Manual Therapy xxx (2015) 1e4
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report Josiah D. Sault a, c, *, Matthew V. Morris b, Dhinu J. Jayaseelan d, Alicia J. Emerson-Kavchak a a
University of Illinois Hospital and Health Sciences System, Chicago, IL, USA University of Illinois at Chicago, Department of Physical Therapy, Doctoral Program, Chicago, IL, USA University of Illinois at Chicago, Department of Physical Therapy, Fellowship in Orthopedic Manual Physical Therapy, Chicago, IL, USA d The George Washington University, Program in Physical Therapy, Washington D.C., USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 December 2014 Received in revised form 18 March 2015 Accepted 19 March 2015
Patients with Morton's neuroma are rarely referred to physical therapy. This case reports the resolution of pain, increase in local pressure pain thresholds, and improvement of scores on the Lower Extremity Functional Scale and Foot and Ankle Ability Measure following a course of joint based manual therapy for a patient who had failed standard conservative medical treatment. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Interdigital neuroma Pressure pain thresholds Foot and ankle Mobilization
1. Introduction Morton's Neuroma (MN) is a condition associated with the common plantar digital nerves, caused by entrapment of the nerve and repetitive traction underneath the deep transverse metatarsal ligament leading to epineural and perineural fibrous overgrowth. While its incidence has not been reported, MN occurs up to 10 times more frequently in women around the age of 50 (Thomson et al., 2004; Jain and Mannan, 2013). Pain onset is often insidious, and the prevalence of neuromas in asymptomatic individuals may be as high as 25e50% (Bencardino et al., 2000; Owens et al., 2011; Symeonidis et al., 2012). Clinical diagnosis can be up to 99% accurate (Owens et al., 2011; Pastides et al., 2012) with typical complaints of plantar webspace pain, paresthesias and/or numbness aggravated by weight-bearing activities and eased by rest and massage (Bencardino et al., 2000; Coughlin and Pinsonneault, 2001; Thomson et al., 2004; Thomas et al., 2009; Owens et al., 2011; Pastides et al., 2012). Treatment often involves corticosteroid injections and surgical excision (Hassouna and Singh, 2005;
* Corresponding author. 1801 W. Taylor St. Clinic 2C, Chicago, IL 60612, USA. Tel.: þ1 630 209 5326. E-mail address: [email protected] (J.D. Sault).
Jain and Mannan, 2013). However, corticosteroid injections or excision do not guarantee complete relief (Coughlin and Pinsonneault, 2001; Thomson et al., 2004). Physical therapy (PT) management of MN has not been described in the available literature to date. Manual therapy has been hypothesized to alter afferent nociceptive barrages, normalize sensori-motor mismatches, activate descending anti-nociceptive pathways (Nijs and Van Houdenhove, 2009), and decrease spinal hyperexcitability (Sterling et al., 2010). Therefore, utilizing manual therapy in cases of pain, and potential tissue stiffness seems appropriate, particularly when alternative options have not shown convincingly good outcomes. The purpose of the following case is to describe the successful PT treatment including joint mobilizations/manipulation in a patient with a symptomatic MN. 2. Clinical presentation A 35-year-old female presented to outpatient PT complaining of right plantar foot pain with walking, wearing heels, and running. She was diagnosed by a podiatrist with an MN. She received a corticosteroid injection 2 months prior without benefit, and was taking over-the-counter non-steroidal anti-inflammatory (NSAID) medications as needed for pain. Her podiatrist recommended surgery but she requested to be referred to PT. She had previously
http://dx.doi.org/10.1016/j.math.2015.03.010 1356-689X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
2
J.D. Sault et al. / Manual Therapy xxx (2015) 1e4
experienced similar pain 10 years prior with resolution following PT. Otherwise, her past medical history was unremarkable. Following an increase in daily walking, she reported a 4 month history of gradual onset and worsening isolated right plantar 3rd webspace pain (Fig. 1) rated as 3/10 at rest, but could range from 0 to 6/10. While weight bearing activities, such as walking her dogs, worsened her pain, it was eased by rest and taking NSAIDs. Shoe modification and orthotics helped but were unsatisfactory. Because of her pain, the patient had stopped running, avoided using stairs or wearing heels. Her goals were pain resolution and resumption of running. She denied other areas of pain and all red flag questions were negative. Self-report outcome measures included the Lower Extremity Functional Scale (LEFS) (Binkley et al., 1999) and the Foot and Ankle Ability Measure (FAAM) (Martin et al., 2005). She scored 66/80 on the