Foot posture in people with medial compartment knee osteoarthritis
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Levinger et al. Journal of Foot and Ankle Research 2010, 3:29
http://www.jfootankleres.com/content/3/1/29
JOURNAL OF FOOT
AND ANKLE RESEARCH
RESEARCH Open Access
Foot posture in people with medial compartment
knee osteoarthritis
Pazit Levinger1*, Hylton B Menz1, Mohammad R Fotoohabadi1, Julian A Feller1, John R Bartlett2, Neil R Bergman2
Abstract
Background: Foot posture has long been considered to contribute to the development of lower limb
musculoskeletal conditions as it may alter the mechanical alignment and dynamic function of the lower limb. This
study compared foot posture in people with and without medial compartment knee osteoarthritis (OA) using a
range of clinical foot measures. The reliability of the foot measures was also assessed.
Methods: The foot posture of 32 patients with clinically and radiographically-confirmed OA predominantly in the
medial compartment of the knee and 28 asymptomatic age-matched healthy controls was investigated using the
foot posture index (FPI), vertical navicular height and drop, and the arch index. Independent t tests and effect size
(Cohen’s d) were used to investigate the differences between the groups in the foot posture measurements.
Results: Significant differences were found between the control and the knee OA groups in relation to the FPI
(1.35 ± 1.43 vs. 2.46 ± 2.18, p = 0.02; d = 0.61, medium effect size), navicular drop (0.02 ± 0.01 vs. 0.03 ± 0.01, p =
0.01; d = 1.02, large effect size) and the arch index (0.22 ± 0.04 vs. 0.26 ± 0.04, p = 0.04; d = 1.02, large effect size).
No significant difference was found for vertical navicular height (0.24 ± 0.03 vs. 0.23 ± 0.03, p = 0.54; d = 0.04,
negligible effect size).
Conclusion: People with medial compartment knee OA exhibit a more pronated foot type compared to controls.
It is therefore recommended that the assessment of patients with knee OA in clinical practice should include
simple foot measures, and that the potential influence of foot structure and function on the efficacy of foot
orthoses in the management of medial compartment knee OA be further investigated.
Background and footwear, have been proposed to minimise the knee
Knee osteoarthritis (OA) is a common painful and adduction moment, and consequently reduce the load-
chronic condition that affects a large proportion of the ing on the medial compartment [10-18].
older population [1,2]. Knee OA may in part be due to Foot posture has long been considered to contribute
excessive loading of the articular cartilage [3]. During to the development of a range of lower limb musculos-
walking, the forces transmitted across the knee joint are keletal conditions [19,20] as it may alter the mechanical
greater in the medial compartment compared to the lat- alignment and dynamic function of the lower limb [21].
eral compartment [4], and increased medial compart- Special attention, therefore, has been given to foot
ment loading has been observed in patients with knee orthoses and footwear modifications as a non-operative
OA [5-8]. The mechanics of gait, in particular the knee treatment of knee OA [13,15,18,22,23]. However, in
adduction moment (the moment that tends to adduct order to fully understand the effect of these interven-
the knee during the stance phase of walking), have been tions on the knee and other lower limb joints and to
shown to be a contributing factor to the progression of identify patients who are most likely to benefit from
medial compartment knee OA [5-7,9]. Treatment strate- them, greater knowledge of foot structure in this popu-
gies for knee OA, such us foot orthoses, knee braces lation is required.
Despite the potential importance of understanding
* Correspondence: p.levinger@latrobe.edu.au foot characteristics of people with medial compartment
1
Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe knee OA, few studies have examined foot posture in
University. Bundoora, Victoria 3086, Australia
Full list of author information is available at the end of the article this population. Reilly et al [24] compared navicular
© 2010 Levinger et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Levinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 2 of 8
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height in sitting and standing in 60 people with hip OA, newspapers. The control group consisted of 28 asympto-
60 people with knee OA and 60 controls, and found no matic participants with no clinical diagnosis of OA,
differences between the knee OA and control groups. rheumatoid arthritis or history of knee trauma or pain.
However, there was a significant difference in frontal Participants from the control group were recruited from
plane calcaneal angle, indicating a more everted rearfoot retirement villages in northern Melbourne and through
in the knee OA group. In a subsequent study, these advertisements in local newspapers. Ethics approval was
authors also compared foot posture index (FPI) scores obtained from the Faculty of Health Sciences Human
between 20 people with knee OA and 20 controls, and Ethics Committee, La Trobe University. All participants
reported a significantly higher median score in those were informed about the nature of the study and signed
with knee OA (7.0 versus 1.0), indicative of a more pro- a consent form prior to participation.
nated foot posture [25].
A key consideration when interpreting these findings Procedure
is the reliability of the foot posture measures. Previous All participants attended the gait laboratory at La Trobe
studies have indicated that frontal plane calcaneal mea- University for a single session, and 23 participants from
sures have questionable reliability [26], while FPI relia- the control group attended on two occasions to assess
bility is moderate to good, depending on the clinical the reliability of the foot measurements. All foot mea-
experience of the assessor [27]. Given the questionable surements were assessed by the same examiner (PL)
reliability reported for some of the foot measures and with previous experience in taking these measures [27].
the expertise required to take these measures [26-30], Participants’ body mass, height and truncated foot
using an objective measure that does not require any length were recorded. The symptomatic leg (or the most
subjective interpretation may be important to include as symptomatic leg in a case of bilateral involvement) in
part of foot posture assessment. However, evaluation of the OA group and the same corresponding leg of each
such a measure in people with knee OA has not pre- peer control matched for age were assessed.
