Economic evaluation corticosteroid injections mortons neuroma

Mortons neuroma is a common cause of forefoot pain. Those who are troubled by this affliction of the plantar nerve usually describe pain and numbness extending from the ball of the foot into the toes.

Current treatments include footwear advice, insoles, corticosteroid injection and in some cases surgical excision of the nerve.

This new paper from the Journal of Foot and Ankle Research (Open Access) examines cost-effectiveness of steroid (methylprednisolone) injections versus anaesthetic alone for the treatment of Morton’s neuroma: economic evaluation alongside a randomised controlled trial (MortISE trial).

Here’s what they did

The authors carried out this work in conjunction with a randomised controlled trial which has been previously published in the Journal of Bone and Joint Surgery. They undertook incremental cost-effectiveness and cost-utility analyses from the perspective of the National Health Service, alongside a patient-blinded pragmatic randomised trial in hospital-based orthopaedic outpatient clinics in Edinburgh, UK.

The economic analysis focused on 109 participants, 55 of whom were in the control group. The intervention group received a mixed corticosteroid and local anaesthetic injection and the control group received a local anaesthetic injection only. Injections were carried out under ultrasound guidance. Follow up was for 3 months.

The outcome measure was the EQ-5D-3L a tool for recording self-reported health status. However, the researchers found this general measure did not seem to be particularly sensitive to changes in foot health and hence the outcome was supplemented by data from the ‘Foot Thermometer’ which is a validated 10cm visual analogue scale of foot health.

For economic analysis they considered two specific areas (1) cost effectiveness as measured by the outcomes recorded with the Foot Thermometer and (2) cost utility.

Here’s what they found

They found that the unit cost of an ultrasound guided steroid injection was £149.
The mean cost for injection and 3 months of follow up care was
- £280 for those who had the steroid injection,
- £202 for those who had the local anaesthetic injection only.
Those who had steroid injection had a significantly greater improvement in foot pain as measured by the Foot Thermometer at 1 and 3 months compared to the control group.
The ethics committee insisted that the research team offer the control group the intervention at 3 months.

The authors concluded

Steroid injections are effective and cost-effective in relieving foot pain measured by the Foot Health Thermometer (FHT) for three months.

Would you have a corticosteroid injection for painful Morton’s neuroma?

The Musculoskeletal Elf’s view

A Cochrane review of interventions for the treatment of Mortons’ neuroma was carried out in 2004 and found that there was ‘insufficient evidence with which to assess the effectiveness of surgical and non-surgical interventions for Morton’s neuroma. The authors of the Cochrane review called for well designed trials to help establish the place of the various available treatments for this condition.

Corticosteroid injections are used in the treatment of Morton’s neuroma by clinicians from many disciplines including GPs, Rheumatologists, Surgeons, Radiologists, Podiatrists and Physiotherapists.With the exception of radiologists most clinicians do not routinely use ultrasound to guide the injection. The authors acknowledge that using ultrasound will have had an impact on the costs and even noted that the cost effectiveness would be significantly improved without using ultrasound (assuming, of course, that unguided injections are as effective).

Research of this nature which examines patient outcomes and cost-effectiveness of treatment is valuable to clinicians. Department of Health guidance (2013) identifies that cost reductions without maintaining or improving outcomes may amount to false savings and have a detrimental effect on the delivery of effective patient care.

This paper is a welcome and valuable addition to the available research on Morton’s neuroma. However, it does leave some questions for future research. There were, of course, questions about the responsiveness of the outcome measure used.

What do you think?

Is it worth having an injection for 3 months pain relief?
How long should patients be managed by injection before considering surgery?
Are ultrasound guided injections superior to injection by palpation alone?
If you were asked to repeat this study would you use the same outcome measures?
Should corticosteroid injections for neuroma only be carried out under ultrasound guidance?
Would you have a corticosteroid injection for painful Morton’s neuroma?
How do you address Morton’s neuroma in your practice?

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