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(Radiology. 1999;213:583-588.)
© RSNA, 1999

Musculoskeletal Imaging

Morton Neuroma: Effect of MR Imaging Findings on Diagnostic Thinking and Therapeutic Decisions1

Marco Zanetti, MD, Josef K. Strehle, MD, Hans-Peter Kundert, MD, Hans Zollinger, MD and Juerg Hodler, MD

1 From the Departments of Radiology (M.Z., J.H.) and Orthopedic Surgery (J.K.S.), Orthopedic University Clinic, Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland; H.P.K. and H.Z. are in private practice in Zurich, Switzerland. Received July 15, 1998; revision requested August 13; final revision received February 12, 1999; accepted June 8. Address reprint requests to M.Z. (e-mail: mzanetti@balgrist.unizh.ch).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To determine the effect of magnetic resonance (MR) imaging results on diagnostic thinking and therapeutic decisions by orthopedic surgeons in cases of a possible Morton neuroma.

MATERIAL AND METHODS: Orthopedic surgeons completed a questionnaire before and after MR imaging for 54 feet in 49 patients thought to have Morton neuroma. Clinical diagnosis (Morton neuroma, differential diagnosis), location, diagnostic confidence, and therapeutic decisions were noted before and after MR imaging. The influence of the size of the neuroma on therapeutic decisions was analyzed. MR imaging diagnoses were compared with surgical results for 23 revised intermetatarsal spaces.

RESULTS: After MR imaging, the clinical diagnosis of Morton neuroma was withdrawn in 15 of 54 (28%) feet. In 14 of 39 maintained diagnoses, the location or number of neuromas was changed after MR imaging. Confidence levels for Morton neuroma increased substantially after MR imaging. In 31 (57%) feet, a change in treatment plan resulted after MR imaging. Diameters of neuromas on MR images were significantly larger (P = .003) in surgically treated feet than in conservatively treated feet. MR imaging diagnoses were correct in all 23 revised intermetatarsal spaces.

CONCLUSION: MR imaging has a major effect on diagnostic thinking and therapeutic decisions by orthopedic surgeons when Morton neuroma is suspected, especially because MR imaging helps in localization and size assessment of Morton neuromas.

Index terms: Efficacy study • Foot, MR, 465.121411 • Foot, neoplasms, 465.369 • Neuroma, 465.369


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Magnetic resonance (MR) imaging has been used successfully in the assessment of Morton neuroma (1–3). Recently, MR imaging has shown high sensitivity (87%) and specificity (100%) for demonstration of Morton neuroma (3). Owing to the need to control the cost of health care, however, the accuracy of an imaging modality alone is no longer sufficient to warrant its use. The clinical effectiveness of the imaging modality must be demonstrated. In the case of Morton neuroma, such evaluation is especially important, because many orthopedic surgeons believe that MR imaging is not effective for the diagnosis of Morton neuroma (4–6).

For assessment of diagnostic effectiveness, a six-level hierarchic model is commonly used (7–9). The six levels of effectiveness are technical, diagnostic-accuracy, diagnostic-thinking, therapeutic, patient-outcome, and societal effectiveness. The authors of several MR imaging investigations (1–3) of the metatarsus have evaluated the first two levels. To our knowledge, no study of the effectiveness of MR imaging of the metatarsus has been performed to evaluate higher levels, other than a publication (10) in which the influence of the results of MR imaging of the entire foot was investigated.

The purpose of our study was to determine the effect of MR imaging findings on diagnostic thinking and therapeutic decisions by orthopedic surgeons when a Morton neuroma is suspected.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Forty-nine consecutive patients (37 women, 12 men; age range, 30–72 years; mean age, 53 years) suspected of having Morton neuroma and referred for MR imaging between August 1997 and June 1998 were included in this prospective study. No patient had to be excluded during the investigation because of claustrophobia, conflicting schedules, or other reasons. MR imaging was routinely performed in patients suspected of having Morton neuroma; patients were not referred specifically for the purpose of our study.

