What is the efficacy of surgical excision for the treatment of interdigital neuritis?

Updated: Oct 15, 2019
  • Author: Minoo Hadjari Hollis, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Mann and Reynolds reported retrospectively on a surgical excision of 76 Morton neuromas. [50] Although 65% of patients still noted some local plantar tenderness to touch, 80% showed subjective improvement. Coughlin and Pinsonneault noted residual pain in either the involved interspace or the adjacent one, which is not uncommon. [70] They also reported 85% good-to-excellent results and noted mild or major footwear restrictions in 70% of patients.

Dereymaeker et al reported on 32 feet treated with excision of a Morton neuroma via a dorsal incision. [71] Of the 32, 25 had a macroscopically visible neuroma, and two had no evidence of a neuroma on histologic examination. After resection, 81% had a good or excellent result, and 6.5% had no improvement. After the operation, 60% of the patients benefited from the long-term use of adapted shoes or inner soles. At the final follow-up, only 30% of the patients were found to be unrestricted in their choice of shoes.

The plantar approach to primary resection of an intermetatarsal neuroma, advocated by some, provides more direct access to the nerve and is technically simpler; however, painful plantar scars, intractable plantar keratosis beneath an adjacent lesser metatarsal head, and wound drainage have been reported. Consequently, most surgeons reserve this approach for revision cases. In a study of 57 plantar procedures done via a plantar incision, 23% of subjects had indurated plantar keratosis after surgery, and only 7% had poor results. [63]

Potential complications of interdigital nerve excision, including development of a stump neuroma and digital numbness, have led some authors to recommend release of the transverse metatarsal ligament with or without epineurolysis. Gauthier, reporting on the release of 304 intermetatarsal ligaments with epineural neurolysis, stated that 83% of patients had rapid and stable improvement and that 15% showed improvement but nonetheless experienced some persistent pain. [72]

Others, such as Weinfeld and Myerson, have advocated this procedure without neurolysis and have reported good preliminary results. [73] Mann and Reynolds cautioned against the use of this procedure except in the case of interdigital neuritis, noting reconstitution of the ligament in revision cases. [50]

Adjacent neuromas in the second and third interspace are not uncommon and should be investigated. Published reports of double neuromas are sparse. Benedetti et al reported simultaneous excision of two primary Morton neuromas in adjacent webspaces and noted significant pain relief in 84% of patients, but substantial numbness involving the third toe resulted. [74] Thompson and Deland described 89 adjacent neurectomies and reported results similar to those achieved with single neurectomies. [75]

Hort and DeOrio described 23 patients with adjacent intermetatarsal nerve irritation who underwent excision of the more enlarged nerve in one space and release of the intermetatarsal ligament in the other space, [76] an approach that allowed preservation of protective sensation. They reported 95% complete satisfaction, with no or only minimal activity limitation. Approximately 11% of patients had persistent pain with compression of the interspace where the nerve was released; none had pain in the interspace where the nerve was excised.

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