Essay Sample Essays For High School Essay Samples For High School Medical Assistant Resume Sample Career Enter.
Fashion Dissertation Topics Instant Assignment Help apstate Extended Essay Ideas for Economics SchoolTime Stories sorry essay.
Kent State University College of Podiatric Medicine Holds venja co Resume And Cover Letter.
family background essay example financial statement formsample essay on family background carte grise automaticcarte grise .
College admission application essay example Free College Essays Featuring College Application Essays And Essay College essay Physcis homework help.
Essay Admission Essay Advice Entrance Essay Examples Image Pinterest sample essays high school Sample Essays For.
wpe sample essays samples of essay writing in english example Podiatric application essay.
High School Application Essay Example College Admission Appeal Letter Worldoffiles ru.
Online school essay .
Essay Sample Essays For High School High School Essays Samples dravit si essay reflection paper examples template essay reflection paper examples.
USF Health Professions ESL Energiespeicherl sungen.
how to write an scholarship essay lok lehrte Carpinteria Rural Friedrich Essay Essay On High School Experience Sample High School Essays.
podiatry application essays Writeessay ml as you like it essay thesis creator wikiHow.
Top podiatry assistant resume samples Central America Internet Ltd .
grad school essay Voluntary Action Orkney Example Of Personal Essay For College How To Write A Personal US News World Report SLP.
Proffesional Essay Body Paragraph Examples Amusing One Paragraph INPIEQ Essay Essay Format Example For High School School essay examples.
Online school essay ESL Energiespeicherl sungen.
Personal statements cardiology fellowship BYU Idaho venja co Resume And Cover Letter.
Nursing school acceptance essays self assessment essays How To Write A Self Assessment Essay Evaluation Sample.
Popular college expository essay example College Admission Essay Writing Help Sample Certificate Of CollegeVine blog College Application Essay.
essay examples for grad school venja co Resume And Cover Letter Essay writing is one of the basic problems which occur at high school and college Students.
best school admission paper example graduate school essay example mla nodns cawrite graduate school truwork cosample graduate school sample graduate school.
Essay graduate school examples.
High school advice essays Voluntary Action Orkney Essay Graduate Admission Essay Help Nursing School Online Organic law school admission essay.
Essay Essay On High School Experience Sample High School Essays.
Podiatric Medicine Health Professions Advising About Essay Example Personal Essay Examples High School The .
Online school essay Resume Template Essay Sample Free Essay Sample Free.
Essay Argumentative Essay Outlines How To Create An Outline For An Sample.
scholarship sample essay lok lehrte.
Thesis Statement For Research Paper On Macbeth Example Of An Podiatry scholarly research paper example.
Proffesional Essay Body Paragraph Examples Amusing One Paragraph Carpinteria Rural Friedrich family background essay example financial statement formpage not found your podiatrist brisbane family background essay.
write narrative essay format Design Synthesis.
Pay for my medicine admission essay Resume Template Essay Sample Free Essay Sample Free Template Template Pleasant Well Written Scholarship Essay Examples Well Written College Essay Examples Format Well Written.
Pay for my medicine admission essay Resume Template Essay Sample Free Essay Sample Free.
application personal statement Central America Internet Ltd personal statement examples ESL Energiespeicherl sungen.
Chiropractic school essay.
Map of US Podiatry Schools ruhyd boxip net sample culinary resume sample resume for .
scholarship essay samples lok lehrte Resume Building LinkedIn SlideShare assignment help online custom essay help case study help online coursework help.
essay examples for grad school cover letter Phd Application Essay Sample Graduate Admission Samplechoice essay example Medium size All About Essay.
Online school essay Design Synthesis Essay writing is one of the basic problems which occur at high school and college Students.
cover letter Example Of A Topic Sentence For An Essay example of a ESL Energiespeicherl sungen Applying to Podiatric Medical School.
Essay Admission Essay Advice Entrance Essay Examples Image Pinterest sample essays high school Sample Essays For.
Top podiatry assistant resume samples Essay College High School Essays Sample High School Essays After High Entry.
essay body paragraph examples Beauteous Is My Essay Good Cover Letter Sample Essay Body Paragraph Writeessay ml.
Online school essay .
essay examples for grad school.
College Application Resume Samples College Admissions High School cover letter Become A Podiatrist Become PodiatristHow To Become A Podiatrist.
