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Comparative results of two different techniques in the treatment of the Morton’s neuroma
The Foot (1999) 9, 134–137 © 1999 Harcourt Publishers Ltd
ORIGINAL ARTICLE
Comparative results of two different techniques in the treatment of the Morton’s neuroma E. M. Díez, S. M. Mas, J. F. Pi, F. Aramburo Department Trauma and Orthopaedic Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain SUMMARY. We carried out a prospective study with 40 patients diagnosed of interdigital neuroma of the foot and who had undergone surgery over a 9 year period. We analysed the advantages of two surgical techniques (neurectomy and neurolysis). The results were similar in both groups. No recurrence occurred in the group where neurectomy was carried out. There were two cases of clinical recurrence in the group where neurolysis was carried out. We concluded that neurectomy was our preferred technique for its simplicity, the shorter surgical time necessary and the reduced risk of relapse. © 1999 Harcourt Publishers Ltd
Regarding associated pathology, there were 12 cases of hallux valgus, four metatarsophalangeal dislocations and one patient with rheumatoid arthritis. By means of a radiological study we analysed the metatarsal formula in all the patients. In 29 feet, the formula was index minus, in eight it was index plus minus and in seven others it was index plus. Measurement of the intermetatarsal space where the neuroma was located did not show any significant difference compared with the asymptomatic contralateral space. The study by Levitsky2 has provided an anatomo-pathological basis for Morton’s neuroma but we found no further evidence for this. Twenty-four patients received infiltrations at the rate of one per week and with an average of four (three to six infiltrations); the recurrence of pain at the clinic made us opt for surgical treatment.1–5 In seven cases, an orthosis was employed without getting any improvement. In 18.1% of the patients two spaces were involved, always the second and third intermetatarsal space. This compares with an incidence of 5% found by Jarde.6 Thompson7 suggested that the clinical association of two contiguous neuromas is very unusual and, generally, due to erroneous diagnosis. By the plantar approach we were able to detect a greater number of contiguous interdigital neuromas, agreeing with Levitsky2 who found 28% of contiguous neuromas present in the second and third spaces. The distribution of the damaged spaces was as follows: in the group of neurolysis, third space in 15 cases, second space in five cases, and second and third spaces in four cases. In the group of neurectomies, third space in 12 cases, second space in four cases, and second and third spaces in four cases. There was no
INTRODUCTION We examined cases of Morton’s neuroma that required surgery after the failure of conservative methods. We showed that the diagnosis was fundamentally clinical. We believe that tests such as ultrasound scan, MRI scan with contrast and electromyography are not sensitive enough. In this series we compared two similar groups of 20 patients, in which the only variable was the surgical technique. The method of approach in all cases was the planter one of Lelièvre.1 In the group where the neurectomy was carried out, the excised specimen was studied histologically, confirming the typical findings of this neuropathy. MATERIALS AND METHODS Our series is made up of 40 patients treated surgically over a 9 year period (1988–1997). In four cases the problem was bilateral. There was a predominance of women, as in most other series with 32 women and eight men. The average age was 48 years at the time of surgery (range 42 to 66 years). In eight feet more than one space was involved, giving a total of 52 neuromas. The average follow-up time of the patients after surgery was 36 months (18–56). Two homogeneous groups were made according to the order in which surgery was performed. For the patients with an odd case number, neurolysis was performed, and for the even numbers, neurectomy.
Correspondence to E. M. Díez, Parc Taulí, s/n 08208 Sabadell, Spain. Tel: +34 93 723 10 10; Fax: +34 93 716 06 46. 134
Treatment of Morton’s neuroma
135
Fig. 1 Distribution of damaged spaces. Fig. 3 Case with damage in the two spaces, once exoneurolysis has been carried out.
Fig. 2 Operation image of the Morton syndrome, with the dissection of the damaged interdigital nerve. The trouble was bilateral in this patient.
significant difference in the distribution of the spaces in both groups involved. The overall distribution in both groups were as follows: third space in 27 cases (61.3%), second space in nine cases (20.4%), and second and third spaces in eight cases (18.1%) (Fig. 1). An anatomo-pathological study was carried out on 24 removed neuromas of the neurectomy group; the macroscopic size of which was very large (>0.8 cm) in 10, large (0.4–0.8 cm) in seven and moderate (<0.4 cm) in the other seven cases. The histological study confirmed the typical findings of this neuropathy, i.e. an enlarged nerve with hypertrophy of the connective tissue (perineural and endoneural fibrosis), with frequent association of thrombosis and arteritis of the digital plantar artery.2,6,8
SURGICAL TECHNIQUE
Fig. 4 (A) Patient with dissection of the third space damaged. (B) Surgical piece, once neurectomy has been carried out.
