Working Diagnosis:
Morton's Neuroma

Treatment:
The patient initially received an ultrasound-guided injection of corticosteroids at the 1st MTP joint, with minimal improvement in symptoms. He then received an additional ultrasound guided steroid injection into his tarsal tunnel. On follow-up, he continued to report pain between his 1st and 2nd MT heads, with no improvement from the corticosteroids. He requested platelet-rich-plasma (PRP) injection, which he had previously had for unrelated symptoms, for treatment of the neuroma, and was injected under ultrasound guidance. Case Photo #1

Outcome:
Over the next 1-2 months, the patient gradually increased his activities, with 90-95% improvement in symptoms and return to full activity. The following year, the patient reported exacerbation of pain after going bowling without orthotic inserts, and again received an ultrasound-guided corticosteroid injection at the 1st MTP. The patient returned for follow-up 6 weeks later reporting minimal improvement in symptoms, and again received an ultrasound-guided PRP injection between the 1st and 2nd MTP heads. On subsequent follow-up, the patient reported full resolution of symptoms, and was back to his usual level of activity, playing basketball 3 times a week.

Author's Comments:
This case demonstrates the potential benefit of PRP use in the treatment of neuromas. The indications for use of PRP in the treatment of musculoskeletal conditions have expanded in recent years, and standard treatments had been unsuccessful in relieving the patient's symptoms. PRP has previously been shown to be effective in nerve-related pain, and further evaluation of its effectiveness in the treatment of Morton's neuromas is warranted.

Editor's Comments:
A good case showing a relatively novel use of PRP.
Also, keeping in mind the adage of 'a patient can have as many diseases as he or she pleases' is important in a case like this, and determining different pain generators can be critical, such as in this individuals foot pain.

References:
1. Jain, S, Mannan, K. "The Diagnosis and Management of Morton's Neuroma: A Literature Review", Foot & Ankle Specialist 2013 6:307

2. Gross, C, Lin, J. "Injection Therapy in the Management of Musculoskeletal Injuries: Foot and Ankle", Operative Techniques in Sports Medicine 2012 20:185-191

3. Vannini, F, Di Matteo, B, Filardo, G, Kon, E, Marcacci, M, Giannini, S. "Platelet-rich plasma for foot and ankle pathologies: A systematic review", Foot & Ankle Surgery 2013 20(1):2-9

4. Tinsley, B, Ferreira, J, Dukas, A, Mazzocca, A. "Platelet-rich plasma nonoperative injection therapy - a review of indications and evidence", Operative Techniques in Sports Medicine 2012 20(2):192-200

5. Nguyen, R, Borg-Stein, J, McInnis, K "Applications of Platelet-Rich Plasma in Musculoskeletal and Sports Medicine: An Evidence-Based Approach", PM&R 2011 3(3):226-250

6. Kuffler, D. "Platelet-Rich Plasma and the Elimination of Neuropathic Pain", Molecular Neurobiology Oct 2013 48(2):315-332

7. De Angelis, B, Lucarini, L, et al. "Regenerative surgery of the complications with Morton's neuroma surgery: use of platelet rich plasma and hyaluronic acid", International Wound Journal 2013 10(4):372-6

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