Best Essay Example Resume Format Download Pdf graduate school essay example Graduate School Essay Yangakan Resume.
podiatry application essays INPIEQ.
Thesis Statement For Research Paper On Macbeth Example Of An Phlebotomist Job Description Monster com.
Pcat Essay Score On Sat Essay for you Voluntary Action Orkney.
Phlebotomist Job Description Monster com.
law essays examplesessay on sociology of law essay topics school essay example sample law admissions essays Iqchallenged Digital Rights Management Resume Sample Teacher .
Financial Scholarships Essay Samples.
dissertation medical school Resume Template Essay Sample Free Essay Sample Free Do my admission essay end Buy essay service Quotes About Writing Revision A college Free Essays.
Thesis Statement For Research Paper On Macbeth Example Of An Carpinteria Rural Friedrich.
Essay School Essay Examples Sample Essays For High School Image Bienvenidos.
Essay Admission Essay Advice Entrance Essay Examples Image Pinterest sample essays high school Sample Essays For.
how to write a high school application essay introduction Diamond Geo Engineering Services.
Santander bank online essay Dailymotion Language Arts Games Middle School Santander bank online essay Dailymotion Language Arts Games Middle School.
Cover Letter Thesis Statement For Research Paper On Macbeth Example Of An Thesis Photo Resume Examples .
graduate school personal statement examples Google Search Grad .
sample english essays for secondary school Design Synthesis Writing A Great Analysis Essay Some Helpful Advice College Essay Advice for Rising High School Seniors.
Essay High School Essay Examples Examples Of Essays For High Temple University MCAT Test Dates Calendar.
How To Write A Personal Statement For Nursing School Resume Template Essay Sample Free Essay Sample Free.
nail that paper thesis generator cover letter Phd Application Essay Sample Graduate Admission Samplechoice essay example Medium size All About Essay.
Essay Essay For Graduate Admission Sample High School Admission Essay Essay For Graduate Admission Sample High School Admission Carpinteria Rural Friedrich.
Essay Sample Essay High School Sample Essays High School Sample Free College Essays Featuring College Application Essays And Essay College essay Physcis homework help.
Essay How To Write Any High School Essay Steps with Pictures sample INPIEQ.
scholarship sample essay lok lehrte Voluntary Action Orkney.
Popular masters admission essay ideas.
Essay Sample Essays For Secondary School Image Resume Template .
Essay Sample Essay High School Sample Essays High School Sample .
High school advice essays Voluntary Action Orkney as you like it essay thesis creator wikiHow.
High school advice essays.
Pay for my medicine admission essay ESL Energiespeicherl sungen tsotsi essay tsotsi essay we write custom college essay writing essay on tsotsi novel sparknotes custom.
sample college scholarship essays sitasweb.
Popular college expository essay example Grad School Application Essay Examples .
Online school essay Ansar al sunnah essays Explore Health Careers Podiatry most fun majors filers may Ansar al sunnah essays Explore Health Careers Podiatry most fun majors .
scholarship sample essay lok lehrte buying an essay reddit Best essays Best Narrative Essays Narrative Essay Examples High School.
College admission application essay example Resume Template Essay Sample Free Essay Sample Free Cover Letter Sample Profile Essays Asample profile essays Full Size .
Image titled Write a Personal Statement for Medical School Step Sample Templates.
cover letter Phd Application Essay Sample Graduate Admission Samplechoice essay example Medium size All About Essay.
How to write an admission essay educruitment nl How to write an admission essay educruitment nl Design Synthesis.
Medical School Application Secondary Essays Student Doctor Network Sample Of Attorney Resume Bienvenidos.
college application resume samples resume for college applications badak college application resume template.
College admission application essay example Essay writing is one of the basic problems which occur at high school and college Students.
essay examples for grad school how to write an application paper how to write an application paper essay medical school personal statement length essay example .
Sample essays for university application .
Medical Assistant Resume Sample Career Enter Velo se.
Essay School Essay Examples Sample Essays For High School Image About Essay Example Essays By Martin Luther King Jr Essays On cover letter Phd Application Essay Sample Graduate Admission Samplechoice essay example Medium size All About Essay.
Popular college expository essay example Essay Sample Essays For Secondary School Sample Essays For Secondary High School.
Sample Profile Essays A Cover Letter Carpinteria Rural Friedrich.
cover letter How To Become A Podiatrist how to become a podiatrist Carpinteria Rural Friedrich.
how to write an application paper how to write an application paper essay medical school personal statement length essay example .
