Clinical Orthopaedic Rehabilitation 2nd Edition s. Brent Brotzman, M.

436 Clinical Orthopaedic Rehabilitation in the third (or second) interspace. The examiner places reveal partial, complete, or no sensory deficit in the the index finger and thumb proximal to the metatarsal nerve's distribution (see Fig. 5 - 79). heads in the interspace, and while pushing firmly into the interspace, \"strips\" distally to the end of the interspace, of­ The patient with a Morton neuroma does not have pain ten feeling a click or pop that elicits pain (Mulder's click). over the metatarsal heads. Widening of the involved (third and fourth) toes Occasionally, the examination will be positive only may be noted on occasion as a result of the neuroma after a vigorous workout or tight shoewear. Often, the pa­ mass in the interspace. Subjective numbness of the in­ tient's physical examination is inconclusive and requires volved toes is often noted, but sensory examination may several serial examinations and a ruling out of related pathology. Lateral planter n. Nerve to abductor Medial plantar n. -+-+----\\\\ digiti quinti m. Nerve to abductor Lateral planter n. digiti quinti m. Medial plantar n.~\\ Abductor digiti quinti m. A Lateral Plantar N. Calcaneal branches L. Plantar N M. Plantar N. B Figure 5-82. A, Distribution of the medial and lateral plantar nerves on the bot­ tom of the foot. B, Distribution of symptoms (numbness) on the plantar aspect (bottom only) of the foot associated with tarsal tunnel syndrome. (A, Left, Gray H: Anatomy: Descriptive and Surgical. Philadelphia, Henry C Tea, 1870, p. 660 Right. Modified from Mann RA, Coughlin MJ: Foot and Ankle Surgery, 6th ed. St. Louis, Mosby, 1993. B, from Chapman MW: Operative Orthopaedics. Philadelphia, JB Lippincott, 1988.)

Figure 5-83. Tarsal tunnel syndrome. Tibialis posterior Chapter 5: Foot and Ankle Injuries 437 A Tinel sign reproduces the pain and/or Posterior tibial artery and vein paresthesias on palpation of the tibial Abductor nerve of the medial ankle. The pares­ hallucis ~-I-_- Flexor hallucis longus thesias occur in the distribution of the ~f-++--Posteriortibial nerve tibial nerve (plantar skin). This may in­ volve the medial plantar nerve, the lat­ Flexor retinaculum eral plantar nerve, or both. (From Mann RA, Coughlin MJ: Surgery of the Foot and Ankle. S1. Louis, Mosby, 1993, p. 554.) Lateral plantar nerve Differential Diagnosis 2. MTP joint pathology • Synovitis of the lesser MTP joint(s) from rheuma­ Morton's neuroma may be mimicked by a number of toid arthritis or nonspecific synovitis has tender­ other conditions. The following differential diagnoses ness over the metatarsal head or MTP joint should be considered to rule out an incorrect diagnosis of rather than the interspace (see Fig. 5-55). a Morton neuroma. • Fat pad atrophy or degeneration of the plantar fat pad or capsule has tenderness over the metatarsal 1. Neurogenic pain, tingling, or numbness head or MTP joint rather than the interspace. • Peripheral neuropathy typically has more global • Subluxation or dislocation of the lesser MTP joints numbness (entire foot or glove and stocking has tenderness over the metatarsal head or MTP rather than in the interspace and its two toes) joint rather than the interspace. and is numb (not painful) unless early in the on­ • Arthritis of the MTP joint has tenderness over the set of neuropathy. metatarsal head or MTP joint rather than the in­ • Degenerative disc disease often has accompanying terspace. motor, sensory, and reflex changes rather than numbness in a single interspace and its corre­ 3. Plantar foot lesions sponding two toes. • Synovial cysts is usually a tender mass but no • Tarsal tunnel syndrome has a positive Tinel sign numbness or tingling. over the tarsal tunnel (medial ankle) and numb­ • Soft tissue tumors of the interspace: ganglion, syn­ ness limited to the plantar aspect of the foot (no ovial cyst, lipoma, soft tissue neoplasm; usually a dorsal foot numbness) (Figs. 5-82 and 5-83). tender mass but no numbness or tingling. • Lesions of the medial or lateral plantar nerves • Abscess. Plantar abscess foot. Usually, a tender (see above). mass but no numbness or tingling. Treatment Rehabilitation Protocol • Work on ankle active ROM exercises and stretching to After Morton's Neuroma Excision avoid stiffening of the ankle. Brotzman • At 3-4 wk, begin using a wide, soft, comfortable loosely laced tennis shoe, low-impact activities (e.g., bicycling). n• Maximal elevation of foot as much as possible for hr. • Light, compressive, well-padded forefoot dressing in a wooden shoe for approximately 3 wk. • Weight-bearing as tolerated with crutches for 1-14 days postoperative.