Written by Check back here if you did not see the first part of this case earlier this week. Then, continue below!
If you guessed Morton’s Neuroma (intermetatarsal neuroma), you were right!
For a full overview of Morton’s Neuroma, you can check out more here and here.
But, the main question I want to know is how do we treat this patient! Google search led me to a non-specific treatment approach (ROM, strengthening, ultrasound, iontophoresis, stretching the heel cord, arch supports, metatarsal pads from a conservative treatment approach) and PubMed search for “Morton’s Neuroma and Physical Therapy” and “Conservative Treatment for Morton’s Neuroma” led me nowhere.
Basically, this patient was getting pain from compression of the interdigital nerve between 4th and 5th interspace (note that most individuals get it between 2nd-3rd and 3rd-4th). From an assessment standpoint, she not only had pain upon provocation to this area, but I noted ~25% less mobility in a dorsal direction of the 5th ray. I postulated that the previous 5th ray fracture (not sure what type) without adequate rehabilitation led to hypomobility and as time progressed, compensated movement patterns and eventually increased pressure between the metatarsal heads.
My Treatment:
What led to my treatment approach is that performing a dorsal glide of the 5th ray and then re-assessing the same painful location resulted in very little pain (barely noticeable)! I opted to perform this further by providing a plantar glide of the 4th ray passively, then getting the patient to splay her toes while I provided this treatment for a more active approach.
Just this mobilization reduced her symptoms while walking up to 75% after re-assessment in a weight-bearing position. I typically practice and also teach my interns the below “5 T’s to OMT care” that then led to next treatment approach.
I then taped the same area using a spiral technique shown below to facilitate this biomechanical hypothesis. Her symptoms were reduced by 90+%. (note in picture that the tape is more mid-ray than behind the metatarsal head. This was due to it improving her symptoms more after an initial trial of the tape more distally).
I also performed cold laser on this area for 5 minutes and prescribed AROM exercises for the foot (DF & EV), self-dorsal glide of 5th ray, as well as toe splaying in non-weight bearing. These were focusing on “opening up” the joint space. These to be performed several times a day. Education was to keep the tape on for another 24-36 hours as long as it is not causing any adverse effects and to avoid closed-toe shoes.
I saw this patient for a total of 3 visits (1x a week for 3 weeks) progressing her weight-bearing load with therapeutic exercise each treatment. At last treatment, she had no symptoms coming into treatment with walking and heel raises in standing. I discharged with encouragement to follow HEP for several more weeks while transitioning into more a walking/running program.
To my knowledge, this is the first case I could find through a search that implemented a specific, tailored treatment approach for this condition. She did not have to buy an insert for the foot as I feel is just a bandaid fix. I hope you learned from it as much as I did!
PT Blog, Mentoring and Consulting of Harrison Vaughan, DPT 
Good job HV, but why the cold laser? To lock in placebo effect? Anyway, I’ve had 50/50 success with similar outcomes, sometimes OMPT to the dysfunctions around the neuroma help, sometimes not. Only had this about 4 times in 14 years.
Thanks E. I just find that it works with very focal pain and I explained this to the patient, so I tried it. Did it work? Tough to say, as I already knew the other treatment worked. It didn’t hurt anything 🙂
You make a good point on 50/50 success. If I had 10 pts walk in with this same complaint, would it work? Tough to say. I don’t see it enough! Typically pts would get a cortizone shot from orthopedist first.
Great post Harrison!!
Thanks Vincent!
well done Harrison. I like the 5 T’s of OMPT! Very introspective indeed.
Thanks Jesse. I found that on a PowerPoint some time ago and really like to show it to students. Some tend to learn from a systematic approach, p,us it helps to put down on paper what goes through my head.
How did you determine that it was Mortons Neuroma?
You never said how you arrived at this diagnosis
Lorcan,
Thanks for reading and commenting! It was a combination of factors including location of pain, aggravating factors (difficulty with toe off and simple weight bearing on the local area), positive Morton’s Test (squeezing metatarsal heads together) which I actually forgot to write in initial post but did mention it in some of the comments (sorry!).
Hope this answers your question.
HV
I really like the management. The taping makes sense to me mechanically, as well as the OMT. Did you have any feeling that you may have been prematurely D/Cing her? Now that she is feeling better and will be progressing back into a walking/running program perhaps she would benefit from a session focused on video recorded running analysis to look at the mechanics of her running? That way you may be able to pick up on things higher up the chain (pelvic drop due to glut med weakness, dynamic genu valgus, etc) and give exercises to target these areas and have a more “well rounded” d/c HEP than the few exercises you listed that you gave her. Great post Harrison!
Steve,
You make good points.
Honestly, there are 2 reasons why I did DC at that last visit. 1 is that under Direct Access is Virginia, we can only see for 14 business days (so about 3 weeks) before getting an order to continue. I told her the limitations with this and that she could call or go see her MD to get a referral to continue but she felt like she was good! Honestly #2 was the biggest factor and that she had a $45 copay and her profession was a teacher. Not a good way to treat teachers! (My mom is one). So I know that was tough financially for her.
She could have definitely benefited from further treatment but just didn’t work out.
Oh and great references you sent over. I haven’t had the chance to look at them all, but I think this would be an awesome case study. Have you written one before?
Haven’t written one for a scholarly jounal before, I really want to though and I think that’s where we all need to get as EBP practitioners eventually. I have gotten into a lower tier journal for an Ergonomics type paper before and its a rewarding experience for sure.
Your welcome for the references, hopefully you get some good tid bits out of them like I did.
I am encouraged to see you have direct access for the 3 week period like you described. I work in WA state and I know we have direct access with very few insurance companies and the majority of referrals come from MDs. I also understand the high co-pays; it kills me when I see patients that I know are going to need a good plan of care have really high co-pays- it’s tough to feel like we’re a financial burden on people even though I know we’re the best profession to make a lasting difference. Hope as we move forward with health care, the nation will start to see the benefit that we have on wellness/injury prevention as well as rehab. This was an awesome case, nice work with it.