viously been investigated. The primary aim of this study
therefore was to investigate foot type in people with and Foot posture measurements
without medial compartment knee OA using a range of The foot posture measurements included the foot pos-
clinical foot measures, including a measure (the arch ture index (FPI), navicular height, navicular drop and
index) that requires no clinical expertise or subjective the arch index. The FPI is a 6-item foot posture assess-
interpretation. A secondary aim was to determine the ment with the subject standing relaxed in a bipedal
reliability of the foot posture measurements. position [29]. The 6 items of the FPI include talar head
palpation, curves above and below the lateral malleoli,
Methods calcaneal angle, talonavicular bulge, medial longitudinal
Two groups participated in the study: a knee OA group arch and forefoot to rearfoot alignment. Each item was
and an age-matched asymptomatic control group. The scored on a 5-point scale between -2 and +2 and pro-
OA group included 32 participants diagnosed with pre- vides a total sum of all items between -12 (highly supi-
dominantly medial compartment OA, determined by nated) and +12 (highly pronated). The raw FPI scores
radiographic assessment. The severity of knee OA was were converted to Rash transformed scores to allow the
based on the loss of joint space determined by an ortho- scores to be used as interval data [32]. The transformed
paedic surgeon from radiographic images [31] and was FPI values were used for the analysis.
graded as follows: 1- less than a half of joint space loss Navicular height and navicular drop measurements
(mild), 2 - more than a half of joint space loss; bone on were taken in subtalar joint neutral (STJN) position and
bone (moderate) and 3 - bone deformity/loss of bone in relaxed standing posture using a business card as
(severe). Each compartment of the knee joint (medial described previously [33] and with the aid of a right-
compartment, lateral compartment and patellofemoral angled metal bracket for stabilising the card [27]. STJN
compartment) was graded and participants with predo- was defined as the position of the foot when the talar
minantly medial compartment OA (severity grade 2-3) head could be palpated just anterior to the ankle mor-
were included in the study. Participants from the OA tise with equal prominence both medially and laterally.
group were included if they were able to walk indepen- The position of the subtalar joint in neutral was main-
dently and were excluded if they had uncontrolled sys- tained and the vertical height of the navicular was
temic disease and or a pre-existing neurological or other marked on the business card. The participants were
orthopaedic condition that affected their walking. Parti- then asked to relax and the vertical height of the navicu-
cipants from the OA group were recruited from the La lar was marked on the card. Navicular drop was mea-
Trobe University Medical Centre, the Warringal Private sured as the difference between the STJN and relaxed
Medical Centre and through advertisements in local stance of the navicular height (see Figure 1). BothLevinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 3 of 8
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Figure 1 Navicular height and drop measurement.
measures were normalised to each participant’s trun- effect, ≥ 1.10 to 1.45 -
cated foot length. Truncated foot length was measured huge effect [38]. To explore the potential correlation
from the most posterior aspect of the calcaneus to the between body weight and the foot posture measures,
first metatarsophalangeal joint. Truncated foot length Pearson’s correlation coefficient was used. Where signif-
was used for normalisation due to the potential presence icant correlations were found, bodyweight was used as a
of toe deformity in older people which can affect the covariate for that particular foot posture measure.
foot length value [34].
The arch index was measured with the participant Results
standing on a carbon paper imprint material in relaxed The demographic characteristics of both groups are
bipedal stance. A static footprint was obtained and was summarised in Table 1. The participants’ age and height
divided to three equal sections. The arch index was then were similar between the groups, although the knee OA
calculated as the ratio of the middle section to the entire group had a significantly greater body weight and body
footprint area using a computer graphics tablet (Wacom mass index. The ICCs for the foot measures ranged
Technology Corporation, Vancouver, Canada). Higher from moderate to excellent. Navicular height and drop
values of the arch index indicate a flatter (more pro- showed ICC = 0.86 and ICC = 0.56, respectively, with
nated) foot [35]. See Figure 2. FPI and arch index having ICC = 0.91 and ICC = 0.93,
respectively. Similarly, low coefficients of variation were
Statistical analysis found for the FPI, navicular height and arch index
All analyses were performed using SPSS 17.0 for Win- (Table 2).
dows (SPSS Inc., Chicago IL, USA). The intra-rater A significant correlation was found between body
reliability of the foot posture measurements was evalu- weight and the arch index (r = 0.44, p < 0.001) with no
ated using intraclass correlation coefficients (ICCs3,1), significant correlation between body weight and FPI (r =
95% limits of agreement and coefficient of variation 0.22, p = 0.09), navicular height (r = 0.008, p = 0.94) or
[36]. ICCs above 0.90 were considered excellent, 0.75 - navicular drop (r = 0.20, p = 0.12). Body weight was
0.90 considered good, 0.50 - 0.75 considered moderate therefore entered as a covariate for the comparison of
and ICC below 0.50 considered poor [37]. Differences the arch index between the groups.
between the groups were assessed using independent Significant differences were found between the groups
samples t-tests for continuously scored variables and for three foot measures, with the knee OA group exhibit-
chi-squared statistics for categorical variables. The mag- ing a more pronated foot compared to the control group
nitude of the differences in continuously-scored vari- for the FPI (2.46 ± 2.18 vs 1.35 ± 1.43.; p = 0.02; d = 0.61,
ables between the groups was assessed using Cohen’s d, medium effect size), navicular drop (0.03 ± 0.01 vs 0.02 ±
with the following cut-offs applied to aid interpretation: 0.01; p = 0.01; d = 1.02, large effect size) and arch indexLevinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 4 of 8
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A
L B
C
Figure 2 Calculation of the AI. The truncated length of the footprint (L) is divided into equal thirds. The AI is then calculated as the area of
the middle third of the footprint divided by the entire footprint area (AI = B/[A + B + C]).
was found between the groups for navicular height (Table of people with medial compartment OA may therefore
3). advance our understanding of the potential role of foot
orthoses and footwear modifications on lower limb
Discussion alignment and function.
