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metatarsal heads and metatarsophalangeal joints during
walking. MN is a form of metatarsalgia, and it has been
hypothesized to result from repeated loading of the metatarsal heads.22 On the basis of the aforementioned theories, the
increased pressure in the forefoot and under the metatarsal
heads may traumatize the common digital nerve, leading to
fibrosis and pathologic changes.
MN is often managed conservatively with the use of
metatarsal pads,17,19,27 which are thought to lead to pain
reduction by decreasing pressure on the nerve by widening
of the forefoot.27 Recently, Bauer et al6 and Catani et al10
advocated percutaneous metatarsal osteotomy to decompress the affected nerve as an operative treatment for MN.
They theorized that symptoms of MN can be managed by
addressing the "hyperpressure" of the affected metatarsal
head. However, they did not investigate plantar pressure
measurements before and after performing metatarsal osteotomy to confirm a change in pressure. Surprisingly, no
case-control studies reported in the literature have investigated forefoot pressure in individuals with MN compared
with an asymptomatic control group.
Other factors such as "wideness" or "splay foot" have
been suggested as contributing to the etiology of MN.15,24,40
The normal contour of the forefoot and the presence of the
transverse arch across the metatarsals is an important mechanism by which shock absorption within the forefoot can
occur during gait.15,23,38 Pathologic conditions, such as
"splay foot," "anterior flat foot," and "collapsed metatarsal
arch," may increase the pressure in the forefoot and cause
metatarsalgia.38 Additionally, "splay foot" may also produce
compressive forces of the forefoot when wearing shoes,
leading to irritation of the affected nerve. On the contrary,
narrowness of the forefoot, which can lead to closer proximity of the metatarsal heads impinging on the nerve, has been
mentioned as an etiology of MN.34 Park et al34 did not find
any significant differences in forefoot width, intermetatarsal
angle, and metatarsal distance between radiographs of subjects with MN (n = 84) and age- and sex-matched control
subjects (n = 84). However, their study was based on weightbearing radiographs that mimic midstance and not during
propulsion, when the forefoot is dynamically under greatest
stress. Although forefoot width is often cited as a contributing cause of MN, no studies in the literature have examined
this factor dynamically.
Dynamic barefoot pressure data can be collected using
the EMED-X capacitance transducer matrix platform
(Novel, Munich, Germany), which has been shown to be a
reliable tool for measuring plantar forefoot pressures and
foot geometry.2,16 The purpose of this research was to first
test the hypothesis that forefoot peak pressure, contact time,
and/or pressure-time integrals would be greater under the
affected metatarsal heads in patients diagnosed with MN
compared with control subjects. We also investigated if there
were any significant differences in geometric measurements,
Foot & Ankle International 39(7)
Table 1. Demographic Description of Patients With Morton's
Neuroma and Control Subjects.a
Variable
Age, y
Weight, kg
Height, m
Body mass index, kg/m2
Sex (female:male)
Feet studied
Foot (right:left)
Patients With
Morton's
Neuroma
(n = 52)
Control
Subjects
(n = 31)
52 ± 14
76 ± 19
1.67 ± 0.07
27 ± 6
39:13
61
30:31
49 ± 10
71 ± 16
1.64 ± 0.10
26 ± 4
19:12
62
31:31
P
.28
.22
.22
.31
a
Data are expressed as mean ± SD or as numbers.
such as forefoot width, foot length, coefficient of spreading,
foot progression angle, and arch index, in patients diagnosed
with MN compared with control subjects.
Methods
Approval was obtained from the University of Western
Australia human research ethics committee for this study
(approval RA/4/1/2543). Eighty-three participants consisting of 52 subjects with MN and 31 control subjects were
recruited from the University of Western Australia Podiatry
Clinic from 2012 to 2014. Control subjects consisted of 12
men and 19 women, and the MN group consisted of 13 men
and 39 women, who were all from the University of Western
Australia staff. The demographic information of the participants is provided in Table 1. Patients with MN and control
subjects were recruited using a university circular e-mail
advertisement. All subjects were given a patient information sheet, and written consent was obtained to participate
in the study. Inclusion criteria for subjects with MN were a
minimum 6-month history of neuroma symptoms and a
clinically demonstrated painful Mulder's click with ultrasound confirmation of MN. All subjects with MN were
treated conservatively prior to the study and were pain free
on the data collection day. Ultrasound diagnosis of MN was
made by an experienced musculoskeletal radiologist and
assessed on both transverse and longitudinal axes as an
abnormal ovoid hypoechoic thickening corresponding to
the location of maximum tenderness.11 Each subject with
MN was clinically examined by the corresponding author
as well as an experienced musculoskeletal radiologist to
rule out any other source of pain such as capsulitis and
lesser metatarsophalangeal joint instability such as plantar
plate pathology. The inclusion criterion for control subjects
was a negative history of MN or neuroma-like pain in the
forefoot. Exclusion criteria for both neuroma and control
groups were any history of surgery to the lower extremity;
Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
Foot & Ankle International - July 2018 - ix
Foot & Ankle International - July 2018 - x
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Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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