LEFS, and 62/84 and 21/32 on the FAAM ADL and Sports subscales respectively. The LEFS and FAAM ask patients to rate their ability to perform specific daily or sporting tasks from 0 (unable to perform) to 4 (no difficulty). The LEFS has demonstrated excellent test-retest reliability and has a Minimally Clinically Important Difference (MCID) which ranges from 9 points (Binkley et al., 1999) to 15.6 (Wang et al., 2011). The FAAM has demonstrated good reliability and validity with MCID of 8 and 9 points for the ADL and Sport subscales respectively (Martin et al., 2005). Additionally, pain with toe walking was assessed using a verbal numeric pain rating scale (NPRS) from 0 to 10. The MCID of the NPRS in chronic pain populations is 2 points (Farrar et al., 2001). 3. Examination The patient was evaluated by a student physical therapist (MM) with direct supervision and input from his clinical instructor (JS). Postural assessment revealed lumbar scoliosis which the patient reported as present since adolescence, slightly elevated pelvic crest on the right side, pes planus and forefoot varus bilaterally, and a drooping of the 4th and 5th metatarsal heads visible in nonweightbearing on the right foot. Trendelenberg gait was noted on the right, which appeared secondary to pelvic height difference, as
her hip strength was normal. Weightbearing dorsiflexion measured by great toe-to-wall distance (Bennell et al., 1998) was 16 cm and 15 cm left and right respectively without pain reproduction. Lumbar, hip, and knee joint screening did not reproduce her symptoms with overpressures or quadrants throughout. In assessing for strength deficits which may contribute to altered foot posture or gait (Geideman and Johnson, 2000), she demonstrated 5/5 strength throughout her foot and ankle bilaterally, with pain reproduction noted during heel raises. Single leg balance was unimpaired bilaterally. Examination of leg length (Sabharwal & Kumar 2008) and neural provocation testing (Coppieters et al., 2006; Scaia et al., 2012) was unremarkable. Sensation was symmetrical throughout the lower leg, foot, and ankle. Passive accessory motion testing findings can be seen in Table 1. Her pain was partially reproduced with dorsal glides of 4th metatarsal on the cuboid and specifically with direct pressure through her 3rd webspace and with a forefoot squeeze test (Owens et al., 2011; Pastides et al., 2012). Webspace tenderness and painful forefoot squeeze are more common in patients with MN than other foot pathologies (Owens et al., 2011). She had no tenderness to deep pressure at her metatarsal heads or along the metatarsal shafts. Pressure pain thresholds (PPT) to quantify local tissue hyperalgesia and detect potential subclinical improvements during treatment were taken at the plantar aspect of her 3rd webspace using a handheld pressure algometer (Force Ten FDX, Wagner Instruments, Greenwich CT, USA) with a 1 cm2 applicator head. The average of three trials was taken based upon a recent protocol (Rolke et al., 2006). She averaged 697 kPa and 233 kPa on her left and right foot respectively. PPT testing has shown good reliability (ICC ¼ 0.97) [95% Confidence Interval: 0.94e0.99] (Walton et al., 2011) with a standard error of measurement at 62.7 kPa (Chesterton et al., 2007) and an intrarater MDC ranging from 42.7 to 137.0 kPa depending on body region tested (Walton et al., 2011). No reference data for measurement at the 3rd plantar webspace or in MN have been reported so the contralateral side was used (Rolke et al., 2006). 4. Clinical impression and initial treatment Differentials considered included lumbar and hip referral, tarsal tunnel syndrome, flexor tendon injury, metatarsophalangeal joint sprain, and metatarsalgia. Based upon her clinical presentation, isolated symptom reproduction at her 3rd webspace, and negative adjacent body segment screening examination, her symptoms appeared consistent with a diagnosis of a symptomatic MN (Owens et al., 2011; Pastides et al., 2012). The primary impairment identified for treatment was midfoot hypomobility. The therapist theorized this contributed to pain through limited available midfoot pronation and supination during stance and push-off leading to greater stress across her lateral forefoot and sensitization of her 3rd plantar digital nerve. Treatment on the initial visit included 4 min of grade IV plantar glide of her right talonavicular joint. Immediately following, she demonstrated increased PPT at her 3rd webspace from 233 kPa to 354 kPa and reported decreased pain which she did not rate. She was instructed in plantar talonavicular glide self-mobilization for home to be performed daily for 2e3 min and was educated on biomechanical mechanisms of her pain. She was instructed to allow her great toe to grip ground during gait to alleviate lateral foot pressure. 5. Manual therapy
Fig. 1. Pain diagram.