Foot posture has long been considered to influence the In this study, we investigated foot characteristics of
mechanical alignment and dynamic function of the people with medial compartment knee OA using several
lower limb and may therefore be related to the develop- foot measures. The OA group exhibited a more pro-
ment of lower limb musculoskeletal conditions. Subse- nated foot type compared to the control group, as indi-
quently, several recent studies have drawn attention to cated by the three foot measures: FPI, navicular drop
the potential benefits of foot orthoses in reducing the and arch index, with medium to large effect sizes. Simi-
load on the knee, particularly the knee adduction lar findings were reported by Reilly and colleagues for
moment [13,15,18,22,23]. Assessing foot characteristics people with severe knee medial compartment OA using
Table 1 Participants’ demographic characteristics
Parameters Control group (n = 28) Knee OA group (n = 32) p value
Age - yr 65.22 ± 11.41 65.84 ± 7.57 0.810
Female - n (%) 15 (54) 16 (46) 0.210
Height - cm 168.61 ± 10.64 168.83 ± 9.54 0.932
Body weight - kg 73.12 ± 15.49 85.13 ± 13.67 0.003*
Body mass index - kg/m2 25.56 ± 3.95 29.97 ± 5.26 0.001*
Values are reported as mean ± SD unless otherwise noted.* significant at p < 0.05.Levinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 5 of 8
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Table 2 Reliability of the foot posture measurements.
Measures Session 1 mean ± SD Session 2 mean ± SD ICC3,1 (95% CI) 95% LoA CV (%)
Foot posture index† 1.33 ± 1.47 1.46 ± 1.33 0.91 (0.82 to 0.96) 1.44 to -1.88 24
Navicular height 0.24 ± 0.03 0.23 ± 0.03 0.86 (0.71 to 0.94) 0.04 to -0.03 6
Navicular drop 0.01 ± 0.01 0.01 ± 0.01 0.56 (0.20 to 0.79) 0.02 to -0.02 38
Arch index 0.21 ± 0.04 0.21 ± 0.04 0.93 (0.84 to 0.97) 0.03 to -0.03 5
NB: ICC - intraclass correlation coefficient; LoA - 95% limit of agreement; CV - coefficient of variation. † Rasch transformed FPI scores
several foot measures, including the FPI [24,25]. How- the foot during gait [42]. Increased foot pronation could
ever, we found no significant difference in navicular potentially reduce the adduction moment by shifting the
height between the groups, which is also in agreement centre of pressure laterally, so it is possible that the foot
with Reilly and colleagues [24]. adapts to reduce the load on the medial compartment.
Whether pronated foot posture is a risk factor for, or a However, the degree of genu varum that can be compen-
consequence of, medial compartment knee OA cannot sated by foot pronation depends on the available range of
be determined from cross-sectional studies such as ours. motion of the ankle, subtalar and midtarsal joints [43].
People with medial compartment knee OA often display Due to the potential effect of foot alignment on the load-
genu varum malalignment of the knee, which has been ing axis of the lower limb, a longitudinal investigation is
shown to increase the risk of development and progres- required to better understand the contribution of foot
sion of knee OA [39,40]. Genu varum malalignment of structure and function to the development of medial
the knee may lead to compensatory foot pronation to compartment knee OA.
enable the foot to be plantigrade when weightbearing The findings reported here may have implications for
[41]. In a recent study, a simulated genu varum walking orthotic and footwear interventions that are commonly
pattern was found to increase the subtalar joint pronation suggested for the management of knee OA. In particu-
moment, suggesting that frontal plane angular deformi- lar, laterally wedged insoles have been proposed for peo-
ties of the knee can alter the kinetic and kinematics of ple with medial compartment knee OA, as they have
Foot Posture Index
arch index
navicular drop
vertical navicular height
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
effect size (95%CI)
Figure 3 Effect sizes and 95% confidence intervals for the difference in foot posture variables between the control and knee OA
groups. Positive values indicate larger scores in the knee OA group, negative values indicate larger scores in the control group.Levinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 6 of 8
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Table 3 Differences in foot posture measurements between the groups.
Measure Control (n = 28) Knee OA (n = 32) p value Effect size (Cohen’s d)
Foot posture index† 1.35 ± 1.43 2.46 ± 2.18 0.022* d = 0.61 (medium)
Navicular height 0.24 ± 0.03 0.23 ± 0.03 0.542 d = 0.04 (negligible)
Navicular drop 0.02 ± 0.01 0.03 ± 0.01 0.019* d = 1.02 (large)
Arch index 0.22 ± 0.04 0.26 ± 0.04 0.040* d = 1.02 (large)
Values are reported as mean ± SD.* significant at p < 0.05. † Rasch transformed FPI scores
been shown to reduce the knee adduction moment and The arch index is a reliable tool that quantifies foot
reduce symptoms [12,13,18,22,23]. However, laterally characteristics based on a static footprint, and as such
wedged insoles can alter foot motion, specifically does not rely on the clinical experience of the examiner.