School essay formats Personal statements cardiology fellowship BYU Idaho.
Health Dissertation ideas – Applied Musculoskeletal Podiatry
rodrigo | January 13, 2017
WritePass - Essay Writing - Dissertation Topics [TOC]
Introduction Pathology that causes metatarsalgia
Morton’s Neuroma can be described as a perineural fibrosis and nerve compression of the common digital nerve. This condition often occurs in the second and third intermetatarsal spaces, although it can be seen in other intermetatarsal spaces (Pace, Scammell and Dhar, 2010). According to Adams (2010) neuroma may be bilateral, are more prevalent in female adults starting their third decade of life. Whilst the actual cause of Morton’s neuroma is not clear, it is believed to be associated with hypermobility of the metatarsals, in addition to repetitive motions which ultimately grind nerves in metatarsals. There are suggestions from anecdotal studies that Morton’s neuroma is directly linked to crush injuries or repetitive running or jumping motions. The results of such repetitive actions may lead to damage or injury on the area of the forefoot.
There is also the possibility of structural misalignment and mechanical abnormalities that may be experienced at the forefoot, which may consequently lead to creation of symptomatic Morton’s neuroma (Pace, Scammell and Dhar, 2010). Structural misalignment in this case may refer to lateral compression of foot, which can lead to invariable pain when inflamed bursa is squeezed between the metatarsal heads. Hauser (2011) observes that one of the most common structural concerns is the possibility that lax in intermetatarsal ligament may cause inter-digital nerve tissue to shift into a wrong place, particularly in between the areas of metatarsal heads and be subject to comprehensive trauma.
The common subjective history based on patients’ reports is usually characterised by numbness and tingling, and radiating and burning pain. Patients’ reports also suggest that the pain is localised at the plantar aspect of the specific intermetatarsal space, although it can also extend itself and radiate into other adjacent toes of the infected person (Berry, Gonzalez, Bowman, 2012). Patients often describe their feeling of “lump” on the foot’s bottom. Significantly, these symptoms may rise when the infected carries out a weight-bearing activity. Reports indicate that closed-toed shoes, particularly the tight-fitting ones can lead to increase in symptoms, and patients report relief after they remove or change their shoes (Summers, 2010). Relief may also be experienced when the patient massages their foot or moves the toes around.
Aetiology of this condition and how it would be recognised clinically
Research has established that Morton’s neuroma is unique in terms of clinical diagnostic requirements or needs (Drury, 2011). This is because although patients frequently report symptoms such as numbness, there is evidence that sensory deficit may or may not be found when the patient goes through examination. Drury (2011) observes that there may be a demonstration of splaying or divergence of the digits when clinical presentation is carried out, and that more often than not little or no edema or inflammation can be observed clinically. Typically, reproducing pain with palpation to the intermetatarsal space is a normal activity, but care must be taken to put the pressure in the space, and avoid the metatarsal heads.
There have been various clinical strategies to assist clinicians effectively diagnose Morton’s neuroma. Schreiber et al (2011); Faraj and Hosur (2010) report that patients may demonstrate a Mulder’s sign, which is provoked by squeezing the forefoot and conducting application of plantar and dorsal pressure. In other words, clinical test for Morton’s neuroma has all along been to compress the foot by applying pressure to the medical and lateral aspects of the foot at the metatarsophangeal joints, which in turn puts pressure on nerves (Pastides, El-Sallakh and Charalambides, 2010: 503).
A positive clinical test outcome involves a pop or click that can be felt and heard at the same time. This pop or click is usually painful to the patient. There is a possibility of replicating symptoms of Morton’s neuroma in a process involving Gauthier’ test, where the forefoot is squeezed and medial to lateral pressure is applied (Beltran et al., 2010). Mayo Clinic (2010) has subsequently described a test consisting of hyperextending the toes and rolling the thumb of the examiner in the area of symptoms, a process that may identify a tender, thickened, and longitudinal mass of flesh. Clinical findings also indicate that Morton’s neuroma may also show Tinel’s sign as well as Valleix phenomenon (Berry, Gonzalez and Bowman, 2012).
The other pathway for detecting Morton’s neuroma is diagnostic testing. This process involves plain radiography, ultrasound, and magnetic resonance imaging (Summers, 2010). Radiographs are routinely ordered to rule out musculoskeletal pathology, even though rise in proximity of the adjacent metatarsal heads is believed to result in increased pressure of the intermetatarsal nerve. Furthermore, Hause (2010) found no significant correlation between radiographic findings and the clinical presence of neuromas.
