The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 374–377

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The Egyptian Journal of Radiology and Nuclear Medicine

journal homepage: www.elsevier.com/locate/ejrnm

Original Article

Ultrasound guided radiofrequency ablation of Morton’s neuroma: A T

substitute for surgery
Ahmed M. Bassiouny
Department of Radiodiagnosis and Interventional Radiology, Ain Shams University Hospitals, Egypt

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: To assess the efficacy of radiofrequency ablation of Morton's neuroma (MN) as a substitute to surgery,
Morton's neuroma in patients not responding to conservative treatment.
Radiofrequency Methods: 15 patients, who performed radiofrequency ablation (RFA) of Morton's neuroma between November
2015 and December 2016, were submitted to follow up to assess the response to therapy over a period of
6 months by assessment of pain relief through visual analogue scale (VAS) scale from 1 to 10 from least to severe
pain.
Results: All of the 15 patients suffered from intense pain during their normal daily activity prior to RF ablation,
pretreatment VAS average was 7.
Follow up of the patients was done after 1 week, 1 month, 3 months and 6 months.
After RF ablation, pain disappeared in 9 cases (60%), 3 had mild pain (20%), 2 moderate pain (13.3%) and 1
with severe pain (6.6%) and proceeded to surgery. Complete resolution of pain was encountered in the patients
with mild and moderate pain with conservative or second session of RFA.
Conclusion: Radiofrequency ablation of Morton's neuroma, is an effective technique in treatment of symptomatic
patient's after failure of conservative treatment and prior to surgical intervention.

1. Introduction 2. Materials and methods

Morton's neuroma (MN) is a painful condition affecting the common
digital nerve of the foot. It is a nerve entrapment condition under the
transverse metatarsal ligament [1,2].
This condition is aggravated by the wearing of tight shoes or by
using compressive stockings. The pain is usually described by the pa-
tient as: acute, severe, radiating to the toes, leg sometimes with strong
burning sensation. Local paresthesia of the 3rd and 4th toes is very
common. The pain is commonly felt in the third intermetatarsal space,
less often in the second, rarely in the fourth and extremely rarely in the
first intermetatarsal space [3].
The incidence of Morton’s neuromas is common in females at their
fifth decade and it affects the digital nerve of the third inter digital
space more than in the second space with ratio 2:1 [1,4].
Radiofrequency ablation is a practical and effective solution in pa-
tients not responding to conservative treatment. Above 88% of the af-
fected patients had complete resolution of the pain without further
surgical intervention or any other procedures [5].
15 patients were reviewed with 15 MN all were females with mean
age 42 years. Patients were diagnosed clinically to have MN, con-
firmation of diagnosis was made by ultrasound and/or MRI (Fig. 1 ),
(Fig. 3A–C).
None of the 15 patients responded to conservative treatment for at
least 3 months and were candidates for surgical excision.
RFA of the neuromas was their last option prior to surgery.
2.1. Technique
The study was approved by our institution review board.
A written consent was taken from the patients with detailed steps of
the procedure and its possible complications.
First ultrasound was done to region of complain to confirm the di-
agnosis of Morton's neuroma, and assess the access for RFA.
The patient is in supine position with sterile field prepared.
Under ultrasound-guidance, a sterile 5 cm long radiofrequency
needle was inserted, through either plantar or dorsal aspect access,
inside the neuroma (Fig. 2).

Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Medicine.
E-mail address: ahmed_bassiouny@med.asu.edu.eg.