increasing rearfoot pronation [44,45]. Accentuation of The arch index however, has not been assessed pre-
rearfoot pronation in already pronated feet could poten- viously in people with knee OA. Our results indicate
tially result in detrimental changes to lower limb kine- that the arch index demonstrates excellent reliability,
matics, and consequently lead to the development of and can detect differences in foot posture between peo-
musculoskeletal problems in other regions. Interestingly, ple with and without medial compartment knee OA.
studies have shown that the biomechanical effects of lat- Importantly, the differences between the groups per-
erally wedged insoles are inconsistent, with some parti- sisted after adjusting for bodyweight, which addresses
cipants exhibiting increases in the knee adduction previous concerns that the arch index may be a measure
moment [46,47]. Furthermore, Nakajima et al [14] have of ‘fat’ rather than ‘flat’ feet [51]. These findings suggest
recently reported that the addition of an arch support to that the arch index may have some clinical utility in the
laterally wedged insoles maintains normal rearfoot assessment of patients with knee OA.
motion while also enhancing the ability of the insole to
reduce the knee adduction moment. These findings Conclusion
indicate that the biomechanical effects of laterally People with medial compartment knee OA exhibit a
wedged insoles may be influenced by individual varia- more pronated foot type compared to controls, as indi-
tion in foot function. As such, there may be a need to cated by the FPI, navicular drop and arch index. It is
include foot posture screening to appropriately identify therefore recommended that the assessment of patients
those who are most likely to benefit from laterally with knee OA in clinical practice should include simple
wedged insoles, in order to guide the selection of modi- foot posture measures, and that the potential influence
fications such as the addition of arch supports. of foot structure and function on the efficacy of foot
The reliability of foot measures has been widely orthoses in the management of medial compartment
reported in a range of populations [26-30]. In the pre- knee OA be further investigated.
sent study, good to excellent intrarater reliability was
found for the navicular height, arch index and FPI Acknowledgements
which was comparable to previous studies assessing This study was funded by the Clive and Vera Ramaciotti Foundation and the
Arthritis Foundation of Australia. HBM is currently a National Health and
intrarater reliability [27,48,49] where the examiners had
Medical Research Council fellow (Clinical Career Development Award, ID:
experience in taking foot measures. In contrast, the 433049). We would like to thank Marg Perrott for her assistance in data
reliability of navicular height was only moderate, which collection.
was similar to the reliability reported by Evans et al for
Author details
an adult population [49]. Measuring navicular drop 1
Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe
involves placing the subtalar joint in neutral which University. Bundoora, Victoria 3086, Australia. 2Warringal Medical Centre,
Heidelberg, Victoria 3084, Australia.
requires clinical experience in order to achieve an
acceptable level of reliability. However, the examiner in Authors’ contributions
our study had previous experience in taking foot mea- PL: designed and managed the study, collected and analysed the data
drafted the manuscript. HBM: participated in the study design and assisted
sures with good intrarater and interrater reliability, as
in the statistical analysis and data interpretation, helped to draft the
we have previously reported in a younger population manuscript. RF: assisted in data collection, data analysis. JF, JB and NB have
[27]. We therefore believe that the moderate reliability assisted in patient recruitment, grading x-ray severity and drafting the
manuscript. PL, HBM and JF obtained the funding. All authors have read and
may be related to the age of our sample. Placing the
approved the final version.
subtalar joint in neutral during standing may be less
reliable in older people as it requires active involvement Competing interests
HBM is Editor-in-Chief of the Journal of Foot and Ankle Research. It is journal
of the participant [50] which can be challenging due to
policy that editors are removed from the peer review and editorial decision
difficulty in maintaining balance. making processes for papers they have co-authored.Levinger et al. Journal of Foot and Ankle Research 2010, 3:29 Page 7 of 8
http://www.jfootankleres.com/content/3/1/29
Received: 13 August 2010 Accepted: 16 December 2010 23. Rodrigues PT, Ferreira AF, Pereira RM, Bonfa E, Borba EF, Fuller R:
Published: 16 December 2010 Effectiveness of medial-wedge insole treatment for valgus knee
osteoarthritis. Arthritis Rheum 2008, 59:603-608.
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www.biomedcentral.com/submitOriginal Article Clinics in Orthopedic Surgery 2021;13:266-277 • https://doi.org/10.4055/cios20256
Corticosteroid Injection for Morton’s Interdigital
Neuroma: A Systematic Review
Jun Young Choi, MD, Hyun Il Lee, MD, Woi Hyun Hong, PhD*, Jin Soo Suh, MD, Jae Won Hur, MD
Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang,
*Medical Research Information Center, College of Medicine, Chungbuk National University, Cheongju, Korea
Background: This review aimed to evaluate the effects of corticosteroid injections on Morton’s neuroma using an algorithmic ap-
proach to assess the methodological quality of reported studies using a structured critical framework.
Methods: Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corti-
costeroid injections in patients diagnosed with Morton’s neuroma. Data search, extraction, analysis, and quality assessments were
performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and clini-
cal outcomes were evaluated using various outcome measures.
Results: With 3–12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfac-
tion scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after
injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections
due to persistent pain.
Conclusions: Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton’s interdigital neuroma
although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research
includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures.
Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.
