PMID- 38334217
OWN - NLM
STAT- MEDLINE
DCOM- 20240214
LR  - 20240514
IS  - 1469-493X (Electronic)
IS  - 1361-6137 (Linking)
VI  - 2
IP  - 2
DP  - 2024 Feb 9
TI  - Treatments for Morton's neuroma.
PG  - CD014687
LID - 10.1002/14651858.CD014687.pub2 [doi]
LID - CD014687
AB  - 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, I(2) = 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, I(2) = 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, I(2) = 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, I(2) = 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, I(2) = 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, I(2) = 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, I(2) = 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.
CI  - Copyright (c) 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
FAU - Matthews, Barry G
AU  - Matthews BG
AD  - Faculty of Health, School of Clinical Sciences, Queensland University of 
      Technology (QUT), Brisbane, Australia.
FAU - Thomson, Colin E
AU  - Thomson CE
AD  - Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh and St 
      John's Hospital Livingston, Edinburgh, UK.
FAU - Harding, Michael P
AU  - Harding MP
AD  - University of South Australia (City East), Adelaide, Australia.
FAU - McKinley, John C
AU  - McKinley JC
AD  - Royal Infirmary of Edinburgh and Royal Hospital for Sick Children, Edinburgh, UK.
FAU - Ware, Robert S
AU  - Ware RS
AD  - School of Medicine and Dentistry, Griffith University, Brisbane, Australia.
LA  - eng
PT  - Journal Article
PT  - Review
PT  - Systematic Review
DEP - 20240209
PL  - England
TA  - Cochrane Database Syst Rev
JT  - The Cochrane database of systematic reviews
JID - 100909747
RN  - 0 (Anesthetics, Local)
SB  - IM
UOF - doi: 10.1002/14651858.CD014687
MH  - Humans
MH  - *Morton Neuroma/therapy
MH  - Anesthetics, Local
MH  - Quality of Life
MH  - Pain
MH  - Atrophy
PMC - PMC10853972
COIS- 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.
EDAT- 2024/02/09 12:44
MHDA- 2024/02/10 22:55
PMCR- 2025/02/09
CRDT- 2024/02/09 07:55
PHST- 2025/02/09 00:00 [pmc-release]
PHST- 2024/02/10 22:55 [medline]
PHST- 2024/02/09 12:44 [pubmed]
PHST- 2024/02/09 07:55 [entrez]
AID - CD014687.pub2 [pii]
AID - 10.1002/14651858.CD014687.pub2 [doi]
PST - epublish
SO  - Cochrane Database Syst Rev. 2024 Feb 9;2(2):CD014687. doi: 
      10.1002/14651858.CD014687.pub2.