In five patients, MR imaging was performed in both feet, which resulted in a total of 54 feet. Twenty patients were referred by the foot surgery team of an orthopedic university clinic. This team consisted of an experienced orthopedic foot surgeon (J.K.S.) and three residents. Twenty-nine patients were referred by two subspecialist orthopedic foot surgeons (H.P.K., H.Z.) in two private practices. The indication for MR imaging was possible Morton neuroma, with symptoms that persisted for longer than 3 months. Surgery had previously been performed in seven of 54 feet: in three feet because of Morton neuroma and in four feet for correction of deformities of a lesser toe.

First Clinical Evaluation
For each foot, the clinician completed a questionnaire in the form of a check-off sheet, both before and after MR imaging. The clinical diagnosis (Morton neuroma, differential diagnosis, or both), the location of the possible abnormality, the degree of confidence in the diagnosis, and the therapeutic decision were noted. The clinical diagnosis was determined on the basis of medical history, physical examination results, and standard radiographs (including at least a dorsoplantar and a lateral view of the symptomatic foot). Confidence in the clinical diagnosis was rated on a five-point scale, with a score of 1 for least confidence and a score of 5 for absolute confidence. Possible differential diagnoses, which can be determined with reasonable accuracy both clinically and with MR imaging, included (a) Morton neuroma, (b) intermetatarsal bursitis, (c) stress fractures, (d) necrosis of the sesamoid bones, (e) synovitis of the metatarsophalangeal joint, (f) infection, or (g) true neoplasm. More than one diagnosis could be selected in the same patient.

The following therapeutic options were offered: (a) no therapy, (b) conservative treatment (foot support, limitation of weight bearing, immobilization, physical therapy, injection of local anesthetics and corticosteroids), and (c) surgery (surgical revision of the intermetatarsal space, metatarsal osteotomy, revision of the metatarsophalangeal joint). For both the clinical diagnosis and the feet treated with surgery, the involved intermetatarsal space or spaces were noted.

The standard surgical therapy for Morton neuroma performed by the two orthopedic surgeons in private practice was neurectomy with division of the transverse intermetatarsal ligament; the standard therapy performed by the orthopedic surgeon affiliated with the university clinic was neurolysis with division of the transverse intermetatarsal ligament. All three surgeons used a dorsal approach.

MR Imaging
MR imaging was performed with a 1.0-T imager (Impact/Expert; Siemens Medical Systems, Erlangen, Germany). MR images were obtained with the patient in the prone position. The foot was placed in plantar flexion in a circularly polarized send-receive extremity coil. The standard protocol consisted of performance of a sagittal T1-weighted spin-echo sequence (repetition time msec/echo time msec, 500/15; field of view, 135 x 180 mm; imaging time, 2 minutes 27 seconds), a T1-weighted spin-echo sequence perpendicular to the metatarsal bones (600/15; field of view, 90 x 120 mm; imaging time, 3 minutes 30 seconds), and a T2-weighted turbo spin-echo sequence perpendicular to the metatarsal bones (repetition time msec/effective echo time msec, 4,500/96; field of view, 90 x 120 mm; imaging time, 3 minutes 42 seconds). For all three sequences, the section thickness was 3 mm, the image matrix was 144 x 256, and two signals were acquired.

Additional sequences (performed in eight of 54 feet), which included a short inversion time inversion recovery sequence (repetition time msec/echo time msec/inversion time msec, 5,320–5,500/150/30) and a contrast material–enhanced T1-weighted fat-suppressed spin-echo sequence (812–850/15), were performed only when the diagnosis remained unclear after review of the images obtained with the first three sequences.

The MR images were evaluated prospectively by one of two experienced musculoskeletal radiologists (M.Z., J.H.). They used previously published criteria (1–3) for abnormalities of the metatarsus. When a Morton neuroma was diagnosed, the transverse diameter was measured on the T1-weighted MR image obtained perpendicular to the metatarsal bones (Fig 1).