Keywords: Morton’s neuroma, Morton’s metatarsalgia, Steroid, Injection, Long term adverse effect
Morton’s interdigital neuroma was first described by Mor- accompanied by a demonstrable painful click known as
ton in 1876 as local pain under the fourth metatarsal head. “Mulder’s click.” Imaging studies, including magnetic reso-
It is a benign fibrous enlargement of the tissue surround- nance imaging and ultrasound, can be useful for confirm-
ing a common plantar digital nerve, most frequently in ing the diagnosis or for atypical cases.
the second and third web spaces. Diagnosis is determined Several treatment options have been introduced
based on the clinical symptoms with severe intermittent from activity modification and orthosis application to
forefoot sole pain, which is aggravated by increased physi- open neurectomy. Before the operative treatment, radio-
cal activity or constrictive footwear. Paresthesia on the frequency ablation, extracorporeal shockwave therapy,
affected toe can be also shown. Axial compression may be cryoablation, laser therapy, or supination/pronation ortho-
sis can be considered. A local injection therapy involves
the use of corticosteroid, alcohol,1-3) phenol,4) botulinum
Received October 17, 2020; Revised December 2, 2020;
Accepted December 2, 2020 toxin,5) and capsaicin.6) Among these, corticosteroid injec-
Correspondence to: Woi Hyun Hong, PhD tion has been used most frequently as a safe and effective
Medical Research Information Center, College of Medicine, Chungbuk conservative treatment modality for patients with Morton’s
National University, 1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea neuroma.
Tel: +82-43-249-1866, Fax: +82-43-266-6775 We designed this systematic review to focus on
E-mail: hong.medric@gmail.com corticosteroid injection therapy for Morton’s neuroma to
Copyright © 2021 by The Korean Orthopaedic Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinics in Orthopedic Surgery • pISSN 2005-291X eISSN 2005-4408267
Choi et al. Steroid Injection for Morton’s Neuroma
Clinics in Orthopedic Surgery • Vol. 13, No. 2, 2021 • www.ecios.org
help readers obtain a more comprehensive understanding operative procedures, (2) studies including patients with
of this therapy. This study aimed to evaluate the positive congenital deformities, intraoperative measures, or non-
and negative effects of corticosteroid injection on Morton’s clinical outcomes, and (3) studies that did not report the
neuroma using an algorithmic approach and a structured effects of corticosteroid injections, including editorial
critical framework for assessment of the methodologi- comments, conference abstracts, or in vitro and animal
cal quality of reported studies. We addressed the current studies.
debates with the following research questions: (1) How
long does the effect of corticosteroid injection persist? (2) Data Collection and Analysis
Can we define what kind of corticosteroid is the most ap- Two investigators (JYC and HIL) independently assessed
propriate for Morton’s neuroma (short/intermediate/long the titles or abstracts of studies identified via the query
acting)? (3) Are there any differences in dorsal, plantar, and then assessed the full papers. Final inclusion was de-
or web-space approaches? (4) Are multiple injections at termined through discussion and consensus. The eligible
the same site safe and effective? (5) What is the eventual data were independently abstracted into predefined for-
transition rate to surgery after corticosteroid injection? (6) mats and checked for accuracy by the investigators. We
Which types of complications are seen after corticosteroid also collected information on the study characteristics:
injection for Morton’s neuroma? information about the authors, journal, country, publica-
tion year, sample size, subject age and sex, injected drug,
number of injections, ultrasound guidance, direction of
METHODS approach (dorsal, plantar, or web space), outcome param-
Study Selection eters, and follow-up period.
To identify relevant studies, we used the controlled vocab- The following changes related to the effects of ste-
ulary and free texts provided in Supplementary Material roid injection were extracted from the studies: (1) estab-
1 in an exhaustive search method to query Medline, Em- lished objective outcome parameters, including visual ana-
base, the Cochrane Central Register of Controlled Trials, log scale (VAS), American Orthopaedic Foot and Ankle
Web of Science, and Scopus databases. This study is based Society (AOFAS) score, EuroQol-5 dimension-3 levels
on the Cochrane Review Methods, and reporting was (EQ-5D-3L) utility index, foot health thermometer (FHT),
carried out according to the Preferred Reporting Items Manchester Oxford Foot Questionnaire (MOxFQ), Man-
for Systematic Reviews and Meta-Analyses (PRISMA) chester Foot Pain and Disability Score (MFPDS), multi-
(Supplementary Material 2). We attempted to identify all dimensional affect and pain survey (MAPS), Mann scale,
relevant studies in English language, recording the publi- and Johnson satisfaction scale; (2) any other unestablished
cation type (article, poster, conference article, instructional measurements to determine pain reduction or functional
course lecture, etc.), publication journal, and publication improvement; (3) eventual transition rate to operative
date. This search was updated in April 2020 and includes treatment; and (4) complications related to steroid injec-
reference lists of included studies and any review articles tion.
that were identified. Studies designed as meta-analyses/ Studies that reported at least one of the primary
systematic reviews, clinical randomized controlled trials objective parameters related to pain, function, or patients’
(RCTs), non-randomized controlled trials (NRCTs), and satisfaction were also searched. Secondary outcomes in-
controlled before-after studies (CBAs) that determined cluded complications and eventual transition to operative
the effect of corticosteroid injection for Morton’s neuroma treatment. These studies were chosen because of their as-
were searched. sociation with the effects of corticosteroid injections and
because a pilot search of the literature identified these as
Eligibility Criteria the most frequently reported and best-studied areas in
Studies were included based on the following criteria: (1) Morton’s neuroma treatment. We did not perform a meta-
the subjects were patients who were diagnosed with Mor- analysis due to the heterogeneity of the included studies
ton’s neuroma and treated with corticosteroid injections and low statistical power since fewer than four studies
and (2) the studies compared clinical outcomes for steroid were included in each field of research. Parameters to as-
treatments with conservative management with various sess the outcome, timing of assessment after injection,
injection approaches and assessment of positive and nega- injected agent, number with interval of injection, and ap-
tive effects. Studies were excluded based on the following proach varied widely by study.