In all cases we used the plantar approach of Lelièvre1 under spinal anaesthesia and a pneumatic mid-thigh tourniquet. We found that this method allowed us to examine more than one intermetatarsal space, as
well as improved proximal exposure of the interdigital nerve than the dorsal approach, as used by other authors.9,10 In this way we could carry out the
© 1999 Harcourt Publishers Ltd
The Foot (1999) 9, 134–137
136 Table 1
The Foot The distribution of results of both groups Exoneurolysis group
Excellent results Average results Bad results
13 (65%) 5 (25%) 2 (10%)
Neurectomy group 12 (60%) 7 (35%) 1 (5%)
dissection of the interdigital nerve with good access (Fig. 2). Neurolysis was performed using a microsurgical technique (Fig. 3). In the group where we carried out neurectomy. the surgical approach was the same (Figs 4A b), carrying out neurectomy and leaving the proximal stump with a suitable covering of muscular and subcutaneous adipose tissue.11–13 Another advantage of the plantar approach is that it respects the intermetatarsal ligament and prevents the possibility of residual metatarsalgias due to alteration of the biomechanics of the forefoot.11,13,14 The suture of the skin and postoperative treatment with elastic bandaging was similar in both groups.
RESULTS We assessed the clinical results as being excellent or good in patients with absence of pain, using regular shoes and in pursuit of their working life without any limitation. Average results included those patients who had shown sensory deficit or with hyperkeratotic scars, but with a high degree of postoperative satisfaction and no metatarsalgia. Poor results included those patients with residual metatarsalgia or who required an orthosis.15 The results in both groups were similar (Table 1). In six operated feet (13.5%), hyperkeratotic scars appeared, in number to that of other published series;6,10,13 however, painful scarring and the use of orthoses was required only in one case alone. Thirty-two patients used normal shoes and in eight cases orthoses were employed. We have observed that in six of these cases, the abnormal interdigital space was the second one with results being poorer than in patients with a neuroma in the third space. Although statistically significant, conclusions cannot be drawn due to the size of the sample; similar results have already been commented on by other authors.16 Nine patients in the neurectomy group presented with anaesthesia of the toes, which with time disappeared due to the reinervation of the area by the dorsal nerve branches. We compared the time of surgery in both groups, with an average time in the neurolysis group of 48 min, compared with 23 min for the neurectomy group. Two patients of the neurolysis group required reoperation due to recurrent neuralgia that did not respond to conservative treatment. In the neurectomy group, no case required further surgery. The Foot (1999) 9, 134–137
DISCUSSION The typical presentation of Morton’s metatarsalgia is that of with acute pain localized to the forefoot radiating to the toes corresponding to the damaged space.4,17–19 Only in half of the cases did we observe the transverse compression test of the forefoot described by Mulder.19 We did not routinely carry out complementary tests such as MRI scans like other authors, as we had found such tests unreliable.20,21 This contrasts with good results reported by Sartoris22 for MRI and Pollack for ultrasound.23 By the dorsal approach, exposure of the interdigital nerve is difficult and the possibility of proximal dissection of the nerve is more limited than in the plantar approach. The plantar approach, in our opinion, permits better visualization and the possibility of a more proximal neurectomy than by the dorsal approach. In previous series using the dorsal method, the number of amputation neuromas was higher.5,7,11,13,14 In addition, the plantar approach allows more than one intermetatarsal space to be explored and avoids the sectioning of the intermetatarsal ligament, thus having a lesser effect on the biomechanics of the forefoot. In our series of 20 neurectomies we have had no relapses, unlike the series in which the dorsal approach was used, which varies between 5–15%.6,11,12,13
