Current Orthopaedics (2001) 15, 275^280

c 2001 Elsevier Science Ltd

doi:10.1054/cuor.2001.0208, available online at http://www.idealibrary.com on

MINI-SYMPOSIUM: NERVE COMPRESSION SYNDROME

(v) Nerve compression in the foot

L. Klenerman
Pentre Garth, Llwynmawr, Pontfadog, Llangollen, N Wales LL20 7BG, UK

INTRODUCTION
Of the examples of nerve compression which occur in
the foot, Mortons metatarsalgia which is diagnosed clinically is the most common and important. Tarsal tunnel
syndrome, has a euphonious title, for a rare condition. It
requires careful clinical assessment and ancillary tests
for accurate diagnosis, whether it aects the posterior
tibial or deep peroneal nerve.

MORTONS METATARSALGIA
History
The pain of a Mortons neuroma was rst described by
Lewis Durlacher, Surgeon Chiropodist to Queen Victoria, inCorns and Bunions published in1845.1 It is a kind of
neuralgia seated between the toes, but which fortunately is not very common. It constitutes a most troublesome and severe complaint and one very dicult of
removal.
The patient complains of a severe pain between two of
the toes, along the inside of one or the other, generally
the second and third, he can seldom tell which, it extends
up the leg and is increased when the toes are pressed together more particularly after walking.
In 1876 Morton,2 Surgeon to the Philadelphia Orthopaedic Hospital, described A Peculiar and Painful Aiction of the Fourth Metatarsophalangeal Articulation the
symptoms of which have now become well known as
Mortons metatarsalgia. He observed that the aection
which had been seen more frequently in females , which
he attributed not only to the delicacy and pliability of the
female foot as compared with the male foot, but in a
measure to the prevailing custom, especially with fashionable women, of wearing tight and very narrow shoes.
The fth metatarsal is thus pressed against the head and
neck of the fourth metatarsal. . .. His treatment was excision of the metatarsal shaft with a quarter of an inch
from the associated proximal phalanx. Hoadley, of Chicago, in 1893 described six patients.3 He operated on only
one of them and cut down on the sole of the foot and
without any diculty found the digital branches of the

lateral plantar nerve. He found a small neuroma on the

nerve, seven-eighths of an inch long and nearly oneeighth of an inch in diameter and resection of the nerve
produced a prompt and perfect cure. His other patients
improved by shoe modication, which consisted of reinforcement of the sole of wide shoes. Jones in1897 considered excision of the metatarsal head, excision of the
joint, or amputation of the metatarsal head and toe as
possible surgical solutions to the problem but favoured
resection of the metatarsal head. He also mentioned
part excision of digital plantar nerve but did not elaborate on this.4
Hoadleys observations do not seem to have aroused
great interest amongst his contemporaries until nearly
40 years later in 1935 when Sir Harold Stiles was operated on for longstanding metatarsalgia. The nerve between the third and fourth toes was resected by
Norman Dott, a neurosurgeon.5 In 1940 Betts of Adelaide6 reported 10 patients on whom he had resected
the fourth plantar digital nerve with a plantar incision.
McElvenny7 reported 12 neuromas in 11 patients and advocated a dorsal web-splitting incision. In 1951 Mulder8 of
Amsterdam described a clinical test for Mortons neuroma in which a click is elicited from the aected foot by
exerting pressure around the forefoot with the left hand
and at the same time using the right thumb to put pressure on the sole at the site of the suspected neuroma.
One may reproduce the characteristic pain with a palpable click. More recently, Mortons metatarsalgia has
been shown with electronmicroscopy to be a typical entrapment syndrome similar to median nerve compression at the wrist and ulnar neuritis at the elbow.9

Clinical Picture
The digital nerve most commonly aected supplies the
cleft between the third and four toes (i.e. middle and
ring). Sometimes the cleft between the second and third
toes is involved, and very rarely both. Mortons neuromata do not occur in any other clefts.The patient is usually a
young or middle-aged woman with a wide age range from
17 to 70 years. Men are much less frequently aected
than women.