criteria: (1) studies that included patients who underwent268
Choi et al. Steroid Injection for Morton’s Neuroma
Clinics in Orthopedic Surgery • Vol. 13, No. 2, 2021 • www.ecios.org
Assessment of Methodological Quality tified by searching four databases and manually searching
Two quality assessment (QA) tools based on the study de- relevant bibliographies as follows: 6,775 studies from
signs were used to verify the quality of each retrieved ar- Medline, 293 from Embase, 4,054 from Cochrane Library,
ticle. Three reviewers (JYC, HIL, and JWH) independently 47 from Web of Science, and 7 by manual searching. We
assessed the methodological qualities of each study using excluded 143 duplicate studies, plus an additional 10,981
the following QA tools: (1) A measurement tool to assess of the remaining 11,033 studies that did not satisfy the
systematic reviews (AMSTAR 27)), (2) the Cochrane Col- selection criteria. We reviewed the full texts of the remain-
laboration’s Risk of Bias (ROB) for RCT studies,8) and (3) ing 52 studies, which resulted in further 35 studies being
the ROB Assessment Tool for Nonrandomized Studies for excluded based on the selection criteria. The reasons for
NRCTs and CBAs.9) To ensure high quality of the reviewed exclusion of these 35 studies were no outcome data (n =
articles, the QA tools chosen differed depending on the 5), insufficient information provided (n = 2), no control
study design. group (n = 25), too short follow-up period (n = 1), ca-
Three assessors (JYC, HIL, and JWH) rated each daveric study (n = 1), and glucocorticoid receptor agonist
study, reaching consensus by majority in the instance of injection (n = 1). After reviewing the full texts, 17 studies
dispute. Scoring system was as follows: 2 = yes; 1 = cannot were finally included in this study.11-27)
determine, not applicable, or not reported; and 0 = no. A
level of evidence (LOE) was graded as high (75%–100%), Study Characteristics
moderate (50%–75%), low (25%–50%), and very low As four studies20,21,26,27) were systematic reviews among
(0%–25%). Any discrepancies were addressed by joint re- 17 included studies, a total of 845 participants were in-
evaluation of the original article by the fourth author (JSS). cluded in the thirteen studies. Five studies12,16,17,23,25) with
376 participants were RCTs. Eight studies,11,13-15,18,19,22,24)
including two NRCTs18,24) and six CBAs,11,13-15,19,22) had 469
RESULTS participants with Morton’s neuroma. The characteristics
Identification of Studies of the studies, their participants, and follow-up durations
Fig. 1 shows a flow diagram of study selection as recom- are shown in Table 1. The detailed results of the QA of the
mended by PRISMA.10) In total, 11,176 studies were iden- four included systematic reviews are presented in Table 2.
11,169 Records identified by database search 7 Additional records identified
Identification
through other sources
6,775 Medline
293 Embase
4,054 Cochrane Library
47 Web of Science
Screening
11,176 Records screened for duplication
143 Records removed
due to duplication
11,033 Records screened by title and abstract
10,981 Records excluded based
Eligibility
on review of title and abstract
Full-text articles of 52 records assessed for eligibility
35 Full-text articles excluded
for reason
15 Narrative review
6 Commentary
4 Case report
5 No outcome study
2 Insufficient information
1 Cadaveric study
1 Too short follow-up period
1 Glucocorticoid receptor
agonist injection Fig. 1. A flow diagram of study selection
as recommended by the Preferred Re
Included
17 Records included in quantitative synthesis porting Items for Systematic Reviews and
Meta-Analyses.269
Choi et al. Steroid Injection for Morton’s Neuroma
Clinics in Orthopedic Surgery • Vol. 13, No. 2, 2021 • www.ecios.org
Table 1. Study Characteristics of 13 Studies Analyzed in This Review
Study Sex Follow-up
Study/country No. of participants Age (yr)
design (male : female) duration
Ruiz Santiago et al. (2019)23)/Spain RCT 56 (I, 29; C, 27) 54.1 ± 2.7 (I) Not reported 6 mo
50.3 ± 1.6 (C)
Lizano-Diez et al. (2017)16)/Spain RCT 35 (I ,16; C, 19) 57.7 ± 9.8 (I) 4 : 12 (I) 6 mo
60.7 ± 11.6 (C) 2 : 17 (C)
Mahadevan et al. (2016)17)/UK RCT 45 (I, 23; C, 22) 57.1 ± 11.7 (I) Not reported 12 mo
58.6 ± 14.3 (C)
Edwards et al. (2015)12)/UK RCT 109 (I, 54; C, 55) 54.3 ± 12.2 (I) 10 : 44 (I) 3 mo
52.6 ± 12.3 (C) 9 : 46 (C)
Thomson et al. (2013)25)/Scotland RCT 131 (I, 64; C, 67) 53 20 : 111 12 mo
18)
Makki et al. (2012) /UK NRCT 39; G1: 17 (neuroma diameter ≤ 5 mm), 30 ± 7.5 (G1) 7 : 10 (G1) 12 mo
G2: 22 (neuroma diameter > 5 mm) 33 ± 8.4 (G2) 8 : 14 (G2)
Saygi et al. (2005)24)/UK NRCT 69; G1: 35 (custom fitted shoe insert), 51.97 ± 11.8 (G1) 4 : 31 (G1) 12 mo
G2: 34 (steroid injection) 51.88 ± 10.97 (G2) 5 : 29 (G2)
Grice et al. (2017)14)/UK CBA 67 Not reported Not reported ≥ 2 yr
19)
Markovic et al. (2008) /Australia CBA 35 54 (29–77) 7 : 28 9 mo
15)
Hassouna et al. (2007) /UK CBA 39 55.8 ± 13.4 7 : 32 11.4 mo
22)
Rasmussen et al. (1996) /USA CBA 43 (51 feet) 53 (24–77) 14 : 29 4 yr (2–6)
Bennett et al. (1995)11)/USA CBA 115 48 (17–79) 16 : 99 3 mo
13)
Greenfield et al. (1984) /USA CBA 62 58 (19–83) Female, 78% 3.8 yr
Values are presented as mean ± standard deviation or mean (range).