Subsequent treatment included grade IV mobilizations and manipulations directed to hypomobile segments of the patient's
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
J.D. Sault et al. / Manual Therapy xxx (2015) 1e4
3
Table 1 Pertinent right foot and ankle joint mobility findings on initial evaluation. Joint
Direction
Mobility
Symptom response
Talocrural Subtalar Talonavicular Middle on Medial Cuneiform Lateral on Middle cuneiform 4th Metatarsal on Cuboid
Anterior-to-Posterior Lateral Plantar Dorsal Dorsal Dorsal
Mild Hypomobility Mild Hypomobility Hypomobile Hypomobile Hypermobile Normal
None None None None None “Zapping” pain
midfoot to restore optimal movement and restore function (Maitland et al., 2005). Specific techniques and responses to treatment can be found in Table 2. Re-assessment of joint mobility was performed each session. 6. Exercise/education No significant deficits in ankle or hip strength or balance were noted, so exercises were not a significant part of intervention. Review of navicular self-mobilizations was performed on visits 2 and 3. Education regarding MN diagnosis (Jain and Mannan, 2013), pain mechanisms (Courtney et al., 2011), and mechanisms of manual therapy (Bialosky et al., 2009) was performed each session. 7. Summary of treatment & outcomes The patient's pain resolved by the 6th visit and a residual dysesthesia was treated over an additional 6 visits. By visit 12, 3 months after presentation to PT, she reported episodic absence of the dysesthesia, completed a two-mile run without symptoms, wore high-heeled shoes throughout the week, and her pain remained resolved. Patient response to treatment can be seen in Table 2. Between session pre-treatment PPT values can be seen in Fig. 2. Between the first and 8th session, the patient reached the MDC of at least 171.3 kPa for PPT change between testers (Walton et al., 2011). Finally, the patient met the MCID for the LEFS and FAAM ADL, and maximized her score on the FAAM Sports subscale between the first and final sessions as noted in Fig. 3. 8. Discussion This case describes resolution of pain and hyperalgesia in a patient with a symptomatic MN following manual therapy and education. In this case, a patient with recurrent plantar pain related to MN had clinically significant functional and symptomatic improvement following 6 sessions of PT including manual therapy and education. Considering she was pain free with all physical examination testing outside of local palpation and the Squeeze test, the treating therapist believed improving joint mobility of the midfoot would improve her gait mechanics, potentially allowing her to offload the forefoot, where she was having symptoms. Grade
Fig. 2. Table: Pressure pain thresholds at the plantar 3rd webspace between sessions, Graph: Right side as a percentage of left side.
IV joint mobilization and thrust manipulations were associated with decreased pain, which is consistent with current evidence describing the hypoalgesic effects of manual therapy (Bialosky et al., 2009). No examples of PT treatment for MN exist in the current literature. One study compared chiropractic treatment to placebo for pain and PPT values in patients with MN, with improvements noted in the experimental group (Govender et al., 2007). However, to date no studies have demonstrated functional change in patients with MN following manual therapy treatments. Manual therapy has been theorized to have efficacy at multiple levels including local, spinal, and supraspinal levels (Bialosky et al., 2009). In animal models, mobilization has demonstrated positive intra-articular, histochemical, anti-inflammatory effects in the local joints (Ferretti et al., 2006; Madhavan et al., 2007), and can activate local opioid (Martins et al., 2012), and local and spinal cannaboid systems (Martins et al., 2013) to reduce mechanical hyperalgesia. Proposed spinal and supraspinal mechanisms also include descending hypoalgesia and improved motor activity (Schmid et al., 2008; Bialosky et al., 2009). It is likely that manual therapy in this
Table 2 Manual Therapy Techniques and response by session. Visit#
Techniques used
Immediate response
1 2
Plantar Navicular Glide Same as visit 1, plus: Dorsal middle on medial cuneiform, grade IV Same as visit 2 Same as visit 3 plus: Dorsal glide 4th ray on cuboid grade IV Same as visit 1, plus: Cuboid whip manipulation 3 Cuboid Whip manipulation 3
PPT improved from 233 kPa to 354 kPa, pain with gait reduced Pain with toe walking improved from 5/10 to 2/10
3 4 5 6
PPT improved from 389 kPa to 428 kPa Pain with toe walking improved from 1/10 to 0/10 Pain with toe walking improved from 2/10 to 1.5/10 Pain with toe walking 0/10 to start, dysesthesia improved following manipulation
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
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J.D. Sault et al. / Manual Therapy xxx (2015) 1e4
Fig. 3. Written Outcome Measures from Eval to Final visit: Lower extremity functional scale (LEFS), Foot and Ankle Ability Measure ADL (FAAM ADL) and sports (FAAM Sports) subscales.
