigital Neuroma

A dorsal approach is used for primary neuromas.

A dorsal incision is made 3 cm proximal to the web, extending distally to the edge of the web space (FIG 6).

The incision is slightly oblique and medial to the extensor tendons. It is important not to follow the tendons
themselves, as they will take a more lateral direction.

The dissection is deepened and the dorsal sensory nerves are retracted to the side of least resistance.

The lumbrical tendon is lateral to the dissection.

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The surgeon should proximally identify the dorsal interosseous fascia and muscle belly and follow it distally to the
bursa overlying the transverse metatarsal ligament.

The surgeon should place a Weitlaner or neuroma retractor between the metatarsals and spread them apart.

The bursa is opened to identify the transverse metatarsal ligament.

FIG 6 For a primary interdigital neuroma, a 3cm incision is made in the affected web space just medial to
the extensor tendons.

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Web space fat is retracted using a Senn retractor and the distal aspect of the intermetatarsal ligament is
identified.

A Freer elevator is placed beneath the transverse metatarsal ligament from distal to proximal, protecting the
underlying structures.

The transverse metatarsal ligament is incised with a no. 15 blade knife, staying on top of the Freer elevator.

The lumbrical tendon is in the lateral aspect of the dissection just plantar to the intermetatarsal ligament.

The neurovascular bundle is identified medial and plantar to the lumbrical.

Recurrent Neuroma

PLANTAR LONGITUDINAL INCISION

A longitudinal plantar incision is made 4 cm proximal to the web, extending distally to within 1 cm of the web
space.

The incision is made between the metatarsal heads (which have been identified and marked before making an
incision) and proceeds just distal to this area (FIG 7).

A small Weitlaner retractor is placed to retract the fat overlying the plantar aponeurosis.

Using a no. 15 blade knife, the aponeurosis is incised in line with the skin incision.

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FIG 7 For recurrent interdigital neuromas, a 4cm longitudinal plantar incision is made proximal to the web
extending distally to within 1 cm of the web space.

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A tenotomy scissors is used to bluntly spread until the common digital nerve is identified proximally.

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The surgeon dissects distally to identify the stump neuroma.

PLANTAR TRANSVERSE INCISION

A 3 to 4cm transverse plantar incision is made over the affected interspace just proximal to the weightbearing
pad and parallel to the natural crease (FIG 8).

The metatarsal heads are continually palpated to provide a reference point to the appropriate interspace to be
explored.

The dissection is carefully deepened with scissors to expose the septa of the plantar fascia.

The interval between the longitudinal limbs of the plantar fascia septa is opened with scissors.

The bands of the plantar fascia are retracted medially and laterally with a Senn retractor and the interspace is
carefully explored with blunt dissection to identify the common digital nerve and vessel.

The nerve (neuroma) will lie superficial (plantar) to the flexor digitorum brevis muscle or tendon and immediately
deep (dorsal) to the plantar fascia.

The surgeon dissects distally to identify the stump neuroma.

The neuroma is identified and dissected proximally 1 to 2 cm.

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FIG 8 Alternatively, one may use a 3 to 4cm transverse plantar incision. The incision is placed over the
affected interspace just proximal to the weightbearing pad and parallel to the natural crease.

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TECHNIQUES
PRIMARYINTERDIGITALNEUROMAEXCISION(DORSAL)
Oncetheapproachhasbeencompletedthenerveshouldbeidentifiedinthewound.Itis
usuallyeasiertoidentifythenerveproximallyanddissectdistally(TECHFIG1A).
Manuallypalpateinthewoundtobesurethetransversemetatarsalligamenthasbeen
completelytransected,asthisisessentialtoasuccessfuloutcome.
Despitethesizeofthenerveortheobviouspresenceofaneuroma,thenerveshouldbe
resectedasplanned.
Structuresthatmaybemistakenforthenerveincludethelumbricaltendon,whichpasses
tothemedialportionoftheadjacentproximalphalanx(extensorexpansion)andtherefore
islateraltothenerve.Thecommondigitalarteryusuallycrossesproximalmedialtodistal
laterallyingdorsallyoverthenerve.Thearteryoftenemergesfromunderthemetatarsal
neckandifidentifiedneedstobedissectedawayfromthenerveandpreserved.

TECH FIG 1 A. The transverse metatarsal ligament must be divided. B. The neuroma is visualized
and the common digital nerve transected 4 cm proximal to the transverse metatarsal ligament and
allowed to retract proximal to the weightbearing pad of the forefoot. (continued)

Usinggentletraction(TECHFIG1B),transectthenerveabout4cmproximaltothe
transversemetatarsalligament.
Thetransverseheadoftheadductorhallucismayneedtoberetracteddorsallytoidentify
theplantardirected
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branchesofthecommondigitalnerve.Dividethesebranchestoallowtheproximalaspect
ofthenervetoretractatleast1to2cmproximaltotheweightbearingpadoftheforefoot
(TECHFIG1C).

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TECH FIG 1 (continued) C. After transection of the intermetatarsal ligament, the nerve is
transected proximally (the transverse head of the adductor hallucis muscle often must be retracted)
and dissected distally past the bifurcation. D. The specimen is sent for pathologic examination. E,F.
For a primary neuroma excision, a mildly compressive dressing is placed and the patient is allowed to
bear weight as tolerated in a postoperative shoe.