RCT: randomized controlled trial, I: intervention, C: control, NRCT: non-randomized controlled trial, G1: group 1, G2: group 2, CBA: controlled before-after study.
A recent systematic review20) showed high LOE scoring 27 Diversity of Outcome Parameters
out of 32, while the other three showed low scores (13/32,21) Numerous parameters were used to assess the effect of ste-
12/3226) and 11/3227)). Supplementary Material 3 shows the roid injection for Morton’s neuroma (VAS, AOFAS score,
ROB graph for RCTs (Supplementary Material 3A and B) EQ-5D-3L utility index, FHT, MOxFQ, MFPDS, MAPS,
and NRCTs and CBAs (Supplementary Material 3C and Mann scale, and Johnson satisfaction scale). Table 3 shows
D). Among RCTs, three studies16,17,25) showed a high LOE the parameters used in each study. Among them, Johnson
while the other two were moderate12) and very low.23) Of satisfaction scale11,15-19,22) and VAS16-18,23,25) were the two
two NRCTs, one study18) showed moderate LOE, while the most commonly used parameters.
other24) showed very low. Only two15,19) of six CBA studies The Johnson satisfaction scale, which contains four
showed moderate LOE, while another two showed low subjective categories—completely satisfied, satisfied with
LOE14,22) and the other two showed very low LOE.11,13) minor reservations, satisfied with major reservations, and
dissatisfied—can be easy to investigate but hard to quan-
Diversity of Outcome Measurement Timing tify, while VAS is one of the most objective quantification
Fig. 2 shows the timing of parameter measurement per- methods. The summary of Johnson satisfaction scores in
formed in all included studies. As the locally injected concerned studies is introduced in Table 4. With 3 to 12
steroid is known to show the effect within a month and months of follow-up, steroid injection seemed to provide
persist for 3 to 6 months, our principle for minimal follow- satisfactory outcomes except in studies.15,22) However,
up should be at least 3 months. Although the timing of out- VAS (Fig. 3) showed the maximal pain reduction had ap-
come measurement greatly varied by authors, all included peared within 1 week to 3 months.16-18,23) Afterwards, VAS
articles were fitted to this minimal follow-up cutoff (Table 1). increased again by 6 months. After 6 months, 2 studies
reported that VAS decreased again by 12 months.17,25) A270
Choi et al. Steroid Injection for Morton’s Neuroma
Clinics in Orthopedic Surgery • Vol. 13, No. 2, 2021 • www.ecios.org
summary of detailed means with standard deviations is
Q16
Yes
Yes
Yes
Yes
presented in Supplementary Material 4. We sent an e-
mail to two corresponding authors17,22) to request missing
No meta-analysis
No meta-analysis
No meta-analysis
conducted means and standard deviations and we received a response
conducted
conducted
from one author.17)
Q15
The AOFAS score,16,18) the EQ-5D-3L utility in-
Yes
12,25)
dex, FHT,12,25) and MFPDS23,25) were used in only two
studies each, so we decided not to summarize these results
Q14
Yes
Yes
Yes
No
in this systematic review.
Q13
Yes
No
No
No
Choice of Optimal Steroid Injection
Three kinds of steroid were used in the literature (Table
No meta-analysis
No meta-analysis
No meta-analysis
3): methylprednisolone,12,14,18,24,25) triamcinolone,11,15,16,17,23)
conducted
conducted
conducted
Table 2. Result of Quality Assessment of Included Systematic Reviews with a Measurement Tool to Assess Systematic Reviews (AMSTAR 2)
and betamethasone.19,22) Multiple drugs were used in one
Q12
study.13) Methylprednisolone and triamcinolone are in-
Yes
termediate acting agents with a half-life of 12–46 hours.
Betamethasone is a long acting agent with a longer half-
No meta-analysis
No meta-analysis
No meta-analysis
life (36–72 hours). Most of the included studies used inter-
conducted
conducted
conducted
mediate acting steroids, while only two CBA studies used a
Q11
NRSI, yes
RCT, yes
long acting agent. A further study is necessary to compare
the effects of short/intermediate/long acting steroid injec-
tions.
Q10
No
No
No
No
Which Approach Is Better? Dorsal, Plantar, or Web
Space Approach?
RCT, includes
only NRSI;
NRSI, yes
NRSI, yes
NRSI, yes
NRSI, yes
Q: question, RCT: randomized controlled trial, NRSI: non-randomized study of healthcare interventions.
We found no comparison studies that focused on the ap-
Q9
RCT, yes;
RCT, yes;
Partial yes RCT, yes;
proach site. Moreover, most of the studies did not men-
The three assessors rated each study, reaching consensus by majority in the instance of dispute.
tion which approach they used.11-15,24) Among the rest of
studies, a dorsal approach was used most commonly in
four studies,16,17,22,23) while a plantar25) or web space18,19) ap-
Q8
Yes
Yes
No
proach was used in a few studies (Table 5). Although it
was not possible to determine the best approach, we could
Q7
No
No
No
No
conclude that it would depend on the surgeon’s preference
since all approaches reported good results.