patient's case may have had effects at all of these levels considering immediate and between session changes in pain and PPTs. 9. Limitations and conclusion One limitation of this case report is that PPT values were taken by the PT intern on visits 1 and 3 and by the supervising therapist thereafter. Variability in PPT testing may be due to variability of testing site, angulation of pressure application, rate of force generation, tester's experience with testing (Chesterton et al., 2007; Nikolajsen et al., 2011), and the patient's understanding of the procedure (Chesterton et al., 2007). Additional sources of error include mistaken reporting of pain tolerance versus threshold and/ or learned response. Therefore, the change in PPT values for this patient may not reflect the full change in PPT. It is important to consider that significant change occurred as side-to-side differences resolved by the final visit and exceeded the inter-rater MDC of 171.3 kPa (Walton et al., 2011). While this patient improved with manual therapy, this is a case report and as such, not generalizable to all patients with MN. However, given the lack of effective conservative management interventions for MN, results from this case are encouraging. Future studies to determine the efficacy of physical therapy treatment in MN are warranted. References Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic? AJR. Am J Roentgenol 2000;175(3):649e53. Bennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiotherapy 1998;44(3):175e80. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009;14(5):531e8. Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. north american orthopaedic rehabilitation research network. Phys Ther 1999;79(4):371e83.
Chesterton LS, Sim J, Wright CC, Foster NE. Interrater reliability of algometry in measuring pressure pain thresholds in healthy humans, using multiple raters. Clin J Pain 2007;23(9):760e6. Coppieters MW, Alshami AM, Babri AS, Souvlis T, Kippers V, Hodges PW. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. J Orthop Res: Off Publ Orthop Res Soc 2006;24(9):1883e9. Coughlin MJ, Pinsonneault T. Operative treatment of interdigital neuroma. A longterm follow-up study. J Bone Jt Surg Am 2001;83-A(9):1321e8. Courtney CA, Clark JD, Duncombe AM, O'Hearn MA. Clinical presentation and manual therapy for lower quadrant musculoskeletal conditions. J Man Manip Ther 2011;19(4):212e22. Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94(2):149e58. Ferretti M, Gassner R, Wang Z, Perera P, Deschner J, Sowa G, et al. Biomechanical signals suppress proinflammatory responses in cartilage: early events in experimental antigen-induced arthritis. J Immunol 2006;177(12):8757e66 (Baltimore, Md.: 1950). Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2000;30(2):68e77. Govender N, Kretzmann H, Price JL, Brantingham JW, Globe G. A single-blinded randomized placebo-controlled clinical trial of manipulation and mobilization in the treatment of morton's neuroma. J Am Chiropr Assoc 2007;44(3):8e18. Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg 2005;71(6):646e55. Jain S, Mannan K. The diagnosis and management of morton's neuroma: a literature review. Foot Ankle Specialist 2013;6(4):307e17. Madhavan S, Anghelina M, Sjostrom D, Dossumbekova A, Guttridge DC, Agarwal S. Biomechanical signals suppress TAK1 activation to inhibit NF-kappaB transcriptional activation in fibrochondrocytes. J Immunol 2007;179(9):6246e54 (Baltimore, Md.: 1950). Maitland GD, Banks K, Hengeveld E. Maitland's peripheral manipulation. Edinburgh; New York: Elsevier/Butterworth Heinemann; 2005. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the foot and ankle ability measure (FAAM). Foot Ankle Int/Am Orthop Foot Ankle Soc Swiss Foot Ankle Soc 2005;26(11):968e83. Martins DF, Bobinski F, Mazzardo-Martins L, Cidral-Filho FJ, Nascimento FP, Gadotti VM, et al. Ankle joint mobilization decreases hypersensitivity by activation of peripheral opioid receptors in a mouse model of postoperative pain. Pain Med (Malden, Mass.) 2012;13(8):1049e58. Martins DF, Mazzardo-Martins L, Cidral-Filho FJ, Gadotti VM, Santos AR. Peripheral and spinal activation of cannabinoid receptors by joint mobilization alleviates postoperative pain in mice. Neuroscience 2013;255C:110e21. Nijs J, Van Houdenhove B. From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: application of pain neurophysiology in manual therapy practice. Man Ther 2009;14(1):3e12. Nikolajsen L, Kristensen AD, Pedersen LK, Rahbek O, Jensen TS, Moller-Madsen B. Intra- and interrater agreement of pressure pain thresholds in children with orthopedic disorders. J Children's Orthop 2011;5(3):173e8. Owens R, Gougoulias N, Guthrie H, Sakellariou A. Morton's neuroma: clinical testing and imaging in 76 feet, compared to a control group. Foot Ankle Surg: Off J Eur Soc Foot Ankle Surg 2011;17(3):197e200. Pastides P, El-Sallakh S, Charalambides C. Morton's neuroma: a clinical versus radiological diagnosis. Foot Ankle Surg 2012;18(1):22e4. Rolke R, Baron R, Maier C, Tolle TR, Treede RD, Beyer A, et al. Quantitative sensory testing in the german research network on neuropathic pain (DFNS): standardized protocol and reference values. Pain 2006;123(3):231e43. Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res 2008;466(12):2910e22. Scaia V, Baxter D, Cook C. The pain provocation-based straight leg raise test for diagnosis of lumbar disc herniation, lumbar radiculopathy, and/or sciatica: a systematic review of clinical utility. J Back Musculoskelet Rehab 2012;25(4): 215e23. Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual therapy? evidence for a central nervous system component in the response to passive cervical joint mobilisation. Man Ther 2008;13(5):387e96. Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide ^ or thermal pain increases nociceptive flexion reflex threshold but not pressureA thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther 2010;15(2):149e53. Symeonidis PD, Iselin LD, Simmons N, Fowler S, Dracopoulos G, Stavrou P. Prevalence of interdigital nerve enlargements in an asymptomatic population. Foot Ankle Int/Am Orthop Foot Ankle Soc Swiss Foot Ankle Soc 2012;33(7):543e7. Thomas JL, Blitch IV,EL, Chaney DM, Dinucci KA, Eickmeier K, Rubin LG, et al. Diagnosis and treatment of forefoot disorders. section 3. morton's intermetatarsal neuroma. J Foot Ankle Surg 2009;48(2):251e6. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of morton's neuroma. Cochrane Database Syst Rev 2004;3(3). CD003118. Walton DM, Macdermid JC, Nielson W, Teasell RW, Chiasson M, Brown L. Reliability, standard error, and minimum detectable change of clinical pressure pain threshold testing in people with and without acute neck pain. J Orthop Sports Phys Ther 2011;41(9):644e50. Wang YC, Hart DL, Stratford PW, Mioduski JE. Baseline dependency of minimal clinically important improvement. Phys Ther 2011;91(5):675e88.
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report Josiah D. Sault a, c, *, Matthew V. Morris b, Dhinu J. Jayaseelan d, Alicia J. Emerson-Kavchak a a
University of Illinois Hospital and Health Sciences System, Chicago, IL, USA University of Illinois at Chicago, Department of Physical Therapy, Doctoral Program, Chicago, IL, USA University of Illinois at Chicago, Department of Physical Therapy, Fellowship in Orthopedic Manual Physical Therapy, Chicago, IL, USA d The George Washington University, Program in Physical Therapy, Washington D.C., USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 December 2014 Received in revised form 18 March 2015 Accepted 19 March 2015
Patients with Morton's neuroma are rarely referred to physical therapy. This case reports the resolution of pain, increase in local pressure pain thresholds, and improvement of scores on the Lower Extremity Functional Scale and Foot and Ankle Ability Measure following a course of joint based manual therapy for a patient who had failed standard conservative medical treatment. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Interdigital neuroma Pressure pain thresholds Foot and ankle Mobilization
1. Introduction Morton's Neuroma (MN) is a condition associated with the common plantar digital nerves, caused by entrapment of the nerve and repetitive traction underneath the deep transverse metatarsal ligament leading to epineural and perineural fibrous overgrowth. While its incidence has not been reported, MN occurs up to 10 times more frequently in women around the age of 50 (Thomson et al., 2004; Jain and Mannan, 2013). Pain onset is often insidious, and the prevalence of neuromas in asymptomatic individuals may be as high as 25e50% (Bencardino et al., 2000; Owens et al., 2011; Symeonidis et al., 2012). Clinical diagnosis can be up to 99% accurate (Owens et al., 2011; Pastides et al., 2012) with typical complaints of plantar webspace pain, paresthesias and/or numbness aggravated by weight-bearing activities and eased by rest and massage (Bencardino et al., 2000; Coughlin and Pinsonneault, 2001; Thomson et al., 2004; Thomas et al., 2009; Owens et al., 2011; Pastides et al., 2012). Treatment often involves corticosteroid injections and surgical excision (Hassouna and Singh, 2005;
* Corresponding author. 1801 W. Taylor St. Clinic 2C, Chicago, IL 60612, USA. Tel.: þ1 630 209 5326. E-mail address: [email protected] (J.D. Sault).
