• Academy of Ambulatory Foot and Ankle Surgery. Intermetatarsal neuroma. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 6 p. [15 references]

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Intermetatarsal neuroma. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 17 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

Intermetatarsal neuroma

Diagnosis
Treatment

Podiatry

Podiatrists

To provide recommendations for the diagnosis and treatment of intermetatarsal neuroma

Patients with intermetatarsal neuroma

Diagnosis

1. History, including an evaluation of the chief complaint (nature, location, duration, onset, course, anything that improves or exacerbates symptoms, and any previous treatment) and past medical history (allergies, medications, medical history, surgical history, family history, social history)
2. Physical examination, including peripheral vascular, neurological, and orthopedic exams
3. Diagnostic procedures, including radiographic examination, laboratory tests, electrodiagnostic studies, current perceptual threshold ultrasound echography, magnetic resonance imaging (MRI), computed tomography (C-T) scan, positron emission tomography (PET) scan

Treatment

1. Nonsurgical treatment, such as padding and strapping (taping), orthotics, shoe modifications, oral anti-inflammatory medications (NSAIDs), anti-inflammatory injectables (i.e., corticosteroids), injection of local injectables (i.e., peripheral nerve block), injection of sclerosing agents (i.e., Vitamin B-12, alcohol), analgesics, physical therapy
2. Surgical treatment, such as neurectomy (excisional, electrocautery, radiocautery, laser), osteotomy of adjacent metatarsal(s), tendon lengthening/tenotomy/capsulotomy, severing of the intermetatarsal ligament
3. Postoperative management, including radiographs, follow-up visits, and weight bearing/immobilization

Not stated

Searches of Electronic Databases

The guideline development process began with a thorough MEDLINE search as well as a "call for papers" from the membership of the Academy of Ambulatory Foot and Ankle Surgery at large.

Not stated

Not stated

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Drafts of the guidelines were reviewed in detail by each member of the Board of Trustees.

1. Diagnosis:
   1. History: This may include any of the following:
      1. An evaluation of the chief complaint (including the nature, location, duration, onset, course, anything that improves or exacerbates, and any previous treatment).
      2. The past medical history (including allergies, medications, medical history, surgical history, family history, and social history).
   2. Physical examination may include:
      1. Peripheral vascular
      2. Neurological (are sensorium in the area intact or altered?)
      3. Orthopedic
      1. Palpation may produce:
         1. A palpable "click" (Mulder's sign)
         2. Pain/symptoms via lateral pressure
         3. Digital splaying/juxtaposing
         4. Palpable interdigital mass
         5. Pain upon palpation (Direct to the intermetatarsal space)
      2. Associated deformities
   3. Diagnostic procedures may include:
      1. Radiographic examination: X-ray examination may be used to rule out bony pathology (differential diagnosis). X-rays may be weight bearing, partial weight bearing, or non-weight bearing.
      2. Laboratory tests: Used to rule out inflammatory disease, degenerative joint disease, systemic illness (again, differential diagnosis)
      3. Electrodiagnostic studies: Possibly useful in ruling out other pathology (i.e. tarsal tunnel syndrome), but not definitive in establishing a diagnosis of intermetatarsal neuroma.
      4. Current perceptual threshold (neurometer CPT test) may be used as indicated.
      5. Ultrasound echography
      6. Magnetic resonance imaging (MRI), computed tomography (C-T) scan, or positron emission tomography (PET) scan
   4. Differential diagnosis may include:
      1. Fracture
      2. Osteochondritis
      3. Arthritis
      4. Neoplasms (malignant/benign), (nodules i.e., rheumatoid)
      5. Capsulitis
      6. Bursitis
      7. Tendonitis
      8. Synovitis
      9. Neuritis
      10. Tarsal tunnel syndrome
      11. Peripheral neuropathy
      12. Reflex sympathetic dystrophy
      13. Vascular insufficiency
      14. Multiple neuromas may be present in the same foot
2. Nonsurgical Treatment
   1. Goals of treatment: Conservative (nonsurgical) treatment is primarily geared to relieving symptomatology. In most cases, conservative care should be utilized prior to surgery.
   2. Types of treatment:
      1. Padding and strapping (taping)
      2. Orthotics
      3. Shoe modifications
      4. Oral anti-inflammatory medications (NSAIDs)
      5. Anti-inflammatory injectables (i.e., corticosteroids)
      6. Injection of local injectables (i.e., peripheral nerve block)
      7. Injection of sclerosing agents (i.e., Vitamin B-12, alcohol)
      8. Analgesics
      9. Physical therapy
3. Surgical Treatment
   1. Goals of treatment: The goal of surgical treatment is not only to relieve the symptom(s), but to correct the underlying deformities, and to improve function as well.
   2. The primary reasons for surgical treatment are:
      1. Failure of nonsurgical treatment
      2. Impracticality of nonsurgical treatment
      3. The patient desires correction of a presenting deformity that is painful and/or causes a degree of loss of function.
      4. The patient is informed of the procedure(s) to be performed, the treatment alternatives, and the reasonable risks involved, and elects to have surgical intervention.
   3. Site of surgery: The surgical treatment of intermetatarsal neuroma may be performed in the doctor's office. The hospital or ambulatory surgical center may also be appropriate.
   4. Anesthesia: Local anesthesia is sufficient, unless there are extenuating circumstances.
   5. Hemostasis: Absence of bleeding is not required.
   6. Surgical preparation: Aseptic preparation ("usual" aseptic scrub, prep, draping, and sterile technique).
   7. Preoperative lab: Necessity based upon the patient's past medical history and current medical status.
   8. Prophylactic antibiotics: At the discretion of the surgeon (or based upon requirement: i.e., mitral valve prolapse).
   9. Pathological analysis of surgically removed tissue: recommended.
   10. Bilateral or multiple surgeries: May be performed at the same surgical session, or in different surgical sessions.
   11. Second opinion: At the option of the patient or doctor.
4. Surgical Procedures for the Treatment of Intermetatarsal Neuroma

