What is the management plan for a patient with pain in the base of the 2nd and 3rd toe, diagnosed with Morton's neuroma bursal complexes and osteoarthritis of the 1st MTP joint?

Management of Morton's Neuroma and Osteoarthritis of the Foot

For a patient with Morton's neuroma bursal complexes in the 2/3 and 3/4 webspaces and osteoarthritis of the 1st MTP joint, treatment should begin with ultrasound-guided corticosteroid injections for the neuromas, combined with orthotic devices and NSAIDs for pain management.

Understanding the Ultrasound Findings

The ultrasound reveals three distinct pathologies:

1. Morton's neuroma bursal complexes in the 2/3 webspace (16 x 14mm) and 3/4 webspace (16 x 6mm)
2. Osteoarthritis of the 1st MTP joint with effusion and chronic synovitis
3. Small effusion of the 1-2 webspace intermetatarsal bursa (4 x 3mm)

Treatment Algorithm for Morton's Neuroma

First-line Treatment:

• Ultrasound-guided corticosteroid injection into the affected webspaces (2/3 and 3/4)
  • Ultrasound guidance significantly improves outcomes compared to non-guided injections with better pain reduction and functional improvement 1, 2
  • A series of three weekly injections of corticosteroid (triamcinolone) is recommended 1

Conservative Measures:

• Orthotic devices:

  • Metatarsal pad or bar to spread the metatarsal heads and reduce pressure on the neuroma
  • Wide, low-heeled shoes with adequate toe box to reduce compression

• Activity modification:

  • Avoid high-impact activities and tight footwear
  • Weight management if applicable

Second-line Treatment:

• If symptoms persist after 6-8 weeks of conservative treatment, consider:
  • Repeat corticosteroid injection (if first injection provided partial relief)
  • Alternative injection options (hyaluronic acid may be considered if corticosteroids are contraindicated) 1

Third-line Treatment:

• Surgical intervention if conservative measures fail after 3-6 months:
  • Neurectomy through dorsal approach is preferred over plantar approach to avoid painful scarring 3, 4
  • Surgical excision has high success rates (85-90%) for pain relief 5

Management of 1st MTP Joint Osteoarthritis

First-line Treatment:

• Topical NSAIDs (particularly diclofenac gel) 6, 7
• Oral NSAIDs at lowest effective dose for shortest duration if topical treatment is inadequate 6
• Hand orthoses (for 1st MTP joint) 7
  • Custom-made orthoses are recommended over prefabricated ones for better compliance 7

Physical Therapy Interventions:

• Exercise program focusing on:
  • Range of motion exercises for the affected joint
  • Strengthening exercises for intrinsic foot muscles
  • Joint mobilization techniques 6, 7

Additional Measures:

• Education on joint protection principles and activity pacing 6
• Proper footwear with adequate toe box and cushioning

Monitoring and Follow-up

• Reassess after 6-8 weeks of initial treatment
• If no improvement occurs, consider referral to a podiatric foot and ankle surgeon 6
• Regular clinical and functional assessments should be performed to evaluate:
  • Pain levels (using visual analog scale)
  • Range of motion
  • Functional improvement
  • Ability to perform daily activities 7

Potential Complications and Precautions

• Corticosteroid injections: Monitor for skin atrophy, hypopigmentation, and plantar fat pad atrophy (reported in 2.6-3.9% of cases) 2
• Surgical complications: Potential for hypoesthesia, painful scarring, or recurrence 3, 4
• NSAIDs: Consider cardiovascular, gastrointestinal, and renal risks, especially in older patients 6, 7

Special Considerations

• The small effusion in the 1-2 webspace intermetatarsal bursa (4 x 3mm) is likely clinically insignificant and may resolve with treatment of the other conditions
• For patients with multiple foot pathologies as in this case, addressing the Morton's neuromas first is recommended as they are likely the primary source of the patient's pain at the base of the 2nd and 3rd toes

By following this structured approach, most patients with Morton's neuroma and osteoarthritis of the foot can achieve significant pain relief and improved function.