Jain and Mannan, 2013). However, corticosteroid injections or excision do not guarantee complete relief (Coughlin and Pinsonneault, 2001; Thomson et al., 2004). Physical therapy (PT) management of MN has not been described in the available literature to date. Manual therapy has been hypothesized to alter afferent nociceptive barrages, normalize sensori-motor mismatches, activate descending anti-nociceptive pathways (Nijs and Van Houdenhove, 2009), and decrease spinal hyperexcitability (Sterling et al., 2010). Therefore, utilizing manual therapy in cases of pain, and potential tissue stiffness seems appropriate, particularly when alternative options have not shown convincingly good outcomes. The purpose of the following case is to describe the successful PT treatment including joint mobilizations/manipulation in a patient with a symptomatic MN. 2. Clinical presentation A 35-year-old female presented to outpatient PT complaining of right plantar foot pain with walking, wearing heels, and running. She was diagnosed by a podiatrist with an MN. She received a corticosteroid injection 2 months prior without benefit, and was taking over-the-counter non-steroidal anti-inflammatory (NSAID) medications as needed for pain. Her podiatrist recommended surgery but she requested to be referred to PT. She had previously
http://dx.doi.org/10.1016/j.math.2015.03.010 1356-689X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
2
J.D. Sault et al. / Manual Therapy xxx (2015) 1e4
experienced similar pain 10 years prior with resolution following PT. Otherwise, her past medical history was unremarkable. Following an increase in daily walking, she reported a 4 month history of gradual onset and worsening isolated right plantar 3rd webspace pain (Fig. 1) rated as 3/10 at rest, but could range from 0 to 6/10. While weight bearing activities, such as walking her dogs, worsened her pain, it was eased by rest and taking NSAIDs. Shoe modification and orthotics helped but were unsatisfactory. Because of her pain, the patient had stopped running, avoided using stairs or wearing heels. Her goals were pain resolution and resumption of running. She denied other areas of pain and all red flag questions were negative. Self-report outcome measures included the Lower Extremity Functional Scale (LEFS) (Binkley et al., 1999) and the Foot and Ankle Ability Measure (FAAM) (Martin et al., 2005). She scored 66/80 on the LEFS, and 62/84 and 21/32 on the FAAM ADL and Sports subscales respectively. The LEFS and FAAM ask patients to rate their ability to perform specific daily or sporting tasks from 0 (unable to perform) to 4 (no difficulty). The LEFS has demonstrated excellent test-retest reliability and has a Minimally Clinically Important Difference (MCID) which ranges from 9 points (Binkley et al., 1999) to 15.6 (Wang et al., 2011). The FAAM has demonstrated good reliability and validity with MCID of 8 and 9 points for the ADL and Sport subscales respectively (Martin et al., 2005). Additionally, pain with toe walking was assessed using a verbal numeric pain rating scale (NPRS) from 0 to 10. The MCID of the NPRS in chronic pain populations is 2 points (Farrar et al., 2001). 3. Examination The patient was evaluated by a student physical therapist (MM) with direct supervision and input from his clinical instructor (JS). Postural assessment revealed lumbar scoliosis which the patient reported as present since adolescence, slightly elevated pelvic crest on the right side, pes planus and forefoot varus bilaterally, and a drooping of the 4th and 5th metatarsal heads visible in nonweightbearing on the right foot. Trendelenberg gait was noted on the right, which appeared secondary to pelvic height difference, as
her hip strength was normal. Weightbearing dorsiflexion measured by great toe-to-wall distance (Bennell et al., 1998) was 16 cm and 15 cm left and right respectively without pain reproduction. Lumbar, hip, and knee joint screening did not reproduce her symptoms with overpressures or quadrants throughout. In assessing for strength deficits which may contribute to altered foot posture or gait (Geideman and Johnson, 2000), she demonstrated 5/5 strength throughout her foot and ankle bilaterally, with pain reproduction noted during heel raises. Single leg balance was unimpaired bilaterally. Examination of leg length (Sabharwal & Kumar 2008) and neural provocation testing (Coppieters et al., 2006; Scaia et al., 2012) was unremarkable. Sensation was symmetrical throughout the lower leg, foot, and ankle. Passive accessory motion testing findings can be seen in Table 1. Her pain was partially reproduced with dorsal glides of 4th metatarsal on the cuboid and specifically with direct pressure through her 3rd webspace and with a forefoot squeeze test (Owens et al., 2011; Pastides et al., 2012). Webspace tenderness and painful forefoot squeeze are more common in patients with MN than other foot pathologies (Owens et al., 2011). She had no tenderness to deep pressure at her metatarsal heads or along the metatarsal shafts. Pressure pain thresholds (PPT) to quantify local tissue hyperalgesia and detect potential subclinical improvements during treatment were taken at the plantar aspect of her 3rd webspace using a handheld pressure algometer (Force Ten FDX, Wagner Instruments, Greenwich CT, USA) with a 1 cm2 applicator head. The average of three trials was taken based upon a recent protocol (Rolke et al., 2006). She averaged 697 kPa and 233 kPa on her left and right foot respectively. PPT testing has shown good reliability (ICC ¼ 0.97) [95% Confidence Interval: 0.94e0.99] (Walton et al., 2011) with a standard error of measurement at 62.7 kPa (Chesterton et al., 2007) and an intrarater MDC ranging from 42.7 to 137.0 kPa depending on body region tested (Walton et al., 2011). No reference data for measurement at the 3rd plantar webspace or in MN have been reported so the contralateral side was used (Rolke et al., 2006). 4. Clinical impression and initial treatment Differentials considered included lumbar and hip referral, tarsal tunnel syndrome, flexor tendon injury, metatarsophalangeal joint sprain, and metatarsalgia. Based upon her clinical presentation, isolated symptom reproduction at her 3rd webspace, and negative adjacent body segment screening examination, her symptoms appeared consistent with a diagnosis of a symptomatic MN (Owens et al., 2011; Pastides et al., 2012). The primary impairment identified for treatment was midfoot hypomobility. The therapist theorized this contributed to pain through limited available midfoot pronation and supination during stance and push-off leading to greater stress across her lateral forefoot and sensitization of her 3rd plantar digital nerve. Treatment on the initial visit included 4 min of grade IV plantar glide of her right talonavicular joint. Immediately following, she demonstrated increased PPT at her 3rd webspace from 233 kPa to 354 kPa and reported decreased pain which she did not rate. She was instructed in plantar talonavicular glide self-mobilization for home to be performed daily for 2e3 min and was educated on biomechanical mechanisms of her pain. She was instructed to allow her great toe to grip ground during gait to alleviate lateral foot pressure. 5. Manual therapy
Fig. 1. Pain diagram.
Subsequent treatment included grade IV mobilizations and manipulations directed to hypomobile segments of the patient's
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
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Table 1 Pertinent right foot and ankle joint mobility findings on initial evaluation. Joint
Direction
Mobility
Symptom response
Talocrural Subtalar Talonavicular Middle on Medial Cuneiform Lateral on Middle cuneiform 4th Metatarsal on Cuboid
Anterior-to-Posterior Lateral Plantar Dorsal Dorsal Dorsal
Mild Hypomobility Mild Hypomobility Hypomobile Hypomobile Hypermobile Normal
None None None None None “Zapping” pain
midfoot to restore optimal movement and restore function (Maitland et al., 2005). Specific techniques and responses to treatment can be found in Table 2. Re-assessment of joint mobility was performed each session. 6. Exercise/education No significant deficits in ankle or hip strength or balance were noted, so exercises were not a significant part of intervention. Review of navicular self-mobilizations was performed on visits 2 and 3. Education regarding MN diagnosis (Jain and Mannan, 2013), pain mechanisms (Courtney et al., 2011), and mechanisms of manual therapy (Bialosky et al., 2009) was performed each session. 7. Summary of treatment & outcomes The patient's pain resolved by the 6th visit and a residual dysesthesia was treated over an additional 6 visits. By visit 12, 3 months after presentation to PT, she reported episodic absence of the dysesthesia, completed a two-mile run without symptoms, wore high-heeled shoes throughout the week, and her pain remained resolved. Patient response to treatment can be seen in Table 2. Between session pre-treatment PPT values can be seen in Fig. 2. Between the first and 8th session, the patient reached the MDC of at least 171.3 kPa for PPT change between testers (Walton et al., 2011). Finally, the patient met the MCID for the LEFS and FAAM ADL, and maximized her score on the FAAM Sports subscale between the first and final sessions as noted in Fig. 3. 8. Discussion This case describes resolution of pain and hyperalgesia in a patient with a symptomatic MN following manual therapy and education. In this case, a patient with recurrent plantar pain related to MN had clinically significant functional and symptomatic improvement following 6 sessions of PT including manual therapy and education. Considering she was pain free with all physical examination testing outside of local palpation and the Squeeze test, the treating therapist believed improving joint mobility of the midfoot would improve her gait mechanics, potentially allowing her to offload the forefoot, where she was having symptoms. Grade
Fig. 2. Table: Pressure pain thresholds at the plantar 3rd webspace between sessions, Graph: Right side as a percentage of left side.