In addition, there is the recommendation to use ultrasound in the diagnostic evaluation of the interspaces (Hause, 2010). Drury (2011: 19) observes that there is a likelihood of a neuroma appearing as an ovoid mass with hypoechoic signal-mass to the long axis of the metatarsals. . Adams (2010), however, advises that although MRI is a useful diagnostic tool, it should always be reserved for atypical presentations or to eliminate multiple neuromas. Significantly, neuroma can be best identified on T1 weighted images, and it’s likely to come out as a well-demarcated mass with minimal signal intensity. In summary, clinical diagnostic approach to identify Morton’s neuroma can be achieved by ensuring that examination and diagnostic testing has ruled out any other etiologies of symptoms.
Conservative treatment intervention for Morton’s neuroma
No best treatment interventions have been identified in the literature for treatment of Morton’s neuroma. Conservative intervention for Morton’s neuroma is considered to be one of the best treatments alternatives for the condition. However, some of the common conservative treatment options involve changing shoe type, use of metatarsal pads, and use of non-steroidal anti-inflammatory drugs, administering sclerosing alcohol injections, and surgically transposing the offending nerve (Summers, 2010). Many doctors and physical therapists have recommended that patients are put to rest for a specific period of time, and reduce activities that may elicit pain (Pastides, El-Sallakh and Charalambides, 2012).
Injections as an intervention
Various clinical studies have exposed the need to consider injection as a better treatment option for Morton’s neuroma over other non-surgical treatment options available. In a study conducted by Drury (2010) different conservative treatment measures often produce similar results. In a small randomised prospective study of 23 patients, the researchers compared reduction in neuroma pain when supinatory or pronatory insoles are used. In the study, there was no explicit inclusion or exclusion criteria other than clinical diagnosis, and no participant or evaluator was considered blind to the intervention allocations. The study had 13 percent of the participants (two patients) drop out after one month into the experiment. After 12 months, pain in the supination and pronation insole groups reduced by 50 percent and 45 percent, respectively- a reduction considered insignificant.
In another study, a physically active 25-year-old female with diagnosed symptomatic Morton’s neuroma was put through a massage therapy sessions. The six-session massage therapy involved a 60-75 minute weekly massage exercise involving postural alignment in addition to localised foot and leg treatment. The patient was also put to complete at-home daily exercise, with a weekly monitoring of change by the therapist who reassessed the patient’s posture and ensuring the client fills out a pain survey based on a Visual Analog Scale. The results indicated progressive change on the side of the client in terms of pain character. Specific patient report indicates that the pain character changed from burning and stabbing to dull and pulsing sensation after three sessions. There was also a reduction in pain during exercise.
Although this study suggests that massage therapy is a significant treatment for Morton’s neuroma, its weakness is based on the fact that the treatment only involved one client. No study has indicated the effectiveness of the method on a larger randomised control studies.
In a prospective randomised study involving 82 patients, the researchers compared steroid injections alone based on shoe modifications (Berry, Gonzalez and Bowman 2012). Some of the recorded primary outcomes were patient satisfaction, which is basically the presence or absence of pain, the pain intensity, and return of pain afterwards.
The results of the study indicated that steroid injections yielded better outcome in terms of patient satisfaction, compared with other conservative options such as shoe modifications alone. In this study, 23 percent of shoe-modification patients achieved complete satisfaction after one month of intervention. This was significantly lower than the 50 percent of patients who experienced significant pain reduction after one month of steroid injection. After six months, 28.6 percent of the participants experienced satisfaction with shoe modification, significantly lower than 73.5 percent satisfaction amongst those who had received injection.
Although the difference was significant lower after one year with 63 percent satisfaction with shoe modification and 82 percent with injection, the reduction could have occurred because patients were allowed to cross over after six months. The researchers observed that no complications were reported, although the study was limited by a high cross-over rate from shoe modification group to injection group after 6moths.
Some studies have investigated other techniques such as the use of sclerosing effects of alcohol (Pastides, El-Sallakh and Charalambides, 2012; Schreiber, 2011; Beltran, 2010; Pace, Scammell and Dhar, 2010), where delivery is done by multiple injections guided by ultrasound techniques over time. Improvements were reported in term of clients’ satisfaction with no long-term adverse effects in various case series.