https://doi.org/10.1016/j.ejrnm.2017.11.008
Received 27 July 2017; Accepted 22 November 2017
Available online 03 May 2018
0378-603X/ copyright 2018 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A.M. Bassiouny
Fig. 1. Figures (A) and (B) show ultrasound appearance of Morton's neuroma
between the 3rd and 4th metatarsal bones.
Fig. 2. Radiofrequency needle in Morton's neuroma.
Proper position of the needle tip is confirmed by ultrasound and
sensory stimulation, where the patient feels pain similar to that of her
symptom, then local anesthesia using 1 cc of 2% Xylocaine was applied.
RFA was done using our machine Neurotherm NT1100
(Neurotherm, USA), guided by superficial ultrasound probe 7.5 MHz
(My Lab 40, Esaote, ITALY) 3 times along the course of the neuroma
with temperature up to 75–80 °C each time for about 60 s.
Pain relief after local radiofrequency nerve ablation is thought to
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The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 374–377
result from an increase in local temperature at the site of application
around the electrode to the point of disruption of the tissue protein
chains, which subsequently destroys the peripheral nerve endings, and
the myelin sheaths, blocking only nociceptive input [6,7].
Other authors thought that pain regression after RF ablation results
are not from the actual destruction of nerve tissue, but are from pow-
erful electric fields induced by voltage fluctuations in the area of lesion
[8,9].
Patients are allowed to leave with bandage at operative site after
observation for 30 min.
Rest at home for 24–48 h and wearing comfortable not tight shoes is
advised before returning to normal life style.
Patient can take NSAIDS for postoperative pain if necessary.
Follow up ultrasound is done at 1, 3 and 6 months post ablation,
MRI was done in selected cases according to their complain or pain
score.
2.2. Statistical analysis
Analysis of data was done by IBM computer using SPSS (statistical
program for social science version 12).
• Description of quantitative variables as mean and range.
• Description of qualitative variables as number and percentage.
3. Results
Of the 15 patients, all suffered from pain during their normal daily
activity prior to RFA, pretreatment VAS average was 7 (Table 1), pain
duration was variable ranging from 3 months up to 8 months, con-
servative treatment was given for 3 months.
In our study patient’s not responding conservative treatment for at
least 3 months are candidates for RFA.
13 MN were found in the 3rd web space (86.6%) while only 2 were
found in the 2nd web space (13.3%).
Follow up of the patients was done after 1 week, 1 month, 3 months
and 6 months.
After RF ablation pain disappeared in 9 cases (60%), 3 had mild
pain (20%), 2 moderate pain (13.3%) and 1 with severe pain (6.6%)
proceeded to surgery (Table 2).
Patients with mild and moderate pain were treated by bupivacaine/
triamcinolone, resolved pain was encountered in the three cases of mild
pain and one of the moderate pain cases, the second patient with
moderate pain was offered another setting of RFA, that totally resolved
the pain (Table 3).
4. Discussion
In patients with symptomatic Morton's neuroma not responding to
conservative treatment, RFA is considered a second option prior to
surgical solution.
In our study, none of our patients had complications, thus sup-
porting the safety and efficacy of the procedure.
Open neurectomy complications are minimal, however as any sur-
gery there are risks, as hematoma, stump neuroma and abscess for-
mation.
Surgical endoscopic decompression of the neuroma (EDIN-Barrett
technique), requires at least 6 months to evaluate success [10].
Previous study showed that failure to respond to conservative
measures radiofrequency treatment is considered a more beneficial
procedure than open neurectomy. It causes destruction of the periph-
eral nerve endings and myelin sheath at site of maximum tenderness
[11].
A.M. Bassiouny The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 374–377

Fig. 3. T1WI Pre ablation (A) T1WI post ablation after 1 month with regression in size, (B) Fat suppression images postcontrast more regression in size after 6 months
with only post therapeutic enhancement pattern (C).

In our study after RFA 60% of the patients had no pain, 20% had
mild pain and 13.3% had moderate pain which was satisfactory for
them compared to the initial pain, only one case had an unsatisfactory
outcome.
Finny et al. found that the procedure is satisfactory in 68% of cases
and non-satisfactory in 32% [12].
In literature radiofrequency ablation is a fast technique that can be
done in ambulatory conditions without sutures and it gives the similar
results of positive outcomes as surgical procedures but without serious
complications. The procedure has minimal or almost no side effects or
disability [13].

Table 2
Table 1 Response to pain after RFA of MN.
Visual analogue scale for pain (VAS).
Response to pain %
0 1 2 3 4 5 6 7 8 9 10
No pain 60 (n = 9)
No complain Annoying Uncomfortable Horrible/agonizing Mild 20 (n = 3)
No pain Mild pain Moderate pain Severe pain Moderate 13.3 (n = 2)
Severe 6.6 (n = 1)

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A.M. Bassiouny The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 374–377

Table 3 References
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Conflict of interest
Morton’s neuroma: a valid minimally invasive treatment procedure in patients re-
sistant to conservative treatment. Open J Orthopedics 2013;2013(3):325–30.
No conflict of interest to be declared.

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