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Symptoms
Acute neuralgic pain is felt under the middle of the forefoot with radiation into one or more of the central three
toes. In the common case of involvement of the 3/4 cleft
pain may be referred to the tip of the fourth toe. The
foot is comfortable on rising from bed in the morning,
but pain develops after walking or standing in closed
well-tting footwear.The patient may have no pain at all
when wearing loose tting footwear, such as sandals,
slippers or Wellington boots, or barefoot. Some patients
complain of pain at night causing broken sleep. During
the day the patients may gain temporary relief by a few
minutes of rest; the patient often takes o the shoe and
manipulates the forefoot. The pain is unpleasant and
disturbing. It may be intermittent with long periods of
quiescence.

CURRENT ORTHOPAEDICS

maintaining pressure in the web with one nger of the

other hand. (Fig. 1). Nearly always the manoeuvre produces a painful click from the lesion being pressed in and
squeezed out of the intermetatarsophalangeal bursa.
The objective sign, the click, is found more frequently
than the subjective sign, the pain. It is known as Mulders
click and must not be confused with the common painless click produced by similar displacement of a fatty
lobule from the sole in feet with unstable splayed metatarsal heads.
The radiographs of the foot are normal. Recently, attempts have been made by using ultrasound and MRI to
demonstrate the lesion prior to operation. Both techniques seem equally successful. Nevertheless, the diagnosis
should be possible without ancillary tests.

Pathology
Signs
There is a marked dearth of physical signs. Hence the importance of a clear and detailed history. Most commonly,
the general architecture of the foot is normal. There is
rarely objective evidence of diminished skin sensibility in
the aected web space.
The cardinal sign is pain on pressure upwards and
backwards in the web over the point of division of the
nerve. The best way to elicit this pain is alternately to
compress and release the forefoot with one hand, while

Figure 1 How to elicit Mulders Click.(A) and (B)

An enlarged communicating branch between the medial

and lateral plantar nerves may be an important factor in
the frequent involvement of the nerve to the third interspace as it probably acts as a tether.10
In cases with a short history, the artery and nerve,
both slightly swollen, are found to be adherent to the
transverse ligament.The typical nding, however, is a fusiform swelling involving the plantar digital nerve and
vessels in the region of their bifurcation. In the special
case of a Mortons toe, the lesion in the 3/4 space is asymmetrical. The swelling is generally called a neuroma, but
this is incorrect; histological sections show that the
neural changes are degenerative in nature, not proliferative.The pathogenesis of the neuroma is the same as entrapment syndromes elsewhere9 (Fig. 2). The digital
neuroma found in Mortons metatarsalgia is quite unlike
the typical neuromatous outgrowths which develop in injured nerves. Sunderland11 has described it as an intraneural neuroma because of the histological picture of
disrupted endoneurial tubes. However, the histological
features of a Mortons neuroma are not specic and can
be found in the nerves of normal elderly patients as a result of age and use.12 The microscopic anatomy shows separation of individual nerve bres by a proliferating
collagen matrix.The presence of Renaut bodies suggests
a compressive pathology. Renaut bodies are loosely textured, whorled, cell-sparse structures in the sub-perineural space of peripheral nerves but this diagnostic
feature is only seen on electronmicroscopy.
Mechanical factors appear to be important in the development of Renaut bodies.13 Blood vessels show periarterial brosis and endarteritis obliterans. Overall, the
changes are similar to those of entrapment syndromes
such as median nerve compression at the wrist or ulnar
neuritis at the elbow. The exact mechanism of entrapment is not clear, but related to tethering of the intermetatarsal nerve to the interspace between the third and

NERVE COMPRESSION IN THE FOOT

277

Figure 2 The variations of the anastomosis between the medial and lateral plantar nerves. There is a strong link and more
tethering of the nerve to the 3/4 space in some cases. Common pattern on the right. (From Foot and Ankle 1984. Permission has
been requested.)

fourth toes with repeated trauma to the nerve on the

inter-metatarsal ligament as the toes are dorsiexed in
walking.
It is important to note that if one sends a specimen for
histology the fact that the pathologist reports it as compatible with Mortons Neuroma does not mean that you
have cured the patient but merely that you have excised
a digital nerve. Normal nerves in the foot because they
are subject to the trauma of weight-bearing show similar
changes on light microscopy.12, 14
The mechanisms of pain remain unclear. A likely cause
is chronic abnormal impulse generation in damaged peripheral nerve axons of all classes, both as spontaneous
activity and mechanical sensitivity.

Treatment
Minor symptoms may be controlled by open types of
footwear and limitation of weight-bearing activities. A
metatarsal pad may be helpful. Injection of the intermetatarsal bursa with hydrocortisone may occasionally relieve symptoms. Unless the diagnosis is absolutely clear
conservative treatment is advisable in the rst instance.
Otherwise the only treatment in my view is excision of
the neuroma. Unless this includes about 2 cm of nerve
proximal to the ligament, the inevitable terminal neuroma may adhere to the transverse ligament and cause
symptoms. Fortunately, our sensory awareness of our
toes is such that resection of a single digital nerve does
not usually bother us.
British surgeons generally follow the example set by
Betts of Adelaide6 and use a longitudinal plantar incision
across the tread in the line of the interspace. This gives
direct access to all the structures concerned. The
anatomy is clearly visible. A slightly longer incision when

retracted allows inspection of the adjacent interspace

as well. The incision heals well, similar to those on the
palm, and is barely visible after a few months. In my
personal experience problems with a painful scar have
been minimal.
Most North American surgeons prefer a dorsal incision in the web giving limited access to one interspace
only, as they want to avoid a scar on the weight-bearing
area. It is dicult to resect a sucient length of nerve
about the transverse ligament without undue traction
on the nerve and without division of the ligament. It is
also dicult to detect and deal with an unexpected lesion such as a ganglion arising from a exor tendon tunnel. Gauthier in 197815 advocated simple division of the
intermetatarsal ligament as the treatment of choice and
claimed 83% success . An additional 15% were improved
but had some persistence of pain. Okafor et al.16 with a
similar technique reported a 98% satisfaction rate.Thus,
we are now in a situation similar to ulnar neuritis, where
there are a number of dierent treatments which all have
a successful outcome. Until a prospective randomized
trial clearly demonstrates the most eective technique I
would recommend excision of the neuroma via a plantar
approach .

OperativeTechnique
Plantar approach A longitudinal incision is made in the
line of the appropriate interspace (3/4 or 2/3). Once the
skin has been incised a self-retaining retractor helps separate the margins of the wound.With blunt dissection it
is possible to identify the intermetatarsal nerve amongst
the fat that lls the space between adjacent tendon
sheaths . Sharp dissection is required to dene the normal part of the nerve proximally, the neuroma and the

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CURRENT ORTHOPAEDICS

Figure 3 Diagram to illustrate the mechanism of entrapment.

Y-shaped distal bifurcation into digital nerves (Fig. 3).The

nerve is resected proximally so that the stump retracts
beneath the plantar aponeurosis away from possible
pressure on weight-bearing. Distally the nerve is divided
just theY-shaped bifurcation. As the neuroma is removed
some of the adjacent wall of the intermetatarsal bursa
usually comes away with it (Fig. 4). After meticulous skin
closure a pressure dressing is applied with plaster wool
and a crepe bandage, and the tourniquet is released.
After 24 h the patient may walk in a wooden-soled
sandal. To ensure sound wound healing the sutures
should not be removed for 14 days.
Dorsal approach A longitudinal incision about 3 cm long
is made on the dorsal aspect of the aected interspace.
The deep transverse intermetatarsal ligament is divided
to expose the underlying neuroma which can be made
obvious by pressure in the sole. A self-retaining retractor
is useful to separate the metatarsal heads. The neuroma
is resected with 1cm of normal nerve proximal to it, and
distally at theY-shaped bifurcation (Fig. 5).
Decompression The approach is dorsal as above. After
division of the intermetatarsal ligament the nerve with
the neuroma is dissected free and left lying away from
contact with the plantar fascia.

Results
There is a shortage of postoperative follow-up studies.
The results of surgery by excision of the neuroma
through a dorsal approach were reported by Mann and
Reynolds in 198317 to be 84% successful. Persistence of

symptoms is due either to the inevitable terminal neuroma being subject to pressure as the resection of the interdigital nerve was not suciently proximal to allow
the divided nerve to retract proximally away from the
weight-bearing area , inadequate resection of the neuroma or missing it altogether.18 It is necessary to re-explore
the aected interspace by a plantar approach to relieve
the unhappy patient.