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  		Figure 1a. Surgically proved Morton neuroma in the third intermetatarsal space in a 55-year-old woman. Before MR imaging, clinical evaluation results were suggestive of a Morton neuroma in the second intermetatarsal space. (a) T1-weighted spin-echo MR image (600/15) obtained perpendicular to the metatarsal bones demonstrates a typical Morton neuroma (arrows) with a transverse diameter (line, 1) of 7 mm. (b) On the corresponding T2-weighted turbo spin-echo MR image (4,500/96 [effective]), the signal intensity of the neuroma (arrows) is lower than that of fat.

 


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  		Figure 1b. Surgically proved Morton neuroma in the third intermetatarsal space in a 55-year-old woman. Before MR imaging, clinical evaluation results were suggestive of a Morton neuroma in the second intermetatarsal space. (a) T1-weighted spin-echo MR image (600/15) obtained perpendicular to the metatarsal bones demonstrates a typical Morton neuroma (arrows) with a transverse diameter (line, 1) of 7 mm. (b) On the corresponding T2-weighted turbo spin-echo MR image (4,500/96 [effective]), the signal intensity of the neuroma (arrows) is lower than that of fat.

 
Second Clinical Evaluation
The second clinical evaluation was performed by the same orthopedic surgeons during the next consultation (interval between evaluations, 0–105 days; mean, 19 days). (The 105-day interval was an outlier. The second longest interval was 60 days.) For this second clinical evaluation, the orthopedic surgeons considered both the MR imaging results and their clinical findings. Therefore, the clinical diagnosis after MR imaging could be in disagreement with that determined on the basis of MR imaging findings.

Diagnostic Accuracy of MR Images in Patients Who Underwent Surgery
The accuracy of the MR imaging diagnoses was determined on the basis of findings in the 23 intermetatarsal spaces (in 20 feet) that had been surgically revised before the end of the investigation. For the feet where neurectomy was performed (n = 10), histologic findings were the standard of reference.

Data Analysis
The questionnaires obtained before and after MR imaging were compared with regard to diagnosis, lesion location, confidence in the diagnosis, and therapeutic decision. Confidence scores were assigned by the orthopedic surgeons only for positive diagnoses. Therefore, comparison of the confidence scores was possible only when the diagnosis did not change after MR imaging. The diameters of Morton neuromas seen on MR images of feet that were subsequently surgically revised were compared with the diameters of Morton neuromas seen on MR images of feet treated conservatively; the differences were assessed with a two-tailed, unpaired Student t test. A P value of less than .05 was considered to indicate a significant difference.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Influence of MR Imaging on Diagnostic Thinking
Before the MR images were obtained, the orthopedic foot surgeons diagnosed a Morton neuroma in the second intermetatarsal space in 21 of 54 feet, in the third intermetatarsal space in 23 of 54 feet, and in both the second and third intermetatarsal spaces in 10 of 54 feet. After MR imaging, the diagnosis of Morton neuroma was withdrawn by the surgeon in 15 of 54 (28%) feet. In 14 of these 15 feet, no Morton neuroma was visible on MR images. In one foot, the diagnosis of Morton neuroma was withdrawn by the surgeon after review of the MR images, although a Morton neuroma was visible at the clinically suspected location. This can be explained by the presence on the MR images of a stress fracture, which better accounted for the patient's symptoms than did the Morton neuroma. Moreover, the Morton neuroma diagnosed on the basis of MR images was small (3 mm in diameter, which is only 1 mm larger than a normal nerve). In 15 feet in which the diagnosis of Morton neuroma was withdrawn by the clinicians after MR imaging, four cases of metatarsophalangeal synovitis, two of intermetatarsal bursitis, and one of stress fracture were diagnosed. In eight feet, the surgeons did not render a final diagnosis.

