Aims. The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton’s neuroma (MN). . Patients and Methods. In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (. sd. ) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis. . Results. The mean visual analogue score for pain improved significantly in both groups (Group A – from 64 mm, . sd. 25 mm to 29 mm, . sd. 27; Group B – from 69 mm, . sd. 23 mm to 37 mm, . sd. 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months. . Conclusion. This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN. Take home message: In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results. Cite this article: Bone Joint J 2016;98-B:498–503

Introduction:. Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings. Methods:. Patients with lesser MTP joint instability and pain underwent ultrasound arthrography by a consultant musculoskeletal radiologist. The main finding was the presence of a full or partial tear of the plantar plate. In some patients the location of the tear along with its size in the long and short axis was also reported. Authors who were not involved in the imaging or surgery reviewed the operation notes of patients who underwent surgery to identify. Whether a partial or full thickness tear was identified. Size and location of the tear. The accuracy of ultrasound arthrography was calculated using surgical findings as the standard. Results:. 53 patients with 55 joints underwent ultrasound arthrography, and of these 34 went on to have surgery. 23 patients had adequate documentation of surgical and ultrasound findings. Surgery confirmed plantar plate tears in 21 patients (91.3%) with 9 full thickness tears and 7 partial thickness tears confirmed both operatively and with ultrasound (in 5 patients the operation note did not specify completeness of tear). In 2 patients, in whom ultrasound demonstrated a partial thickness tear, no tear was found at surgery. The sensitivity of ultrasound arthrography for plantar plate tears is 100%, specificity is 0% (although based on few patients), and positive predictive value of 91.3%. Conclusion:. Ultrasound arthrography has a high sensitivity, but low specificity for plantar plate tears, comparable with ultrasound in previous studies. It allows differentiation of partial and full thickness tears which may be important for treatment

Aims

A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition.

Aim. To determine the effects of knee and ankle position on tendo Achilles (TA) gap distance in patients with acute rupture using ultrasound. Methods. Twenty seven patients with twenty-eight acute complete TA ruptures confirmed on ultrasound were recruited within a week of injury. The mean age at presentation was 42 years (range 23-80 years). Ultrasound measurements included location of the rupture and the gap distance between the superficial tendon edges with the ankle in neutral and knee extended. The gap distance was sequentially measured with the foot in maximum equinus and 0°, 30°, 60° and 90° of knee flexion. Results. The mean distance of the rupture from the enthesis was 52mm (range: 40-76mm). The mean gap distance with the ankle in neutral and knee extended was 11.4mm (95%CI: 9.9, 12.9). This reduced to 4.8mm (95%CI: 3.3, 6.4) when the foot was in maximum equinus, 3.8mm (95%CI: 2.5, 5.1) with 30° knee flexion, 2.6mm (95%CI: 1.7, 3.6) with 60° knee flexion and 1.5mm (95% CI: 0.8, 2.2) with 90° knee flexion. Expressing the reduction in gap distance with each successive position as a percentage of the gap distance with the knee extended and ankle in neutral revealed a mean reduction of 58.9%, 66.9%, 77.1% and 85.9% with maximum equinus and 0°, 30°, 60° and 90° of knee flexion respectively. The difference in gap distance between each of these positions was statistically significant (p<0.05). Discussion. Maximum equinus alone significantly reduces the gap distance in acute TA rupture. Increasing knee flexion demonstrates a lesser effect throughout the initial 90° arc suggesting apposition is encouraged by use of a below knee maximum equinus cast permitting full knee flexion

Background. Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with chronic plantar fasciitis, refractory to conservative treatment. Method and Materials. Patients undergoing dry needling for plantar fasciitis, followed by perifascial injection between Jan ′09 and Feb ′10 were identified. Pain scores were recorded on a visual analogue scale from 0 (no pain) to 10 (worst pain possible) before the procedure, 2 weeks and 6 weeks post procedure. Patients were also contacted in April to assess their current pain level. Responses were graded as excellent (> 75% pain score improvement), good (50-74%), fair (25-49%) and poor (<25% relief). Any complications or need for any further intervention were recorded. Results. 55 feet (46 patients) were identified. All patients had had no relief with previous treatment. 24 feet who had calf tightness had undergone a gastrocnemius muscle lengthening. All patients had radiological confirmation of diagnosis prior to undergoing the procedure. At 2 weeks: 1 foot lost to follow-up. 43/54 feet had excellent or good pain relief. At 6 weeks: 5 feet (4 patients) were lost to follow up. 37 feet (28 patients) reported excellent or good pain relief. 11/13 feet patients with fair to poor response underwent a repeat procedure. Redo-Procedure. Using the same outcome measures, 8/11 and 9/11 feet had excellent or good response at 2 and 6 weeks respectively. Long-term follow-up:. 42 feet (34 patients) were contacted. 13 feet (12 patients) lost to follow-up. Follow-up duration from 2 to 13 months. Mean F/U = 7 months. 23 feet (5 redos) had excellent or good outcome 19 feet (6 redos) had fair or poor outcome. If symptoms reoccurred, average duration of total analgesic effect was 3 months. Conclusion. 80% and 74% of patients had excellent or good outcome at 2 and 6 weeks respectively. After an average of 7 months follow-up, 55% patients had excellent or good results. In those patients in whom symptoms recurred, the average duration of total analgesic effect was 3 months. We believe that ultrasound guided dry needling is an effective treatment method for plantar fasciitis

