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Morton's Neuroma


Referrals for USS guided steroid injections to RCHT Clinical Imaging have restarted.  Please note there is limited capacity so referrals should be reserved for patients with significant disabling and persistent symptoms.  Please click here for full details



Covid-19 Update: Corticosteroid Injections During The Coronavirus Pandemic  

Please ensure and document that a discussion has happened that the patient is aware corticosteroid injections pose a possible and quantifiably unknown increased risk of, and complications from, Covid and the possible risk of reduced Covid vaccine efficacy prior to performing.  Secondary care referrals for steroid injection, including image guided injections, require the patient to be counselled and risk assessed prior to referral and this documented in the referral.  Please see guidance available here for detailed information. 


 

Morton’s Neuroma diagnosis can be made clinically, an USS is not required for diagnosis.

Three months of conservative measures must be tried before considering injection or USS-guided injection

 

Conservative Measures

3 Months of footwear modifications and metatarsal pads

*Improves symptoms in one third of people

Advise to avoid high heels, shoes with a constricting toe box and thin soles to reduce pressure
Use Metatarsal Pads (available to buy over the counter) Place just proximal to the metatarsal heads to reduce pressure from the nerve
NSAIDs if not contraindicated

Exclude other causes of metatarsalgia if diagnosis uncertain

  • Including biomechanical, soft tissue, fracture, arthopathy, gout, inflammatory arthritis

 

If symptoms persist despite this
Refer the person to an Orthotist/Podiatrist for a Metatarsal Dome Orthotic

 

Following Conservative Measures And Orthotics Consider A Therapeutic Steroid Injection

 

Therapeutic Steroid Injections

Generally 1/3 of patients benefit with resolution, 1/3 benefit but then symptoms return and 1/3 have no benefit.

Consider whether to delay performing or referring for any therapeutic steroid injections or referral during the Covid pandemic.  Only perform or refer if the pain is severe, all conservative measures are exhausted and the potential benefits outweigh any harm.  Counsel on the potential increased risk of Coronavirus due to increased risk of steroid induced immunosuppression and travel to/being in a healthcare setting for all steroid injections.


A blind steroid injection can be performed within Primary Care

  • If this works and pain returns a second injection can be performed after 6 months, this can be performed within Primary Care
  • If the first steroid injection fails or is unable to be performed in Primary Care refer for USS-guided injection to Radiology

If there is diagnostic uncertainty an USS for diagnosis can be requested. 

 

Please note that any requests for USS guided injection must satisfy the following requirements:

  • 3 Months of conservative measures including footwear modifications, metatarsal pads AND orthotics/podiatry documented
  • Request for therapeutic injection must be documented on the form
  • Counselling of the potential increased risk of Coronavirus due to increased risk of steroid induced immunosuppression and exposure in hospital documented
  • Patients who have had 2 prior steroid injections USS guided or otherwise will not be considered due to the risk of fat atrophy
  • If a first steroid injection is performed in Primary and is not successful, there is a 3 month minimum duration required before second attempt under USS guidance

 

Orthopaedic Referral Criteria

  • 3 Months of conservative measures including footwear modifications, metatarsal pads AND orthotics/podiatry input
  • Trial of 2 steroid injections
  • Diagnostic USS and up to date weight bearing X-ray is required

 

Red Flag

If red/hot distal foot with or without collapse which cannot be explained by gout or superficial skin infection refer to on call Orthopaedics urgently

 

References

  1. Morton’s Neuroma.  Clinical Knowledge Summaries.  National Institute Of Clinical Evidence September 2016
  2. Management Of Patients With Musculoskeletal And Rheumatic Conditions Who Are On Corticosteroids, Require Initiation Of Oral/IV Corticosteroids, Require A Corticosteroid Injection.  British Orthopaedic Association Intercollegiate Guidance.  26 June 2020

Contributors

  1. Dr Kim Farmer, Consultant Radiologist, Royal Cornwall Hospital
  2. Dr Dinuka Kurrupu, Consultant Radiologist, Royal Cornwall Hospital
  3. Mr Michael Butler, Consultant Orthopaedic Surgeon, Royal Cornwall Hospital
  4. Dr Tom Bean, Consultant Radiologist, Royal Cornwall Hospital
  5. Tariq Karim, Advanced Orthopaedic Practitioner, Royal Cornwall Hospital
  6. Dr Sheona Burns, General Practitioner, Kernow Referral Management Service
  7. Dr Rebecca Hopkins, General Practitioner, Kernow Referral Management Service


 

Date reviewed                     04/03/2022

Next review due                  04/03/2023

Sifter name                          Dr Rebecca Hopkins