IV joint mobilization and thrust manipulations were associated with decreased pain, which is consistent with current evidence describing the hypoalgesic effects of manual therapy (Bialosky et al., 2009). No examples of PT treatment for MN exist in the current literature. One study compared chiropractic treatment to placebo for pain and PPT values in patients with MN, with improvements noted in the experimental group (Govender et al., 2007). However, to date no studies have demonstrated functional change in patients with MN following manual therapy treatments. Manual therapy has been theorized to have efficacy at multiple levels including local, spinal, and supraspinal levels (Bialosky et al., 2009). In animal models, mobilization has demonstrated positive intra-articular, histochemical, anti-inflammatory effects in the local joints (Ferretti et al., 2006; Madhavan et al., 2007), and can activate local opioid (Martins et al., 2012), and local and spinal cannaboid systems (Martins et al., 2013) to reduce mechanical hyperalgesia. Proposed spinal and supraspinal mechanisms also include descending hypoalgesia and improved motor activity (Schmid et al., 2008; Bialosky et al., 2009). It is likely that manual therapy in this
Table 2 Manual Therapy Techniques and response by session. Visit#
Techniques used
Immediate response
1 2
Plantar Navicular Glide Same as visit 1, plus: Dorsal middle on medial cuneiform, grade IV Same as visit 2 Same as visit 3 plus: Dorsal glide 4th ray on cuboid grade IV Same as visit 1, plus: Cuboid whip manipulation 3 Cuboid Whip manipulation 3
PPT improved from 233 kPa to 354 kPa, pain with gait reduced Pain with toe walking improved from 5/10 to 2/10
3 4 5 6
PPT improved from 389 kPa to 428 kPa Pain with toe walking improved from 1/10 to 0/10 Pain with toe walking improved from 2/10 to 1.5/10 Pain with toe walking 0/10 to start, dysesthesia improved following manipulation
Please cite this article in press as: Sault JD, et al., Manual therapy in the management of a patient with a symptomatic Morton's neuroma: A case report, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.010
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J.D. Sault et al. / Manual Therapy xxx (2015) 1e4
Fig. 3. Written Outcome Measures from Eval to Final visit: Lower extremity functional scale (LEFS), Foot and Ankle Ability Measure ADL (FAAM ADL) and sports (FAAM Sports) subscales.
patient's case may have had effects at all of these levels considering immediate and between session changes in pain and PPTs. 9. Limitations and conclusion One limitation of this case report is that PPT values were taken by the PT intern on visits 1 and 3 and by the supervising therapist thereafter. Variability in PPT testing may be due to variability of testing site, angulation of pressure application, rate of force generation, tester's experience with testing (Chesterton et al., 2007; Nikolajsen et al., 2011), and the patient's understanding of the procedure (Chesterton et al., 2007). Additional sources of error include mistaken reporting of pain tolerance versus threshold and/ or learned response. Therefore, the change in PPT values for this patient may not reflect the full change in PPT. It is important to consider that significant change occurred as side-to-side differences resolved by the final visit and exceeded the inter-rater MDC of 171.3 kPa (Walton et al., 2011). While this patient improved with manual therapy, this is a case report and as such, not generalizable to all patients with MN. However, given the lack of effective conservative management interventions for MN, results from this case are encouraging. Future studies to determine the efficacy of physical therapy treatment in MN are warranted. References Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic? AJR. Am J Roentgenol 2000;175(3):649e53. Bennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiotherapy 1998;44(3):175e80. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009;14(5):531e8. Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. north american orthopaedic rehabilitation research network. Phys Ther 1999;79(4):371e83.
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