MORTON’S NEUROMA: THE ACCURACY, ECONOMICS AND EFFECT ON TREATMENT TIME OF DIRECT REFERRAL TO ULTRASOUND BY PRIMARY CARE PHYSICIANS.

Abstract

Introduction: The first line treatment in our centre for Morton’s neuroma (MN), sufficient to warrant intervention, is a peri-neural Ultrasound guided injection of corticosteroid (USI).

The NHS will soon implement 18 week referral to treatment targets.

A prospective study was performed whereby from 2004–6, referral letters from General Practitioners suggesting a diagnosis specifically of Morton’s neuroma, resulted in randomised assignment to either direct referral for USI or to the specialist Foot and Ankle outpatient clinic.

Patients with less specific referral letters were evaluated in clinic and referred for USI as appropriate.

A comparison was made of the sensitivity and specificity of the referral pathways, financial implications and the time to treatment (TTT).

Results: 121 patients were referred for USI.

Of 57 patients for whom the GP had diagnosed a MN, 40 (70%) had the diagnosis confirmed on USI (other diagnoses were: 7 NAD, 3 ganglions, 2 bursae, 2 degenerative change, 1 glomus tumour, 1 angioleiomyoma, 1 SOL); this was comparable to the overall number referred to radiology with a suspected MN (69%).

In the directly referred group, the mean TTT was 115 days (95%CI = 89 – 141), compared to 241 days (95%CI = 223 – 259) for those patients who went via a Foot and Ankle clinic. P< 0.0001.

Conclusion: For patients with features highly suggestive of a Morton’s neuroma, direct referral from primary care for USI has a similar sensitivity and specificity to referral from a specialist hospital clinic and the TTT is significantly shorter.

The mean wait of this group is within the 18 week government target without any changes to our current radiology protocols. Using this direct referral protocol we saved 29 outpatient appointments; if followed for all eligible patients we would have saved 57 outpatient appointments.