CONCLUSION We consider that the longer surgical time in carrying out exoneurolysis, the training the surgeon requires, the cost of microsurgical material and, most of all, the possibility of relapse24 leads us to the conclusion that neurectomy is the most suitable technique for treating Morton’s neuroma. REFERENCES 1. Lelievre J, Lelievre JF. Pathologie du pied. Masson Edit. Paris 1981; 557–560. 2. Levitsky KA, Alman BA, Jevsevar DS, Morehead J. Digital nerves of foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot & Ankle 1993; 14: 208–214. 3. Bennett GL, Graham CE, Maudiln DM, Morton’s interdigital neuroma: A comprehensive treatment protocol. Foot & Ankle 1995; 16: 760–763. 4. Gaynor R, Hake D, Spinner SM, Tomczak RL, A comparative analysis of conservative versus surgical treatment of Morton’s neuroma (see comments). J Am Podiatr Med Assoc 1989; 79: 27–30. 5. Mann RA, Reynolds JC. Interdigital neuroma: a critical clinical analysis. Foot & Ankle 1983; 3: 238–243. 6. Jarde O, Trinquier JL, Pleyber A, Vives P. Treatment of Morton’s neuroma by neurectomy. A review of 43 cases. Revue de Chirurgie Orthopédique 1995; 81: 142–146. 7. Thompson FM, Deland JT. Ocurrence of two interdigital neuromas in one foot. Foot & Ankle 1993; 14: 15–17. 8. Pazzaglia UE, Moalli S, Leutner M, Gera R. Morton’s neuroma: an immunohistochemical study. The Foot 1996; 6: 63–65. © 1999 Harcourt Publishers Ltd
Treatment of Morton’s neuroma 9. Dielbold PF, Delagoutte JP. True neurolysis in the treatment of Morton’s neuroma Acta Orthop Belg 1989; 55: 467–471. 10. Gauthier G. Thomas Morton’s diseae: a nerve entrapment syndrom. A new surgical technique. Clin Orthop 1979; 142: 90–92. 11. Beskin JL, Baxter DE. Recurrent pain following interdigital neurectomy: a plantar approach. Foot & Ankle 1988; 9: 34–39. 12. Dellon AL. Treatment of recurrent metatarsalgia by neuroma resection and muscle implantation: Case report and proposed algorithm of management for Morton’s ‘neuroma’. Microsurgery 1989; 10: 256–259. 13. Johnson JE, Johnson KA, Unni KK. Persistent pain after excision of an interdigital neuroma: Results of reoperation. J Bone Joint Surg (Am) 1988; 70: 651–657. 14. Gudas CJ, Mattana GM. Retrospective analysis of intermetatarsal neuroma excision with preservation of the transverse metatarsal ligament. J Foot Surg 1986; 25: 459–463. 15. Schroven I, Geutjens G. Results of excision of the interdigital nerve in the treatment of Morton’s Metatarsalgia. The Foot 1995; 5: 196–198. 16. Barrios RH, Clara JA, Amillo S. Results of excision of the interdigital nerve in the treatment of Morton’s Metatarsalgia. Rev de Med y Cir del Pie 1995; 9: 15–20.
© 1999 Harcourt Publishers Ltd
137
17. Betts LO. Morton’s Metatarsalgia: neuritis of the fourth digital nerve. Med J Australia 1940; 1: 514–515. 18. Mc Elvenny R. The etiology and surgical treatment of intractable pain about the fourth metatarsophalangeal joint (Morton’s Toe). J Bone Joint Surg 1943; 25: 675–679. 19. Mulder JD. The causative mechanism in morton’s metatarsalgia. J Bone and Joint Surg 1951; 30-B: 94–95. 20. Terk MR, Kwong PK, Suthar M, Horvath BC, Colletti PM. Morton’s neuroma: evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 1993; 189: 239–241. 21. Theodoresco B, Lalandre G. Magnetic resonance and Morton’s neuroma. Rev Chir Orthop Reparatrice Appar Mot 1991; 77: 273–275. 22. Sartoris DJ, Brozinsky S, Resnick D. Magnetic Resonance Images. J Foot Surg 1989; 28: 78–82. 23. Pollak RA, Bellacosta RA, Dornbluth NC. Sonographic analysis of Morton’s neuroma. J Foot Surg 1992; 31: 534–537. 24. Nemoto K, Mikasa M, Tazaki KI. Neurolysis as surgical procedure for Morton’s neuroma. J Jpn Orthop Ass 1989; 63: 470–474.
