Top

Published in:

Open Access 01-07-2013 | Original Research Article

Treatment of Morton Neuroma with Botulinum Toxin A: A Pilot Study

Authors: José M. Climent, Francisco Mondéjar-Gómez, Carmen Rodríguez-Ruiz, Ismael Díaz-Llopis, Diego Gómez-Gallego, Patricia Martín-Medina

Published in: Clinical Drug Investigation | Issue 7/2013

Abstract

Background and Objective

Morton neuroma is a common cause of metatarsalgia of neuropathic origin. Systematic reviews suggest that insufficient studies have been performed on the efficacy of the different treatments available. OnabotulinumtoxinA has shown a degree of usefulness in other conditions associated with neuropathic pain. The aim of this study was to investigate the therapeutic potential of onabotulinumtoxinA in Morton neuroma.

Patients and Methods

We present an open-label, pilot study with 17 consecutive patients with Morton neuroma and pain of more than 3 months’ duration that had not responded to conservative treatment with physical measures or corticosteroid injection. Patients received one onabotulinumtoxinA injection in the area of the neuroma. The main outcome measure was the variation in the pain on walking evaluated using a visual analogue scale (VAS) before treatment and at 1 and 3 months after treatment. The secondary outcome was the change in foot function, which was assessed using the Foot Health Status Questionnaire.

Results

In the overall group, the mean initial VAS score on walking was 7. This mean score had fallen to 4.8 at 1 month after treatment and to 3.7 at 3 months. Twelve patients (70.6 %) reported an improvement in their pain and five patients (29.4 %) reported no change; exacerbation of the pain did not occur in any patient. Improvements were also observed in two of the dimensions of the Foot Health Status Questionnaire: foot pain, which improved from a mean of 38.88 before treatment to 57 at 3 months, and foot function, which improved from a mean of 42.27 before treatment to 59.9 at 3 months. Clinical variables including age, sex, site and size of the lesion, standing activity, weekly duration of walking, footwear, foot type and footprint had no influence on the outcome. No adverse effects were reported.

Conclusions

In this pilot study, injection with onabotulinumtoxinA was shown to be of possible usefulness to relieve the pain and improve function in Morton neuroma. This finding opens the door to further clinical research.

Hassouna H, Singh D. Morton’s metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005;71(6):646–55.PubMed

Bennett GL, Graham CE, Mauldin DM. Morton’s interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int. 1995;16:760–3.PubMedCrossRef

Sofka CM, Adler RS, Ciavarra GA, et al. Ultrasound-guided interdigital neuroma injections: short-term clinical outcomes after a single percutaneous injection: preliminary results. HSS J. 2007;3(1):44–9.PubMedCrossRef

Zanetti M, Weishaupt D. MR imaging of the forefoot: Morton neuroma and differential diagnoses. Semin Musculoskelet Radiol. 2005;9(3):175–86.PubMedCrossRef

Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton’s neuroma. Cochrane Database Syst Rev. 2004;(3):CD003118.

Greenfield J, Rea J Jr, et al. Morton’s interdigital neuroma. Indications for treatment by local surgery. Clin Orthop Relat Res. 1984;185:142–4.PubMed

Morton TG. The classic. A peculiar and painful affection of the fourth metatarso-phalangeal articulation. Thomas G. Morton, M.D. Clin Orthop Relat Res. 1979;142:4–9.

Pasero G, Marson P. Filippo Civinini (1805–1844) and the discovery of plantar neuroma [in Italian]. Reumatismo. 2006;58(4):319–22.PubMed

Lee MJ, Kim S, Huh YM, et al. Morton neuroma: evaluated with ultrasonography and MR imaging. Korean J Radiol. 2007;8(2):148–55.

10.

Saygi B, Yildirim Y, Saygi EK, et al. Morton’s neuroma: comparative results of two conservative methods. Foot Ankle Int. 2005;26:556–9.PubMed

11.

Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg. 1999;38:403–8.PubMedCrossRef

12.

Singh SK, Ioli JP, Chiodo CP. The surgical treatment of Morton’s neuroma. Curr Orthop. 2005;19:379–84.CrossRef

13.

Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve. 1997;Suppl 6:146–68.

14.

Costa J, Espírito-Santo C, Borges A, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev. 2004;(4):CD004315.

15.

Jabbari B, Machado D. Treatment of refractory pain with botulinum toxins: an evidence-based review. Pain Med. 2011;12(11):1594–606.PubMedCrossRef

16.

Lipton RB, Varon SF, Grosberg B, et al. Onabotulinum toxin A improves quality of life and reduces impact of chronic migraine. Neurology. 2011;77(15):1465–72.PubMedCrossRef

17.

Díaz-Llopis IV, Rodriguez-Ruiz CM, Mulet-Perry S, et al. Randomized controlled study of the efficacy of the injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six months. Clin Rehabil. 2012;26(7):594–606.PubMedCrossRef

18.

Argoff C. The emerging use of botulinum toxins for the treatment of neuropathic pain. Pain Med. 2010;11(12):1750–2.PubMedCrossRef

19.

Ranoux D. Botulinum toxin and peripheral neuropathies: what should be expected? Rev Neurol (Paris). 2011;167(1):46–50.

20.

Dworkin RH, O’Connor AB, Audette J. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. 2010;85(3 Suppl):S3–14.PubMedCrossRef

21.

Sim WS. Application of botulinum toxin in pain management. Korean J Pain. 2011;24(1):1–6.PubMedCrossRef

22.

Ruiz-Huete C, Bermejo PE. Toxina botulínica tipo A en el tratamiento del dolor neuropático en un caso de neuralgia postherpética. Neurología. 2008;23(4):259–62.PubMed

23.

Tsai CP, Liu CY, Lin KP, et al. Efficacy of botulinum toxin type A in the relief of Carpal tunnel syndrome: a preliminary experience. Clin Drug Investig. 2006;26(9):511–5.PubMedCrossRef

24.

Vanelderen P, Lataster A, Levy R, et al. Occipital neuralgia. Pain Pract. 2010;10(2):137–44.

25.

Yuan RY, Sheu JJ, Yu JM, et al. Botulinum toxin for diabetic neuropathic pain: a randomized double-blind crossover trial. Neurology. 2009;72(17):1473–8.PubMedCrossRef

26.

Ngeow WC, Nair R. Injection of botulinum toxin type A (Botox) into trigger zone of trigeminal neuralgia as a means to control pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):e47–50.PubMedCrossRef

27.

Piovesan EJ, Teive HG, Kowacs PA, et al. An open study of botulinum-A toxin treatment of trigeminal neuralgia. Neurology. 2005;65:1306–8.PubMedCrossRef

28.

Aoki KR. Review of a proposed mechanism for the antinociceptive action of botulinum toxin type A. Neurotoxicology. 2005;26(5):785–93.PubMedCrossRef

29.

Sirera-Vercher MJ, Sáez-Zamora P, Sanz-Amaro MD. Traducción y adaptación transcultural al castellano y al valenciano del Foot Health Status Questionnaire. Rev Esp Cir Ortop Traumatol. 2010;54(4):211–9.

30.

Bennett PJ, Patterson C, Wearing S, et al. Development and validation of a questionnaire designed to measure foot-health status. J Am Podiatr Med Assoc. 1998;88:419–28.PubMed

31.

Hassouna H, Singh D, Taylor H, et al. Ultrasound guided steroid injection in the treatment of interdigital neuralgia. Acta Orthop Belg. 2007;73(2):224–9.PubMed

32.

Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton’s neuroma. Foot Ankle Int. 2008;29(5):483–7.PubMedCrossRef

33.

Mozena JD, Clifford JT. Efficacy of chemical neurolysis for the treatment of interdigital nerve compression of the foot: a retrospective study. J Am Podiatr Med Assoc. 2007;97(3):203–6.

34.

Magnan B, Marangon A, Frigo A, et al. Local phenol injection in the treatment of interdigital neuritis of the foot (Morton’s neuroma). Chir Organi Mov. 2005;90(4):371–7.

