4. Grayscale Images Through the Third Webspace
+ D = 15.1 mm
x D = 7.4 mm
xx
xx
Sagittal and axial grayscale sonographic images at the level of
the third metatarsal head demonstrate an ovoid hypoechoic
mass
+
+
+
+
7. Neuroma Case Points
Tibial n.
Medial
Plantar n. Lateral
Plantar n.
• Fibrosis, local
vascular proliferation,
and edema adjacent
to an enlarged digital
branch of the medial
or lateral plantar
nerves
8. Neuroma Case Points
Tibial n.
Medial
Plantar n. Lateral
Plantar n.
• Fibrosis, local
vascular proliferation,
and edema adjacent
to an enlarged digital
branch of the medial
or lateral plantar
nerves
• Found on the plantar
side of the transverse
metatarsal ligament
9. Neuroma Case Points
Tibial n.
Medial
Plantar n. Lateral
Plantar n.
• Fibrosis, local
vascular proliferation,
and edema adjacent
to an enlarged digital
branch of the medial
or lateral plantar
nerves
• Found on the plantar
side of the transverse
metatarsal ligament
• Patients present with
metatarsalgia
12. Neuromas: US
• Typically hypoechoic on US
• May be hypervascular on power Doppler
• Can see continuity with the digital nerve
13. Neuromas: US
• Typically hypoechoic on US
• May be hypervascular on power Doppler
• Can see continuity with the digital nerve
Digital
Nerve
Neurom
a
14. Neuromas: US
• Typically hypoechoic on US
• May be hypervascular on power Doppler
• Can see continuity with the digital nerve
• Sonographic Mulder‟s sign: Palpable „click‟ from
the neuroma popping out of the intermetatarsal
space upon tranverse compression of the
metatarsal heads while the transducer applies
pressure on the plantar surface of the neuroma
17. Neuromas: MRI
• Teardrop shaped
• Iso/hypointense on T1 and
iso/hyperintense T2
• May be associated with intermetatarsal
edema/bursitis
18. Neuromas: MRI
• Teardrop shaped
• Iso/hypointense on T1 and
iso/hyperintense T2
• May be associated with intermetatarsal
edema/bursitis
• Variable enhancement or nonenhancing
20. Neuromas: Treatment
This 34 year old dancer has a history of two prior steroid injections of a
second webspace neuroma. Note the foci decreased echogenicity
consistent with scarring. Foci of increased echogenicity are related to
microbubble formation and the inherent contrast effect of the steroid/
anesthetic mixture
22. Neuromas: Treatment
36 year old male with a
third webspace
neuroma, status post
prior steroid/anesthetic
injection with only
temporary relief
US guided placement of
a cryoablation needle
into the third webspace
neuroma
Post cryoablation
image with formation
of an “ice ball” (see
next slide)
23. Neuromas: Treatment
Cryoablation of
neuromas typically
involves 2-3 cycles of
freezing with
intervening shorter
cycles of thawing,
resulting in the
formation of the
characteristic “ice ball”
25. References
• Bencardino J, Rosenberg ZS, Beltran J, et al. Morton‟s neuroma: is it
always symptomatic? AJR Am J Roentgenol 2000; 175: 649-653
• Hughes RJ, Ali K, Jones H, et al. Treatment of Morton‟s neuroma
with alcohol injection under sonographic guidance: follow-up of 101
cases. AHR Am J Roentgenol 2007;188: 1535-1539
• Quinn TJ, Jacobson JA, Craig JG, et al. Sonography of Morton‟s
Neuromas. AJR Am J Roentgenol 2000;174: 1723-1728
• Sofka CM, Adler RS, Ciavarra GA, et al. Ultrasound-guided
Interdigital Neuroma Injections: Short-term Clinical Outcomes after
a Single Percutaneous Injection- Preliminary Results. HSSJ, 2007;3:
44-49
• Neumann V, O‟Connor RJ, Bush D. Cryoprobe treatment: an
alternative to phenol injections for painful neuromas after
amputation. AJR Am J Roentgenol, 2008;191: W313