The Foot (1999) 9, 134–137
ORIGINAL ARTICLE
Comparative results of two different techniques in the treatment of the Morton’s neuroma E. M. Díez, S. M. Mas, J. F. Pi, F. Aramburo Department Trauma and Orthopaedic Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain SUMMARY. We carried out a prospective study with 40 patients diagnosed of interdigital neuroma of the foot and who had undergone surgery over a 9 year period. We analysed the advantages of two surgical techniques (neurectomy and neurolysis). The results were similar in both groups. No recurrence occurred in the group where neurectomy was carried out. There were two cases of clinical recurrence in the group where neurolysis was carried out. We concluded that neurectomy was our preferred technique for its simplicity, the shorter surgical time necessary and the reduced risk of relapse. © 1999 Harcourt Publishers Ltd
Regarding associated pathology, there were 12 cases of hallux valgus, four metatarsophalangeal dislocations and one patient with rheumatoid arthritis. By means of a radiological study we analysed the metatarsal formula in all the patients. In 29 feet, the formula was index minus, in eight it was index plus minus and in seven others it was index plus. Measurement of the intermetatarsal space where the neuroma was located did not show any significant difference compared with the asymptomatic contralateral space. The study by Levitsky2 has provided an anatomo-pathological basis for Morton’s neuroma but we found no further evidence for this. Twenty-four patients received infiltrations at the rate of one per week and with an average of four (three to six infiltrations); the recurrence of pain at the clinic made us opt for surgical treatment.1–5 In seven cases, an orthosis was employed without getting any improvement. In 18.1% of the patients two spaces were involved, always the second and third intermetatarsal space. This compares with an incidence of 5% found by Jarde.6 Thompson7 suggested that the clinical association of two contiguous neuromas is very unusual and, generally, due to erroneous diagnosis. By the plantar approach we were able to detect a greater number of contiguous interdigital neuromas, agreeing with Levitsky2 who found 28% of contiguous neuromas present in the second and third spaces. The distribution of the damaged spaces was as follows: in the group of neurolysis, third space in 15 cases, second space in five cases, and second and third spaces in four cases. In the group of neurectomies, third space in 12 cases, second space in four cases, and second and third spaces in four cases. There was no
INTRODUCTION We examined cases of Morton’s neuroma that required surgery after the failure of conservative methods. We showed that the diagnosis was fundamentally clinical. We believe that tests such as ultrasound scan, MRI scan with contrast and electromyography are not sensitive enough. In this series we compared two similar groups of 20 patients, in which the only variable was the surgical technique. The method of approach in all cases was the planter one of Lelièvre.1 In the group where the neurectomy was carried out, the excised specimen was studied histologically, confirming the typical findings of this neuropathy. MATERIALS AND METHODS Our series is made up of 40 patients treated surgically over a 9 year period (1988–1997). In four cases the problem was bilateral. There was a predominance of women, as in most other series with 32 women and eight men. The average age was 48 years at the time of surgery (range 42 to 66 years). In eight feet more than one space was involved, giving a total of 52 neuromas. The average follow-up time of the patients after surgery was 36 months (18–56). Two homogeneous groups were made according to the order in which surgery was performed. For the patients with an odd case number, neurolysis was performed, and for the even numbers, neurectomy.
Correspondence to E. M. Díez, Parc Taulí, s/n 08208 Sabadell, Spain. Tel: +34 93 723 10 10; Fax: +34 93 716 06 46. 134
Treatment of Morton’s neuroma
135
Fig. 1 Distribution of damaged spaces. Fig. 3 Case with damage in the two spaces, once exoneurolysis has been carried out.
Fig. 2 Operation image of the Morton syndrome, with the dissection of the damaged interdigital nerve. The trouble was bilateral in this patient.
significant difference in the distribution of the spaces in both groups involved. The overall distribution in both groups were as follows: third space in 27 cases (61.3%), second space in nine cases (20.4%), and second and third spaces in eight cases (18.1%) (Fig. 1). An anatomo-pathological study was carried out on 24 removed neuromas of the neurectomy group; the macroscopic size of which was very large (>0.8 cm) in 10, large (0.4–0.8 cm) in seven and moderate (<0.4 cm) in the other seven cases. The histological study confirmed the typical findings of this neuropathy, i.e. an enlarged nerve with hypertrophy of the connective tissue (perineural and endoneural fibrosis), with frequent association of thrombosis and arteritis of the digital plantar artery.2,6,8
SURGICAL TECHNIQUE
Fig. 4 (A) Patient with dissection of the third space damaged. (B) Surgical piece, once neurectomy has been carried out.
