Bibliographic Source(s)

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

Guideline Status

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).

Guideline Category

Diagnosis
Treatment

Intended Users

Podiatrists

Guideline Objective(s)

To provide recommendations for the diagnosis and treatment of intermetatarsal neuroma

Target Population

Patients with intermetatarsal neuroma

Interventions and Practices Considered

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

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

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.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not applicable

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

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

Major Recommendations

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.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

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

Potential Benefits

Treatment may relieve symptomatology and improve function.

Potential Harms

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

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

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

Adaptation

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

Source(s) of Funding

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Guideline Committee

Preferred Practice Guidelines Committee

Composition of Group that Authored the Guideline

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.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

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).

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available from the Academy of Ambulatory Foot and Ankle Surgery (AAFAS) (formerly the Academy of Ambulatory Foot Surgery) 1601 Walnut Street Suite 1005 Philadelphia PA 19102; Web site www.academy-afs.org.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

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).

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