TARSALTUNNEL SYNDROME
First described in 196219, 20 this is a diagnosis to be made
with care. In comparison with the carpal tunnel syndrome it is very rare. It should only be diagnosed after
thorough clinical investigations which must include electrodiagnostic tests and MRI scanning. The rarity of this
type of nerve compression is related to the anatomy. All
the structures which pass beneath the exor retinaculum are in separate compartments except the neurovascular bundle. The exor retinaculum is about half the
thickness of the transverse carpal ligament at the wrist.
The shape of the tarsal tunnel with its thin retinacular
covering makes it unlikely that compression of the posterior tibial nerve will occur unless there is a space-occupying lesion within the tunnel such as a ganglion, lipoma
or anomalous muscle belly.21 This suggestion was supported by Pfeier and Cracchiolo in 199422 in a detailed
follow-up study who noted that as only 44% of their series of 30 patients had a good or excellent result they concluded that unless there was an associated lesion near or
within the tarsal tunnel, decompression should be considered with caution. This approach is similar to that of

NERVE COMPRESSION IN THE FOOT

279

Figure 5 A neuroma excised with bursal tissue and a long

proximal segmentto avoid a terminal neuroma.

Symptoms
There is diuse burning pain and paraesthesiae over the
region of the distribution of the medial plantar nerve.
The pain may be aggravated by walking and relieved by
rest. It may be worse at night.

Examination

Figure 4 Stages in the plantar dissection of a neuroma. (A)

preliminary dissection, and (B) with the neuroma exposed.

Takakura et al.23 who reported that in most cases in

need of an operation there was a space-occupying lesion.
In cases with a clear-cut lesion an excellent result can be
expected from surgery.

There are few obvious clinical signs. The most useful is a

Tinnel sign on percussion of posterior tibial nerve behind
the medial malleolus. Sensory examination of the foot is
often negative. Plain radiographs of the foot and ankle
are necessary and an MRI scan to eliminate the presence
of a space occupying lesion. Of the electrodiagnostic
tests the sensory nerve conduction velocity is the most
helpful.24

Treatment
This is surgical provided the diagnosis is clear.

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Operative technique
A curved incision is used which starts above the exor
retinaculum and ends just distal to it. The procedure is
aimed at decompression of the posterior tibial nerve
and its medial and lateral plantar nerve branches. The
nerve should be exposed proximally above the level of
the exor retinaculum and traced distally into the foot
so that all sites of the potential constriction have been
inspected and released. A space occupying lesion can be
readily removed.
Postoperatively the foot and ankle should be splinted
in plaster for 2 weeks to allow sound healing of the operation wound.

Complications
Augustijn and Vanneste25 described three cases of tarsal
tunnel syndrome in which the underlying cause was a
more proximal lesion; in two cases an arterial lesion
and in one a tibial fracture and thus the possibility of a
more proximal lesion must be excluded. This should be
possible by precise electrodiagnosis. Birch et al.26 state
that their experience of failures of tarsal tunnel surgery
have been discouraging. This shows the importance of
careful and accurate preoperative investigations to ensure that the diagnosis is correct.

ANTERIOR TARSALTUNNEL
SYNDROME
Even less common than on the medial side of the ankle,
this is an entrapment lesion of the deep peroneal nerve
beneath the extensor retinaculum at the ankle.
The symptoms are pain on the dorsum of the foot
with occasional radiation into the rst web space. Pain
usually occurs with athletic activities and subsides when
the shoe is removed and with rest. The pain may be aggravated by plantarexion.There may be decreased skin
sensation in the rst web space.There may be atrophy or
weakness of the extensor digitorum brevis. The largest
series reported is from China.27 The causes of the onset
of the syndrome included a contusion of the dorsum of
the foot, tight shoe laces, talonavicular osteophytes, a
ganglion and pes cavus. Electromyography is essential
for the diagnosis. Treatment consisted of division of the
inferior extensor retinaculum and the removal of any
space occupying lesion such as a ganglion. The authors
did not suture the retinaculum and found no bow-stringing occurred.

CURRENT ORTHOPAEDICS

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