In 39 of 54 feet, the diagnosis of Morton neuroma was maintained by the orthopedic surgeons after review of the MR images. In 14 of these 39 feet, the location or number of Morton neuromas was changed after MR image review. In seven feet, MR images depicted a neuroma at a different location from that determined at the initial clinical evaluation. The different location was accepted by the clinician in three feet; in the remaining four feet, the clinicians diagnosed a Morton neuroma at two locations (one at the location determined at the initial clinical evaluation, one at the location depicted on MR images). In six feet, MR imaging demonstrated an additional neuroma (Fig 2). Four of these diagnoses of additional neuroma were accepted by the orthopedic surgeon; in the other two feet, the surgeons maintained the diagnosis of one neuroma. In five feet, MR imaging demonstrated one rather than two neuromas. This diagnosis was accepted by the surgeons in three feet; in the other two feet, the initial diagnosis of neuroma at two locations was maintained.



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  		Figure 2a. (a) T1-weighted spin-echo (600/15) and (b) T2-weighted turbo spin-echo (4,500/96 [effective]) MR images, both obtained perpendicular to the metatarsal bones, show two surgically proved Morton neuromas (arrows) in a 61-year-old woman. Before MR imaging, clinical evaluation results were suggestive of only one Morton neuroma in the third intermetatarsal space.

 


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  		Figure 2b. (a) T1-weighted spin-echo (600/15) and (b) T2-weighted turbo spin-echo (4,500/96 [effective]) MR images, both obtained perpendicular to the metatarsal bones, show two surgically proved Morton neuromas (arrows) in a 61-year-old woman. Before MR imaging, clinical evaluation results were suggestive of only one Morton neuroma in the third intermetatarsal space.

 
Intermetatarsal bursitis was considered as an additional or differential diagnosis before MR imaging in 22 of 54 feet. This diagnosis was maintained by the surgeons after MR imaging in one foot. In three feet, intermetatarsal bursitis was newly diagnosed by the surgeons after MR imaging.

Stress fracture was considered as the differential diagnosis in three feet before MR imaging. In two feet, stress fracture was confirmed by the surgeons after MR imaging. In three other feet, stress fracture was diagnosed by the surgeons only after MR imaging.

Synovitis of the metatarsophalangeal joints was considered as an additional or differential diagnosis in 13 of 54 feet before MR imaging. The diagnosis was maintained by the surgeons after MR imaging in one foot. In four feet, synovitis was newly diagnosed by the surgeons after MR imaging. In two feet (in one patient), large nodules with low T2-weighted signal intensity were visible in the first intermetatarsal space on MR images, and a giant cell tumor of the tendon sheath was suggested on the basis of the size, location, and signal intensity typical of such a lesion (Fig 3). Histologic analysis revealed nodules associated with rheumatoid arthritis. Sesamoid necrosis, infection, and neoplasm were never suspected before or after MR imaging.



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  		Figure 3a. Histologically proved nodule associated with rheumatoid arthritis in a 42-year-old woman. Before MR imaging, clinical evaluation results were suggestive of a Morton neuroma in the second intermetatarsal space. (a) T1-weighted spin-echo (600/15) and (b) T2-weighted turbo spin-echo (4,500/96 [effective]) MR images, both obtained perpendicular to the metatarsal bones, show what was believed to be a giant-cell tumor of the tendon sheath (arrows), which was suspected on the basis of size, location, and relatively low signal intensity in b.

 


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  		Figure 3b. Histologically proved nodule associated with rheumatoid arthritis in a 42-year-old woman. Before MR imaging, clinical evaluation results were suggestive of a Morton neuroma in the second intermetatarsal space. (a) T1-weighted spin-echo (600/15) and (b) T2-weighted turbo spin-echo (4,500/96 [effective]) MR images, both obtained perpendicular to the metatarsal bones, show what was believed to be a giant-cell tumor of the tendon sheath (arrows), which was suspected on the basis of size, location, and relatively low signal intensity in b.