Useahemostattoplacetheremainingnervestumpwellproximalanddorsalintothe
interosseousmuscles.
Circumferentiallydissectthenervedistallytothebifurcationoftheproperdigitalbranches.
Dividetheproperdigitalnervejustdistaltothebifurcation.
Sendthespecimen(TECHFIG1D)forpathologicexamination.
WiththeWeitlanerorneuromaretractorstillinplace,releasetheankletourniquet.Use
cauterytoobtainhemostasis.
Irrigatethewoundwithsterilesaline.

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Closethewoundwith40nylonsutureinarunninglockingfashion.
Ifsubcutaneoussutureisdesired,usea30Monocryl,takingcarenottoincludethedorsal
sensorynerves.
PlaceamildlycompressivedressingoveraXeroformgauzecoveringthewound(TECHFIG
1E,F).

REVISIONINTERDIGITALNEUROMAEXCISION(PLANTARLONGITUDINAL
INCISION)
Oncetheapproachhasbeencompleted,theneuromaisidentifiedjustdeeptothedistal
extensionsoftheplantarfasciathatfanouttoattachtotheplantaraspectsoftheMTP
jointsandjustsuperficial(plantar)totheflexordigitorumbrevis.
Theintermetatarsalligamentisoftenscarredinbutdoesnotneedtobetransectedasitis
distalanddorsaltotheneuroma.
Placegentletractiononthecommondigitalnerve(TECHFIG2A).Identifyandexcisethe
neuroma(TECHFIG2B).
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TECH FIG 2 A. The plantar longitudinal incision is shown with gentle traction placed on the
common digital nerve. B. Excision of the recurrent neuroma through a plantar longitudinal incision.

Allowthecommondigitalnervetoretractproximallyasfaraspossible.
Releasetheankletourniquetandobtainhemostasis.
Irrigatethewoundwithsterilesaline.
Closethewoundwithinterrupted30nylonsutureinaverticalmattressfashion.
PlaceamildlycompressivedressingoveraXeroformgauzeonthewound.
Placethepatientinashortlegposteriorsplint.

REVISIONINTERDIGITALNEUROMAEXCISION(PLANTARTRANSVERSE
INCISION)

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Oncetheplantartransverseapproachismade,thetechniqueisexactlythesameas
describedabovefortheplantarlongitudinalincision.

PEARLSANDPITFALLS
Always perform a thorough history and physical examination. This is the Perform standing, sitting, and prone examination of the
primary basis of diagnosis and treatment. foot and ankle

Attempt conservative treatment before surgery.

Discuss with the patient possible complications of surgery, especially

incomplete relief and recurrence.

Transect the common digital nerve at least 3 to 4 cm proximal to the Grasp the nerve and with gentle traction pull it distally.
transverse metatarsal ligament (Tech Fig 1C). Transect and allow the nerve to retract.

Release the tourniquet and obtain hemostasis before closure. Hematoma formation increases the risk of slow wound
healing and infection.

POSTOPERATIVE CARE
For 24 hours the operative extremity is maximally elevated and the patient ambulates only for bathroom
privileges.

For a primary excision (dorsal approach), the patient is then allowed to ambulate with weight bearing as tolerated
in a hardsoled postoperative shoe for 4 weeks.

For a revision excision (plantar approach), the patient is kept nonweightbearing on crutches for 2 weeks and
then transitioned into a stiffsoled postoperative shoe for another 2 weeks with weight bearing as tolerated.

Sutures are removed at 2 weeks and SteriStrips are placed on the wound.

At 4 weeks after surgery the patient is allowed into a wide toebox, softvamp comfortable shoe and progressed as
tolerated.

OUTCOMES
Surgical excision of a primary neuroma has a reported success rate of 51% to 90%, although results tend to diminish
with time. A recent study by Womack et al 22 suggests longterm pain relief is not as significant as once thought.

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These results seem to be similar for both second and third web space neuroma excisions.

After reexploration for a recurrent neuroma, lessthancomplete satisfaction can be expected in 20% to 40% of
individuals.

COMPLICATIONS
Recurrence of symptoms: This may be due to incorrect diagnosis, incomplete resection, or true recurrence.

Recurrence of symptoms due to incorrect diagnosis and incomplete resection usually occurs within the first 12
months.

Recurrence after 1 year is more likely related to the formation of a stump neuroma.

Significant wound complications are rare, but slow wound healing and superficial cellulitis are more common.

Incisional tenderness after a plantar approach is less common than one may suppose but may occur if placed
under a weightbearing portion of the forefoot.

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REFERENCES

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2. Amis JA, Siverhus SW, Liwnicz BH. An anatomic basis for recurrence after Morton's neuroma excision. Foot
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3. Beskin JL, Baxter DE. Recurrent pain following interdigital neurectomy a plantar approach. Foot Ankle
1988;9:34.

4. Bradley N, Miller WA, Evans JP. Plantar neuroma: analysis of results following surgical excision in 145
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5. Coughlin MJ, Pinsonneault T. Operative treatment of interdigital neuroma: a longterm followup study. J
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14. Mann RA, Reynolds JC. Interdigital neuroma: a critical analysis. Foot Ankle 1983;3:238.

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19. Sharp RJ, Wade CM, Hennessy MS, et al. The role of MRI and ultrasound imaging in Morton's neuroma and
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