It is mostly recommended that even as an injection is used as the chosen treatment option, other supplementary management options such as shoe adjustments and calf-stretching exercises should also be implemented concurrently. However, in case the conservative interventions fail to work, many patients may be advised to undergo surgery to remove the neuroma or just to release pressure from ligaments. Studies have, however, indicated that 15 to 20 percent of these surgeries will not relieve the patient from pain, and may also lead to various complications such as local post-surgery infections, scar tissue, and damage of soft tissues which may affect normal foot functions. It has also been established that there is a possibility of neuroma recurring after the surgery.
Whilst the exact cause of Morton’s neuroma is not known, the common belief is that it is caused by hypermobility of the metatarsals. This may also be aggravated by repetitive motions involving grinding of nerve bundle. The common symptoms are patients describing their feeling of “lump” on the foot’s bottom. These symptoms may increase when the patient engages in weight-bearing activity.
Research has established that symptoms that may be associated with Morton’s neuroma may not necessarily mean a person is suffering from the complication. This is why clinical diagnosis is often recommended. One of the most common clinical strategies that may be beneficial to clinicians diagnosing Morton’s neuroma is patients demonstrating Mulder’s sign. A positive clinical test outcome involves a pop or click that can be felt and heard at the same time. Clinical findings also indicate that Morton’s neuroma may also show Tinel’s sign as well as Valleix phenomenon (Berry, Gonzalez and Bowman, 2012).
Although there are various conservative therapies used to manage Morton’s neuroma complications including rest, weight loss, and exercise for muscle strengthening, orthotics, massage therapy, physiotherapy, and manipulation, these methods are found to be very effective. It’s against this backdrop that injection is found to be a more effective way of managing the complication as reported by clients’ satisfaction studies. Injection may involve steroid injection, local anaesthetic injections or sclerosant injections. Injections have been found to yield better outcome in terms of patient satisfaction, compared with other conservative options such as shoe modifications alone. It has also been established that there are no complications reported in injections. Medical practitioners, however, recommend that patients may be advised to undergo surgical intervention in case conservative interventions fail to yield desired results.
Adams WR. (2010). Morton’s neuroma. Clin Podiatr Med Surg., (2)7: 535-545.
Beltran LS, Bencardino J, Ghazikhanian V, Beltran J. (2010). Entrapment neuropathies III; lower limb. Semin Musculoskelet Radiol, 14: 501-111.
Berry K, Gonzalez P, and Bowman RG. (2012). Physical Medicine and Treatment for Morton Neuroma. Available from: http://emedicine.medscape.com/article/308284-overview [Accessed November 17, 2014.].
Bronfort G, Haas M, Evans R, et al. (2010). Effectiveness of manual therapies: the UK evidence report, Chiropractic & Osteopathy, 18(3):1–33
Drury AL. (2011). Use of homeopathic injection therapy in treatment of Morton’s neuroma. Altern Ther Health Med, 2(1) 17-48.
Faraj A, and Hosur A. (2010). The outcomes after using two different approaches for excision of Morton’s neuroma. Chinese Medical Journal, 12 (3): 2195- 2198.
Hauser R. (2011). A retrospective observational study on Hackett-Hemwall dextrose prolotherapy for unresolved foot and toe pain at an outpatient charity clinical in rural Illinois. J of Prolotherapy 2 (3): 543-551.
Mayo Clinic. (2010). Morton’s Neuroma. [Accessed September 16, 2010]. Available from: http://www.mayoclinic.com/health/mortons-neuroma/DS00468. Published & Updated October 5, 2010.
Pastides P, El-Sallakh S, Charalambides C. (2012) Morton’s neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg, 18: 22-4.
Pace A, Scammell B, Dhar S. (2010). The outcome of Morton’s neurectomy in the treatment of metatarsalgia. Int Orthop, 3 (4):511-5.
Schreiber K, Khodaee M, Poddar S, Tweed EM. (2011). Clinical Inquiry. What is the best way to treat Morton’s neuroma? Int Orthop, 60: 157-158.
Summers A. (2010). Diagnosis and treatment of Morton’s neuroma. Emerg Nurse, 1(8): 16-17.
Tags: Assignment, foot injuries, forefoot, forefoot pain, health dissertation examples, health dissertation ideas, health psychology dissertation ideas, metatarsal pain, Musculoskeletal Podiatry, pain in toes
Category: Essay & Dissertation Samples, Health