 
The changes in diagnosis (diagnostic-thinking effectiveness) and the confidence scores are listed in Table 1. In the 39 patients with a diagnosis of Morton neuroma both before and after MR imaging, the confidence score after MR imaging increased by 1 in 10 feet and by 2 in five feet and decreased by 1 in one foot and by 2 in another foot. In 22 feet, the confidence score did not change after MR imaging. The mean confidence score for the diagnosis of Morton neuroma increased from 3.9 before MR imaging to 4.4 after imaging. Slightly lower confidence scores were assigned before MR imaging when no Morton neuroma was subsequently seen on MR images (mean score, 3.5) and when the location changed after MR imaging (mean score, 3.6). Low confidence scores were assigned before MR imaging for intermetatarsal bursitis (mean score, 2.4) and metatarsophalangeal synovitis (mean score, 2.6).


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  		TABLE 1. Effect of MR Imaging Results on Diagnostic Thinking
 
Influence of MR Imaging on Therapeutic Decisions
In 31 of 54 (57%) feet, a change in the treatment plan resulted after MR imaging (Table 2). In 15 feet, the treatment plan changed from conservative treatment to surgery; in five feet, from surgery to conservative treatment. In seven feet, the treatment plan changed after imaging (revision in a different intermetatarsal space or in a metatarsophalangeal joint rather than an intermetatarsal space). In one foot, the treatment plan changed from surgical revision of the intermetatarsal space to osteotomy. In three feet, the plan changed from conservative treatment to discontinuation of therapy. Morton neuromas depicted on MR images had a significantly larger diameter (P = .003) in feet in which surgery was performed (mean diameter, 6.3 mm; range, 3–11 mm) than in feet in which conservative treatment was continued (mean diameter, 4.5 mm; range, 3–7 mm).


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  		TABLE 2. Effect of MR Imaging Results on Therapeutic Decisions
 
Diagnostic Accuracy of MR Imaging
The MR imaging diagnosis was correct in all 23 cases of surgically revised intermetatarsal spaces (20 true-positive, three true-negative). Three intermetatarsal spaces were surgically explored for Morton neuroma despite negative MR imaging results owing to clinical findings suggestive of such an abnormality.


   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Morton neuroma is one of the most common diagnoses to account for pain in the metatarsus (6). The exact etiology of Morton neuroma is controversial. Local entrapment of the nerve by the transverse intermetatarsal ligament, with subsequent perineural fibrosis, is one of the more commonly accepted causes of Morton neuroma (6,11). Other possible pathogeneses include ischemia (12) and compression of the nerve by an inflamed and enlarged intermetatarsal bursa (13).

The symptoms of Morton neuroma have been known since Thomas Morton's (14) description in 1876. The main complaint is localized pain in the region of the metatarsal head, which is aggravated by walking in narrow shoes and can be relieved by means of rest. Palpation of the intermetatarsal space causes pain that often radiates to the toes (15).

Many orthopedic foot surgeons believe that Morton neuroma should be diagnosed clinically. Therefore, the use of imaging—and especially of MR imaging—has been debated (4–6). In an orthopedic textbook (5) published in 1994, MR imaging was labeled as "dubious and costly in the routine diagnosis of interdigital neuroma."

Our results demonstrate that such an opinion should be rejected. In our study, the diagnosis of Morton neuroma was withdrawn by the orthopedic surgeon after MR imaging in 28% of feet. In more than one-third of the remaining feet, MR imaging demonstrated a change in the location or number of neuromas. This result is consistent with the large percentage of changed treatment plans (57%).

Results of previous studies have demonstrated that larger (>5-mm-diameter) Morton neuromas are more commonly symptomatic than are smaller ones (3,16,17). This cut-off value of 5 mm has been confirmed recently in an outcome study (Biasca N, written communication, 1998). The fact that, in our series, larger neuromas were more commonly treated surgically may be related to their less equivocal clinical presentation. It also is feasible, however, that surgeons were more confident about their diagnostic and therapeutic decisions when the neuroma was relatively large on MR images.