It is difficult to determine the safe timing of weight-bearing or reconstructive surgery in patients with Charcot arthropathy of the foot and ankle. In this study the Doppler spectrum of the first dorsal metatarsal artery was used to monitor the activity of the disease activity and served as a guideline for management. A total of 15 patients (seven men and eight women) with acute diabetic Charcot arthropathy of the foot and ankle were immobilised in a non-weight-bearing cast. They were followed at two-week intervals and bilateral Doppler spectra of the first dorsal metatarsal arteries were obtained using a 10 MHz linear ultrasound probe. The patients were allowed to start weight-bearing or undergo surgery after the Doppler spectrum had returned to normal pattern. The Doppler spectra in the unaffected limbs were triphasic in pattern, whereas those in limbs with active Charcot arthropathy showed monophasic forward flow. They returned to normal after a mean of 13.6 weeks (6 to 20) of immobilisation. Three patients underwent pan-talar arthrodesis to correct gross instability and deformity. Doppler spectrum analysis of the foot may reflect the activity of the disease in patients with Charcot arthropathy, and may be used as a guide to begin weight-bearing or undergo reconstructive surgery

Aims

This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment.

Background. Infiltration is considered the first treatment option for symptomatic Morton's neuroma and can be performed with various medications. The aim of this study was to compare the effects of hyaluronic acid infiltration versus corticosteroid injection in the treatment of Morton's neuroma. Methods. A randomised clinical trial was conducted with 46 patients (50 feet) diagnosed with Morton's neuroma. After randomisation, the control group (CG) received three injections (one per week) of triamcinolone (Triancil®) guided by ultrasound, while the study group (SG) received three applications of hyaluronic acid (Osteonil Plus®). Patients were followed up for six months after the intervention. The primary outcome measure used was the Visual Pain Analog Scale (VAS). Secondary endpoints included patient-reported outcome measures using the American Orthopaedic Foot & Ankle Society (AOFAS) score and complications. Results. Both groups showed significant improvement in VAS and AOFAS scores (p < 0.001). The CG showed greater improvement than the SG in the VAS (p < 0.05) and AOFAS (p < 0.001) variables. Four patients in the CG experienced skin hypochromia at the injection site, while there were no complications in the SG. Conclusion. Ultrasound-guided hyaluronic acid infiltration in Morton's Neuroma proved to be safe, showing improvement in pain and function after six months of follow-up, without major complications, but with a significantly lower improvement when compared to corticosteroid injection. Taking into account cost implications and the potential for longer lasting improvement from viscosupplementation further medium- and long-term studies are needed

Background. Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy. Methods. We conducted a retrospective review of our clinical records, on patients with histologically confirmed musculoskeletal tumours of the foot and ankle, treated in a single nstitution between 2010 and 2019. The maximum diameter of each lesion was determined through MRI or Ultrasound analysis in centimeters. To develop a scoring system we compared the risk of malignancy with five criteria: site (proximal or distal to the first TMTJ), gender, age, composition and the diameter as observed. Results. Our study included 496 patients, of whom 39 (7.9%) were identified as having malignancies. The incidence of malignancy demonstrated an increased propensity among male patients, patients over 50 years of age and lesions located proximal to the TMTJ. A ROC Analysis determined that lesions measuring over 2.85 cm had an increased risk of malignancy, with a PPV of 31.1%, a NPV of 94.2%, a Sensitivity of 0.82, and a Specificity of 0.62. These identified patterns of risk were employed to formulate a scoring system, aimed at facilitating informed clinical judgment in the referral of patients to regional tumor services. Conclusion. The new OxFAT scoring system highlights the importance of lesion size, site, age and gender of the patient in determining the risk of malignancy in lump in the foot and ankle. We propose this new scoring system to aid health care professionals in managing these patients. Based on our results any patient with a foot or ankle mass of less than 2.85cm, an OxFAT score < 4/7 and no malignant or sinister features on MRI or USS can be managed locally with excision biopsy. All other patients should be referred urgently to a Regional Tumour Service