In all cases we used the plantar approach of Lelièvre1 under spinal anaesthesia and a pneumatic mid-thigh tourniquet. We found that this method allowed us to examine more than one intermetatarsal space, as
well as improved proximal exposure of the interdigital nerve than the dorsal approach, as used by other authors.9,10 In this way we could carry out the
© 1999 Harcourt Publishers Ltd
The Foot (1999) 9, 134–137
136 Table 1
The Foot The distribution of results of both groups Exoneurolysis group
Excellent results Average results Bad results
13 (65%) 5 (25%) 2 (10%)
Neurectomy group 12 (60%) 7 (35%) 1 (5%)
dissection of the interdigital nerve with good access (Fig. 2). Neurolysis was performed using a microsurgical technique (Fig. 3). In the group where we carried out neurectomy. the surgical approach was the same (Figs 4A b), carrying out neurectomy and leaving the proximal stump with a suitable covering of muscular and subcutaneous adipose tissue.11–13 Another advantage of the plantar approach is that it respects the intermetatarsal ligament and prevents the possibility of residual metatarsalgias due to alteration of the biomechanics of the forefoot.11,13,14 The suture of the skin and postoperative treatment with elastic bandaging was similar in both groups.
RESULTS We assessed the clinical results as being excellent or good in patients with absence of pain, using regular shoes and in pursuit of their working life without any limitation. Average results included those patients who had shown sensory deficit or with hyperkeratotic scars, but with a high degree of postoperative satisfaction and no metatarsalgia. Poor results included those patients with residual metatarsalgia or who required an orthosis.15 The results in both groups were similar (Table 1). In six operated feet (13.5%), hyperkeratotic scars appeared, in number to that of other published series;6,10,13 however, painful scarring and the use of orthoses was required only in one case alone. Thirty-two patients used normal shoes and in eight cases orthoses were employed. We have observed that in six of these cases, the abnormal interdigital space was the second one with results being poorer than in patients with a neuroma in the third space. Although statistically significant, conclusions cannot be drawn due to the size of the sample; similar results have already been commented on by other authors.16 Nine patients in the neurectomy group presented with anaesthesia of the toes, which with time disappeared due to the reinervation of the area by the dorsal nerve branches. We compared the time of surgery in both groups, with an average time in the neurolysis group of 48 min, compared with 23 min for the neurectomy group. Two patients of the neurolysis group required reoperation due to recurrent neuralgia that did not respond to conservative treatment. In the neurectomy group, no case required further surgery. The Foot (1999) 9, 134–137
DISCUSSION The typical presentation of Morton’s metatarsalgia is that of with acute pain localized to the forefoot radiating to the toes corresponding to the damaged space.4,17–19 Only in half of the cases did we observe the transverse compression test of the forefoot described by Mulder.19 We did not routinely carry out complementary tests such as MRI scans like other authors, as we had found such tests unreliable.20,21 This contrasts with good results reported by Sartoris22 for MRI and Pollack for ultrasound.23 By the dorsal approach, exposure of the interdigital nerve is difficult and the possibility of proximal dissection of the nerve is more limited than in the plantar approach. The plantar approach, in our opinion, permits better visualization and the possibility of a more proximal neurectomy than by the dorsal approach. In previous series using the dorsal method, the number of amputation neuromas was higher.5,7,11,13,14 In addition, the plantar approach allows more than one intermetatarsal space to be explored and avoids the sectioning of the intermetatarsal ligament, thus having a lesser effect on the biomechanics of the forefoot. In our series of 20 neurectomies we have had no relapses, unlike the series in which the dorsal approach was used, which varies between 5–15%.6,11,12,13