The correct location and diagnosis of multiple neuromas may be difficult to determine at clinical examination. Symptoms in the intermetatarsal space adjacent to the space containing a Morton neuroma may have an anatomic explanation: Variable, communicating branches between intermetatarsal nerves have been found (4,18,19) during surgery and in dissected cadaveric feet. Depending on the surgical approach, preoperative determination of the precise location is important. Some orthopedic surgeons explore the adjacent intermetatarsal space when they do not find a neuroma in the initially explored space (19). When a dorsal approach and longitudinal incision (the most commonly performed technique in North America [4,5]) are used, however, exploration of the adjacent intermetatarsal space is not possible without an additional incision. A plantar approach with an ample transverse incision allows exploration of the adjacent intermetatarsal space through the same incision (19); however, this approach is uncomfortable for the patient. After surgery, the patient must limit weight bearing for at least 2 weeks; therefore, the patient returns to work later than would be the case after the dorsal approach (20). Other authors (4) do not favor the plantar approach owing to the possibility of hypertrophic scar formation and persistent pain.

The information provided by MR imaging may improve outcomes after surgery to treat Morton neuroma. Failure rates of 14%–27% after neurectomy for Morton neuroma have been reported (11,15,21). Mann and Reynolds (15) reevaluated failed surgeries by means of clinical examination and radiography but did not find a satisfactory explanation for this problem. They stated that no evidence of a pathologic condition was observed in any adjacent structure of the revised intermetatarsal space. This statement should be critically reassessed on the basis of MR imaging findings such as those presented in this report. A second neuroma in the adjacent space may be responsible for persistent pain. However, assessment of the outcome after MR imaging in patients with Morton neuroma was beyond the scope of this study; moreover, the outcome may also be dependent on the surgical techniques used and on other, uncontrollable factors.

In contrast to other musculoskeletal therapeutic decision-making studies, such as those of abnormalities of the wrist (22) and the knee (23), no tendency to change to more conservative therapy after MR imaging was demonstrated in our study. This does not necessarily mean that MR imaging results induce more expensive treatment. Surgical treatment of Morton neuroma would presumably have been initiated even without findings from MR imaging in many patients after continuation of conservative treatment with limitation of weight bearing, immobilization, physical therapy, and injection of local anesthetics and corticosteroids. It has been estimated (5) that 50%–80% of conservatively treated patients ultimately require excision of the interdigital neuroma as a definitive solution.

On the basis of our experience, we favor MR imaging for the assessment of Morton neuroma. Ultrasonography (US) might prove to be a less expensive alternative to MR imaging—results of a previous study (17) showed that US can demonstrate Morton neuroma—but this would require further study.

To this point, we have assumed that there is a direct causal relationship between the effect of MR imaging findings and changes in therapeutic decisions. However, other influences unrelated to MR imaging may be present. Clinical symptoms may have changed between the first and second clinical evaluation. In addition, patients may need time before they will consent to undergo surgery and may more readily agree with an intervention during the second visit, even without the additional information provided by MR imaging. Patients may also have been influenced by additional information about the possible procedure from elsewhere (eg, a second opinion by another physician). These are the inherent drawbacks of any "before-and-after study" in which the influence of imaging results on the clinician's diagnostic and therapeutic thinking is investigated.

In conclusion, given the limitations of this study, MR imaging results have a major effect on diagnostic thinking and therapeutic decisions in patients suspected of having Morton neuroma. This effect can be explained by the high diagnostic accuracy of MR imaging, which facilitates assessment of the exact location and size of a Morton neuroma. Moreover, differential diagnoses such as stress fracture, metatarsophalangeal synovitis, and intermetatarsal bursitis can be ruled out.