Aims. Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. Methods. Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. Results. In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson’s correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). Conclusion. Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535–1541

We conducted a randomised controlled trial to determine whether active intense pulsed light (IPL) is an effective treatment for patients with chronic mid-body Achilles tendinopathy. A total of 47 patients were randomly assigned to three weekly therapeutic or placebo IPL treatments. The primary outcome measure was the Victorian Institute of Sport Assessment – Achilles (VISA-A) score. Secondary outcomes were a visual analogue scale for pain (VAS) and the Lower Extremity Functional Scale (LEFS). Outcomes were recorded at baseline, six weeks and 12 weeks following treatment. Ultrasound assessment of the thickness of the tendon and neovascularisation were also recorded before and after treatment. . There was no significant difference between the groups for any of the outcome scores or ultrasound measurements by 12 weeks, showing no measurable benefit from treatment with IPL in patients with Achilles tendinopathy. Cite this article: Bone Joint J 2013;95-B:504–9

Aims. The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs. Patients and Methods. Between 2006 and 2017, five patients with five mICGs were retrospectively reviewed. There were five men with a mean age of 50.2 years (33 to 68) and a mean follow-up of 3.8 years (0.8 to 6). Case history, physical examination, imaging, and intraoperative findings were reviewed. The outcomes of interest were ultrasound and/or MRI features of mICG, as well as the clinical outcomes. Results. The five intraneural cysts followed the principles of the unifying articular theory. Connection to the posterior subtalar joint (pSTJ) was identified or suspected in four patients. Re-evaluation of preoperative MRI demonstrated a degenerative pSTJ and denervation changes in the abductor hallucis in all patients. Cyst excision with resection of the articular branch (four), cyst incision and drainage (one), and percutaneous aspiration/steroid injection (two) were performed. Removing the connection to the pSTJ prevented recurrence of mIGC, whereas medial plantar nerves remained cystic and symptomatic when resection of the communicating articular branch was not performed. Conclusion. Our findings support a standardized treatment algorithm for mIGC in the presence of degenerative disease at the pSTJ. By understanding the pathoanatomic mechanism for every cyst, we can improve treatment that must address the articular branch to avoid the recurrence of intraneural ganglion cysts, as well as the degenerative pSTJ to avoid extraneural cyst formation or recurrence. Cite this article: Bone Joint J 2018;100-B:183–9

Aims

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE.

Aim. To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation. Methods. Twenty six patients with acute complete TA ruptures underwent ultrasound (US) within a week of injury. Measurements included the distance of the rupture from the enthesis and the gap distance between the tendon edges in three positions –. foot plantigrade,. maximum equinus and. maximum equinus with 90. o. knee flexion. All patients were managed non-operatively in functional weightbearing orthoses. Nineteen patients were followed up at a mean of 6.1 years (range 5.8–6.5). Outcomes included ultrasound confirmation of healing, Achilles Tendon Rupture Score (ATRS) and Modified Lepilahti score (MLS). Results. The mean distance of the rupture from the enthesis was 52mm (range: 40–76mm). The mean gap distance with the foot plantigrade was 11.4mm (95%CI: 9.9, 12.9) which reduced to 4.8mm (95%CI: 3.3, 6.4) in equinus and 1.5mm (95%CI: 0.8, 2.2) with 90° knee flexion. At follow up, no re-ruptures had occurred. US demonstrated continuity in all healed tendons. Mean ATRS was 86 (95%CI: 78.8, 93.9). There was a significant correlation between the distance of the rupture with the MLS (p=0.015) and the ATRS domains of strength (p=0.037) and fatigue (p=0.017). There was no significant correlation between the measured gap distance in the three positions with respect to the MTLS, ATRS or individual ATRS domain scores. There was no significant difference when comparing outcomes between left and right TAs or comparing gaps less than 1cm with those greater than 1 cm. Discussion. The distance of the gap from the enthesis may be more predictive of mid term clinical outcome in patients with TA rupture managed with accelerated functional rehabilitation compared with the magnitude of the gap and extent of closure with equinus and knee flexion

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings. . The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed. . Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (. sd . 14), 64.9 (. sd. 15) (n = 135), six months 67.8 (. sd. 16), 73.8 (. sd. 15) (n = 103) and nine months (72.4; . sd. 14) 72.3 (. sd. 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum. The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs. Cite this article: Bone Joint J 2015; 97-B:510–15

ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma activating cytokine mediated response stimulating local angiogenesis and tissue repair. Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan. Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64□86 in the ECSWT group and 72□79 in the physiotherapy group. VISA-A scores also increased in both groups from 39□73 in the ECSWT group and from 36□56 in the physiotherapy group. Scores were significantly higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding from 10.9 mm□9.9 mm in physiotherapy group while 9.8 mm□8.7 mm in the ECSWT group with hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using SPSS 16 p < 0.001in post treatment group. Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the groups

Introduction:. Primary functions of heel and forefoot fat pad - shock absorber at heel strike, energy dissipation, load bearing, grip and insulation. •Reliability of weight bearing heel pad thickness measurements by ultrasound has been determined by Rome et al. Importance of soft tissue fillers has been recently popularised by Coleman. Methods and materials:. Harvesting done by standard low pressure liposuction using small cannula. Grafting using small needle depositing the small globules of fat in multiple layers of soft tissue. There is an expectation that up to 50% of the fat will be lost and so upto 19mls of fat placed per foot. Patients were kept NWB for 4–6 weeks post op and then allowed to mobilise fully. Case notes were prospectively collated and analysed. Pre and post-op ultrasound scans were performed to document the depth of the heel/forefoot fat pad. Clinical pictures were taken and post-op patient satisfaction scores were done as well. Results:. We treated 9 feet in 5 patients. 5 heel fat pad transfers and 4 forefoot. Pain completely relieved in all feet. No complications. Average pre-op VAS - 3/ Post-op – 9. Average pre-op AOFAS score - 70/ post-op - 105. Follow-up 6months - maximum 23 months. Conclusion:. Fat transfer is usually used for cosmetic reasons and occasionally to improve scars. Very few reports from South America have been published for patients using high heels giving pain but none for patients with a pathological anomaly. The technique seems to highly effective with no complications so far. It is currently being used on other painful problems in other areas of the sole with equal success. Abdominal fat transfer is an innovative technique aimed at getting rid of the ‘heel pad syndrome’

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

The aim of this study was to identify the incidence of post-operative symptomatic deep-vein thrombosis (DVT), as well as the risk factors for and location of DVT, in 665 patients (701 ankles) who underwent primary total ankle replacement. All patients received low-molecular-weight heparin prophylaxis. A total of 26 patients (3.9%, 26 ankles) had a symptomatic DVT, diagnosed by experienced radiologists using colour Doppler ultrasound. Most thrombi (22 patients, 84.6%) were localised distally in the operated limb. Using a logistic multiple regression model we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT. The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement

A Morton's neuroma is a compressive neuropathy most commonly affecting the common digital nerve of the third inter-space. Symptoms are variable but usually the diagnosis can be made quite easily and the diagnosis is essentially a “clinical” one. When symptoms relate to the second inter-space the clinician needs to be alert to mechanical causes of metatarsalgia leading to secondary irritation of the nerve. Imaging with MRI scanning and/or ultrasound can be helpful but equally can be misleading, as there may be false positives and false negatives. In the case of ultrasound the accuracy of imaging depends on the experience and expertise of the radiologist. Morton's neuroma surgery is usually associated with high levels of success but some reports suggest as many as 30% of patients under-going such surgery are dissatisfied with the outcome. The reasons for failed surgery can be broadly divided into three groups: a) wrong diagnosis b) wrong surgery and c) right diagnosis and right operation but unfavourable outcome. Wrong diagnosis is most commonly encountered in second space pathology when there is an underlying mechanical reason for the symptoms such as second MTP joint synovitis. This is usually secondary to joint overload associated with first ray insufficiency eg hallux valgus. This is the so-called Moron's neuroma. Wrong surgery occurs when the wrong space is operated upon, when mechanical causes are overlooked or when a plantar incision is made over the weight-bearing part of the forefoot, leading to painful scar formation. Wrong surgery can also involve failure to recognise anomalous anatomy within the space or insufficient nerve resection. Unfavourable outcomes include infection, stump neuroma formation or the onset of CRPS. Occasionally despite an appropriate assessment and operation a patient will derive no relief of symptoms and the cause of the pain remains totally unexplained. Careful history and examination and careful pre-operative planning can reduce the incidence of failed Morton's neuroma surgery. The role of imaging is probably greater in such cases compared with those presenting with a primary Morton's neuroma but the diagnosis remains essentially clinical. Stump neuroma resection should be considered in patients presenting with repeat symptoms especially if there is initial surgical success followed by recurrent symptoms. If two explorations result in no success then a third exploration is unlikely to resolve the problem. Some patients are left with intractable symptoms and should be referred to a pain specialist, as further surgery often has nothing more to offer