CONCLUSION We consider that the longer surgical time in carrying out exoneurolysis, the training the surgeon requires, the cost of microsurgical material and, most of all, the possibility of relapse24 leads us to the conclusion that neurectomy is the most suitable technique for treating Morton’s neuroma. REFERENCES 1. Lelievre J, Lelievre JF. Pathologie du pied. Masson Edit. Paris 1981; 557–560. 2. Levitsky KA, Alman BA, Jevsevar DS, Morehead J. Digital nerves of foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot & Ankle 1993; 14: 208–214. 3. Bennett GL, Graham CE, Maudiln DM, Morton’s interdigital neuroma: A comprehensive treatment protocol. Foot & Ankle 1995; 16: 760–763. 4. Gaynor R, Hake D, Spinner SM, Tomczak RL, A comparative analysis of conservative versus surgical treatment of Morton’s neuroma (see comments). J Am Podiatr Med Assoc 1989; 79: 27–30. 5. Mann RA, Reynolds JC. Interdigital neuroma: a critical clinical analysis. Foot & Ankle 1983; 3: 238–243. 6. Jarde O, Trinquier JL, Pleyber A, Vives P. Treatment of Morton’s neuroma by neurectomy. A review of 43 cases. Revue de Chirurgie Orthopédique 1995; 81: 142–146. 7. Thompson FM, Deland JT. Ocurrence of two interdigital neuromas in one foot. Foot & Ankle 1993; 14: 15–17. 8. Pazzaglia UE, Moalli S, Leutner M, Gera R. Morton’s neuroma: an immunohistochemical study. The Foot 1996; 6: 63–65. © 1999 Harcourt Publishers Ltd
Treatment of Morton’s neuroma 9. Dielbold PF, Delagoutte JP. True neurolysis in the treatment of Morton’s neuroma Acta Orthop Belg 1989; 55: 467–471. 10. Gauthier G. Thomas Morton’s diseae: a nerve entrapment syndrom. A new surgical technique. Clin Orthop 1979; 142: 90–92. 11. Beskin JL, Baxter DE. Recurrent pain following interdigital neurectomy: a plantar approach. Foot & Ankle 1988; 9: 34–39. 12. Dellon AL. Treatment of recurrent metatarsalgia by neuroma resection and muscle implantation: Case report and proposed algorithm of management for Morton’s ‘neuroma’. Microsurgery 1989; 10: 256–259. 13. Johnson JE, Johnson KA, Unni KK. Persistent pain after excision of an interdigital neuroma: Results of reoperation. J Bone Joint Surg (Am) 1988; 70: 651–657. 14. Gudas CJ, Mattana GM. Retrospective analysis of intermetatarsal neuroma excision with preservation of the transverse metatarsal ligament. J Foot Surg 1986; 25: 459–463. 15. Schroven I, Geutjens G. Results of excision of the interdigital nerve in the treatment of Morton’s Metatarsalgia. The Foot 1995; 5: 196–198. 16. Barrios RH, Clara JA, Amillo S. Results of excision of the interdigital nerve in the treatment of Morton’s Metatarsalgia. Rev de Med y Cir del Pie 1995; 9: 15–20.
© 1999 Harcourt Publishers Ltd
137
17. Betts LO. Morton’s Metatarsalgia: neuritis of the fourth digital nerve. Med J Australia 1940; 1: 514–515. 18. Mc Elvenny R. The etiology and surgical treatment of intractable pain about the fourth metatarsophalangeal joint (Morton’s Toe). J Bone Joint Surg 1943; 25: 675–679. 19. Mulder JD. The causative mechanism in morton’s metatarsalgia. J Bone and Joint Surg 1951; 30-B: 94–95. 20. Terk MR, Kwong PK, Suthar M, Horvath BC, Colletti PM. Morton’s neuroma: evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 1993; 189: 239–241. 21. Theodoresco B, Lalandre G. Magnetic resonance and Morton’s neuroma. Rev Chir Orthop Reparatrice Appar Mot 1991; 77: 273–275. 22. Sartoris DJ, Brozinsky S, Resnick D. Magnetic Resonance Images. J Foot Surg 1989; 28: 78–82. 23. Pollak RA, Bellacosta RA, Dornbluth NC. Sonographic analysis of Morton’s neuroma. J Foot Surg 1992; 31: 534–537. 24. Nemoto K, Mikasa M, Tazaki KI. Neurolysis as surgical procedure for Morton’s neuroma. J Jpn Orthop Ass 1989; 63: 470–474.
The Foot (1999) 9, 134–137