   Footnotes
 
Author contributions: Guarantor of integrity of entire study, M.Z.; study concepts, M.Z.; study design, M.Z., J.H.; definition of intellectual content, M.Z.; literature research, M.Z.; clinical studies, J.K.S., H.P.K., H.Z.; data acquisition, J.K.S., H.P.K., H.Z.; data analysis, M.Z., J.H., J.K.S.; statistical analysis, M.Z.; manuscript preparation, M.Z.; manuscript editing, J.H., H.P.K.; manuscript review, J.K.S., H.Z.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Erickson SJ, Canale PB, Carrera GF, et al. Interdigital (Morton) neuroma: high-resolution MR imaging with a solenoid coil. Radiology 1991; 181:833-836.[Abstract/Free Full Text]
  2. Terk MR, Kwong PK, Suthar M, Horvath BC, Colletti PM. Morton neuroma: evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 1993; 189:239-241.[Abstract/Free Full Text]
  3. Zanetti M, Ledermann T, Zollinger H, Hodler J. Efficacy of MR imaging in patients suspected of having Morton's neuroma. AJR 1997; 168:529-532.[Abstract/Free Full Text]
  4. Mann RA, Baxter DE. Diseases of the nerves. In: Mann RA, Coughlin MJ, eds. Surgery of the foot and ankle. Vol 1. St Louis, Mo: Mosby–Year Book, 1993; 543-573.
  5. Amis JA. Primary interdigital neuroma resection. In: Johnson KA, eds. The foot and ankle. New York, NY: Raven, 1994; 163-177.
  6. Beskin JL. Primary and salvage procedures for Morton's interdigital neuroma. In: Myerson M, eds. Current therapy in foot and ankle surgery. St Louis, Mo: Mosby–Year Book, 1994; 183-187.
  7. Ledley RS, Lusted LB. Reasoning foundations of medical decision making. Science 1959; 130:9-21.[Free Full Text]
  8. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94.
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  12. Nissen KI. Plantar digital neuritis: Morton's metatarsalgia. J Bone Joint Surg [Br] 1948; 30:84-94.
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  16. Zanetti M, Strehle JK, Zollinger H, Hodler J. Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers. Radiology 1997; 203:516-520.[Abstract/Free Full Text]
  17. Redd RA, Peters VJ, Emery AF, Branch HM, Rifkin MD. Morton neuroma: sonographic evaluation. Radiology 1989; 171:415-417.[Abstract/Free Full Text]
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  19. Viladot A. The metatarsals. In: Jahhs MH, eds. Disorders of the foot and ankle. Vol 2. Philadelphia, Pa: Saunders, 1991; 1229-1268.
  20. Nashi M, Venkatachalam AK, Muddu B. Surgery of Morton's neuroma: dorsal or plantar approach?. J R Coll Surg Edinb 1997; 42:36-37.[Medline]
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Interpretation of Digital Mammograms: Comparison of Speed and Accuracy of Soft-Copy versus Printed-Film Display
Radiology, May 1, 2002; (2002) 2232010704.
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C. J. Ashman, R. J. Klecker, and J. S. Yu
Forefoot Pain Involving the Metatarsal Region: Differential Diagnosis with MR Imaging
RadioGraphics, November 1, 2001; 21(6): 1425 - 1440.
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C. Martinoli, S. Bianchi, N. Gandolfo, M. Valle, S. Simonetti, and L. E. Derchi
US of Nerve Entrapments in Osteofibrous Tunnels of the Upper and Lower Limbs
RadioGraphics, October 1, 2000; 20(90001): 199S - 217.
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T. T. Miller, C. Martinoli, L. E. Derchi, and S. Bianchi
Invited Commentary
RadioGraphics, October 1, 2000; 20(90001): 213S - 217.
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N. H. Theumann, C. W. A. Pfirrmann, C. B. Chung, A. V. R. Mohana-Borges, P. Haghighi, D. J. Trudell, and D. Resnick
Intermetatarsal Spaces: Analysis with MR Bursography, Anatomic Correlation, and Histopathology in Cadavers
Radiology, November 1, 2001; 221(2): 478 - 484.
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E. D. Pisano, E. B. Cole, E. O. Kistner, K. E. Muller, B. M. Hemminger, M. L. Brown, R. E. Johnston, C. M. Kuzmiak, M. P. Braeuning, R. I. Freimanis, et al.
Interpretation of Digital Mammograms: Comparison of Speed and Accuracy of Soft-Copy versus Printed-Film Display
Radiology, May 1, 2002; 223(2): 483 - 488.
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