35.

Fanucci E, Masala S, Fabiano S, et al. Treatment of intermetatarsal Morton’s neuroma with alcohol injection under US guide: 10-month follow-up. Eur Radiol. 2004;14(3):514–8.PubMedCrossRef

36.

Hughes RJ, Ali K, Jones H, et al. Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007;188(6):1535–9.CrossRef

37.

Wu H, Sultana R, Taylor KB, et al. A prospective randomized double-blinded pilot study to examine the effect of botulinum toxin type A injection versus Lidocaine/Depomedrol injection on residual and phantom limb pain: initial report. Clin J Pain. 2012;28(2):108–12.PubMedCrossRef

38.

Aoki KR, Francis J. Updates on the antinociceptive mechanism hypothesis of botulinum toxin A. Parkinsonism Relat Disord. 2011;17(Suppl 1):28–33.CrossRef

39.

Acquadro MA, Borodic GE. Treatment of myofascial pain with botulinum A toxin [letter]. Anesthesiology. 1994;80:705–6.PubMedCrossRef

40.

Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994;59:65–9.PubMedCrossRef

41.

Kuan T-S, Chen J-T, Chen S-M, Chien C-H, Hong C-Z. Effect of botulinum toxin on endplate noise in myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil. 2002;81:512–20.PubMedCrossRef

42.

Gobel H, Heinze A, Reichel G, Hefter H, Benecke R. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blinded placebo-controlled multicentre study. Pain. 2006;125(1–2):82–8.PubMedCrossRef

43.

Wheeler AH, Goolkasian P, Gretz SS. A randomized, double-blind, prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome. Spine. 1998;23:1662–7.PubMedCrossRef

44.

Yue SK. Initial experience in the use of botulinum toxin A for the treatment of myofascial related muscle dysfunctions. J Musculoskelet Pain. 1995;3(Suppl 1):22.

45.

Kapural L, Stillman M, Kapural M, et al. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series. Pain Pract. 2007;7(4):337–40.PubMedCrossRef

46.

Tilton AH. Injectable neuromuscular blockade in the treatment of spasticity and movement disorders. J Child Neurol. 2003;18(Suppl 1):S50–66.PubMed

47.

Compérat E, Reitz A, Delcourt A, Capron F, Denys P, Chartier-Kastler E. Histologic features in the urinary bladder wall affected from neurogenic overactivity: a comparison of inflammation, oedema and fibrosis with and without injection of botulinum toxin type A. Eur Urol. 2006;50(5):1058–64.PubMedCrossRef

Title: Treatment of Morton Neuroma with Botulinum Toxin A: A Pilot Study
Authors: José M. Climent
Francisco Mondéjar-Gómez
Carmen Rodríguez-Ruiz
Ismael Díaz-Llopis
Diego Gómez-Gallego
Patricia Martín-Medina
Publication date: 01-07-2013
Publisher: Springer International Publishing AG
Published in: Clinical Drug Investigation / Issue 7/2013
Print ISSN: 1173-2563
Electronic ISSN: 1179-1918
DOI: https://doi.org/10.1007/s40261-013-0090-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Treatment of Morton Neuroma with Botulinum Toxin A: A Pilot Study

Abstract

Background and Objective

Patients and Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background and Objective

Patients and Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 7/2013

The Effect of Moderate Hepatic Impairment on the Pharmacokinetics of Ipragliflozin, a Novel Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitor

Current Topics in Opioid Therapy for Pain Management: Addressing the Problem of Abuse

Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of Single and Repeat Inhaled Doses of Umeclidinium in Healthy Subjects: Two Randomized Studies

A Comparison of the Steady-State Pharmacokinetic and Pharmacodynamic Profiles of 100 and 200 U/mL Formulations of Ultra-Long-Acting Insulin Degludec

Dose-Dependent Effect of Landiolol, a New Ultra-Short-Acting β1-Blocker, on Supraventricular Tachyarrhythmias in Postoperative Patients

Twenty-Four-Hour Ambulatory Blood Pressure Reduction with a Perindopril/Amlodipine Fixed-Dose Combination