Yes
Yes
Yes
Q6
No
Partial yes Yes
Partial yes Yes
Q5
No
No
Number of Injections
Evaluation after a single injection was performed in 8 stud-
ies,11,12,15,17-19,22,25) while the other 4 studies13,16,23,24) evaluated
Q4
multiple injections (Table 5). There was one study that did
No
No
not define the number of injections.14) Regarding multiple
Q3
Partial yes Yes
Yes
Partial yes Yes
Partial yes Yes
steroid injections, indications and timings differed greatly
from one study to another, so it was not possible to deter-
mine the safety and effectiveness of multiple injections for
Q2
Morton’s neuroma with this level of heterogeneity.
Yes
Q1
Matthews et al. Yes
Yes
Eventual Transition to Surgery after Steroid Injection
No
No
Table 5 includes 10 studies reporting the eventual transi-
Thomson et al.
Valisena et al.
Morgan et al.
tion rates or patient numbers after corticosteroid injec-
Study
(2019)27)
(2019)20)
(2018)26)
(2014)21)
tion.11,13-19,22,25) Operative procedures varied from inter-
digital neurectomy to nerve transposition superior to the271
Choi et al. Steroid Injection for Morton’s Neuroma
Clinics in Orthopedic Surgery • Vol. 13, No. 2, 2021 • www.ecios.org
2 wk 1.5 mo
1 wk 1 mo 2 mo 3 mo 4 mo 5 mo 6 mo 9 mo 12 mo Timeline
Injection
Edwards et al.
Greenfield et al. 3.8 yr
Grice et al. > 2 yr
Hassouna et al. 11.4 mo
Lizano-Diez et al.
Mahadevan et al.
Makki et al.
Markovic et al.
Rasmussen et al.
Ruiz Santiago et al.
Saygi et al. 2 6 yr
Thomson et al. Fig. 2. The timing of parameter measure
Bennett et al. ments in all included studies.
Table 3. Injected Agents and Outcome Parameters of Each Study
Study/study design Injected agent Outcome parameter
Ruiz Santiago et al.23)/RCT Triamcinolone 40 mg + 2% mepivacaine 1 mL (I, C) VAS, MFPDS, own subjective satisfaction questionnaire
16)
Lizano-Diez et al. /RCT Triamcinolone 40 mg + 2% mepivacaine 1 mL (I); 2% VAS, AOFAS score, Johnson satisfaction scale
mepivacaine 2 mL (C)
Mahadevan et al.17)/RCT Triamcinolone 40 mg + 1% lignocaine 2 mL (I, C) VAS, MOxFQ index, Johnson satisfaction scale
12)
Edwards et al. /RCT Methylprednisolone 40 mg + 2% lignocaine 1 mL (I); 1% FHT score, EQ-5D-3L utility index
lignocaine 2 mL (C)
Thomson et al.25)/RCT Methylprednisolone 40 mg + 1% lignocaine 1 mL (I); 1% VAS, MFPDS, FHT score, MAPS, general health
lignocaine 2 mL (C) thermometer, EQ-5D
Makki et al.18)/NRCT Methylprednisolone 40 mg + 1% lidocaine 1 mL (G1, G2) VAS, AOFAS score, Johnson satisfaction scale
Saygi et al.24)/NRCT Methylprednisolone 40 mg + Prylocayn HCL 1 mL (G2) Own subjective satisfaction questionnaire
14)
Grice et al. /CBA Methylprednisolone 40 mg + 0.5% Marcaine Existence of pain, activity level, use of orthosis
Markovic et al.19)/CBA Betamethasone 1 mL + 1% lidocaine 0.5 mL Johnson satisfaction scale, modified lower extremities
functional scale (functional daily activity)
Hassouna et al.15)/CBA Triamcinolone 20 mg + 0.5% bupivacaine 2 mL Johnson satisfaction scale, subjective pain intensity,
subjective activity limitation, rate of foot wear
modification
Rasmussen et al.22)/CBA Betamethasone 1 mL + 0.5% bupivacaine 1 mL Johnson satisfaction scale, subjective pain intensity,
subjective activity limitation, rate of foot wear
requirement, Mann scales
Bennett et al.11)/CBA Triamcinolone 40 mg + Xylocaine 2 mL Johnson satisfaction scale
13)
Greenfield et al. /CBA Prednisolone tebutate 1 mL or Betamethasone 1 mL or Time to pain relief (short-term effect), subjective degree of
triamcinolone 1 mL + 1% xylocaine 2 mL pain relief (long-term effect)
RCT: randomized controlled trial, I: intervention, C: control, VAS: visual analog scale, MFPDS: Manchester foot pain and disability score, AOFAS:
American Orthopaedic Foot and Ankle Society, MOxFQ: Manchester Oxford foot questionnaire, FHT: foot health thermometer, EQ-5D-3L: EuroQol-5
dimension-3 levels, MAPS: multidimensional affect and pain survey, NRCT: non-randomized controlled trial, G1: group 1, G2: group 2, CBA: controlled
before-after study.
intermetatarsal ligament. In our study, we found that 140 Complications Related to Steroid Injection
subjects out of 469 (29.85%) eventually underwent opera- Table 5 shows the possible complications related to cor-
tive treatment after steroid injection due to the persistent ticosteroid injection in all included studies. Skin depig-
pain. mentation on the injected site was mentioned in six stud-You can also read
