Comparison of Alcohol and Steroid Injection for Treating Morton's Neuroma

Interdigital neuroma, or Morton’s Neuroma, is a painful forefoot disorder characterized by
plantar pain and paresthesias radiating to toes. The condition was first described in 1845
by Lewis Durlacher as a painful “neuralgic affection” of the plantar nerve between the third
and fourth metatarsals. T.G. Morton, in 1876, attributed the painful symptom complex to a
“neuroma.” His observation was confirmed by Hoadley who, in 1893, performed a curative
excision of a "neuroma" between the third and fourth metatarsals.

Current understanding of interdigital neuroma is based on Gauthier’s conclusion in 1979 that
the symptom complex was a result of an entrapment neuropathy of the interdigital nerve by
the overlying transverse metatarsal ligament. Presently, no definitive single etiology has
been confirmed. Additional potential pathoetiologies include the aberrant anatomy of the
plantar nerve in this location, trauma and extrinsic mass effect above or below the level of
the transverse metatarsal ligament.(3,6) The histological appearance of the affected nerve,
however, is consistent and suggests that “neuroma” is a misnomer for this condition. The
nerve tissue demonstrates demyelination and deposition of amorphous eosinophilic material,
but no exuberant proliferation of nerve endings characteristic of neuroma.(3)

Multiple treatments have been recommended for the management of interdigital neuroma. The
usual algorithm begins with an attempt at conservative therapy consisting of shoe wear
modifications and the application of a metatarsal pad. Failure of conservative management
may prompt a trial of corticosteroid injections.(8) Persistent symptoms ultimately require
surgical excision or division of the transverse metatarsal ligament, both of which have good
long term outcomes in literature.(2,7)

Recently, serial ethanol injection therapy has been reported to be an effective alternative
to surgical excision and has been widely adopted in the treatment of Morton’s neuroma.
Dockery et. al. reported 89% success rate in a series of 100 consecutive patients treated
with 3 to 7 injections of 4% ethanol solutions with an average follow-up of 13 months.
Fanucci and Masala reported a 90% success rate at 10 month follow-up after 3 to 7 injections
of 30% alcohol in a consecutive series of 40 patients. However, none of these studies were
performed in a randomized, double blinded fashion with adequate controls. Therefore, no
scientifically valid conclusions concerning treatment efficacy can be made.

The proposed study investigates alcohol sclerosing therapy for the treatment of Morton’s
neuroma in a randomized, double-blinded, placebo-controlled clinical trial. The primary end
point will be evaluation of patient physical function according to the standardized SF-36
questionnaire after the treatment period. Secondary end points include evaluation of pain
and satisfaction levels after treatment using, respectively, a standardized and a novel
questionnaire.

Inclusion Criteria:

2 months of 2 or more of the following

- Plantar pain increased by walking localized to the 2nd and 3rd interspaces

- Relief of pain by resting

- Pain radiating into toes

- Numbness in toes or foot

- Cramping in toes and foot

2 or More of the Following physical Findings

- Plantar tenderness

- Radiation of elicited pain into the toes

- Palpable plantar mass

- Numbness in toes

- Exacerbation of symptoms with Mulder’s maneuver

Exclusion Criteria:

- Past treatment for Morton’s neuroma or had prior foot surgery.

- Concurrent conditions such as hallux valgus, metatarsalgia, lesser toe abnormalities,
atraumatic synovitis of metatarsophalangeal joint and other foot and ankle based
nerve compression neuropathies.

- Further, patients with neuroma symptoms in the 1st and 4th interspaces.