   These may include:

   1. Neurectomy
      1. Excisional
      2. Electrocautery
      3. Radiocautery
      4. Laser
   2. Osteotomy of adjacent metatarsal(s) may be used for intermetatarsal neuroma in the event that the metatarsal is malpositioned or malformed, and that the purpose of the osteotomy is for treatment of both the neuroma and the pathological metatarsal as well.
   3. Tendon lengthening/tenotomy/capsulotomy may be used for intermetatarsal neuroma in the event that the purpose of these procedures is both for treatment of the neuroma and the soft tissue pathology.
   4. Severing of the intermetatarsal ligament.
5. Postoperative Management
   1. Radiographs: Necessary only if there is accompanying osseous and/or soft tissue surgery.
   2. Postoperative visits: In the absence of complications, the patient should initially be seen within the first week following the procedure(s). Subsequent visits are determined by the procedures performed and the postoperative course.
   3. Weight bearing/immobilization: Based upon the procedures performed and upon the individual patient, full, partial, or non-weight bearing may be utilized. A postoperative shoe may be indicated. Generally, a surgical dressing is applied in the immediate postoperative period. This is modified with time and the postoperative course. The return to a normal shoe is based upon the procedure(s) performed and the postoperative course of the individual patient. Casting is usually not necessary.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Treatment may relieve symptomatology and improve function.

Postoperative Complications

• Numbness
• Edema
• Recurrence
• Pain
• Digital or metatarsophalangeal joint instability
• Hematoma
• Stump neuroma
• Infection
• Painful and/or hypertrophic scar formation
• Reflex sympathetic dystrophy
• Vascular complications
• Gangrene
• Fibrosis (intermetatarsal)
• Tissue necrosis
• Plantar fat pad atrophy

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Academy of Ambulatory Foot and Ankle Surgery. Intermetatarsal neuroma. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 6 p. [15 references]

Not applicable: The guideline was not adapted from another source.

2000 (revised 2003 Sep)

Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Preferred Practice Guidelines Committee

The committee consisted of five (5) members who were board certified, had a minimum of ten (10) years of clinical practice experience, and a minimum of five (5) years of teaching experience.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Intermetatarsal neuroma. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 17 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

None available

None available

This summary was completed by ECRI on October 12, 2000. The information was verified by the guideline developer as of December 8, 2000. This summary was updated by ECRI on December 19, 2003. The information was verified by the guideline developer on December 29, 2003. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs).

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer.