Bursal- Neuromal complex
REDUCE YOUR FORFOOT PAIN TODAY
What is a ‘Bursal – Neuromal Complex’ ?
(How does it differ from Intermetatarsal Bursitis and a Neuroma?)
A ‘bursal – neuromal complex’ is a recent term suggested by Cohen, et al. 2016 (5).
The study compared the sonographic findings of the interdigital mass (commonly referred to as an interdigital neuroma or bursitis) to the pathological findings after surgical excision of the mass.
They concluded that the interdigital masses were a combined appearance of the
“degenerated nerve, perineural scarring, tangled vessels, and scarred inter-metatarsal bursa”
A ‘bursal – neuromal complex’ often presents as pain on the ball of the foot. Neurological symptoms are also common including burning, tingling, numbness and pain in the region of the forefoot reflecting the neurological component of the mass.
What Causes a Bursal – Neuromal Complex?
The exact cause of a ‘Bursal – Neuromal complex‘ is unclear.
It is thought that a mass is the result of a combination of a compression trauma and ischemic (lack of blood flow) entrapment of the intermetarsal structures (3, 6, 7, 8, 9)
(see the diagram below of a cross section of the forefoot). 
It has been suggested that the common plantar digital nerve and bursa are repeatedly compressed, resulting in chronic irritation of the nerve and bursa. Over time the repeated irritation results in the subsequent development of a benign fibrotic degeneration of the nerve and bursa (3, 6, 7, 8, 9).
The irritation of the nerve is thought to be made worse with:
- Tight fitting footwear
- Hypermobile joints
- Digital deformities (clawtoes or (Hallux valgus) bunions)
- A flat foot
- A high arched foot
Diagnosis of a Bursal Neuromal Complex?
Diagnosis is usually based or symptoms and a complete assessment of your foot and ankle.
At the Ankle and Foot Centre we are able to provide additional information about the presence of a Bursal Neuromal Complex with ultrasound imaging.
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Typically a ‘bursal-neuromal complex’ will present as a non compressible mass between the web space as shown in the pictures above and the video below.
Treatment of a Bursal Neuromal Complex
Treatment aims to reduce the disorganised mass within the nerve and also offload the forefoot to prevent its re-occurrence.
1. Reduction of the disorganised mass can be achieved with
- Ultrasound guided injection therapy
- Cortisone Injection (51% success rates) (16)
- Alcohol (Ethanol) Sclerosis (71% success rate) (16)
- Radiofrequency nerve ablation (84% success rate) (16)
(percentage success rate from a recent systematic review published in 2017 by Valisena click here for the article)
2. Offloading the interdigital mass can be achieved with
- Shoe stretching and modification (rocker sole modification)
- Metatarsal domes
- Custom made Orthotics with a metatarsal dome incorporated into the design
What else could it be? (differential diagnosis)
Other problems that can cause similar pain to a ‘Bursal – Neuromal Complex’ include:
- Inter metatarsal bursitis
- Neuroma
- Mortons Neuroma
- Corns
- Plantar plate pathology
- Friebergs infraction
- Metatarsal stress fracture
The Ankle, Foot and Orthotic Centre’s Northcote Podiatrists can help you with all lower limb complaints, including Bursal . Make an appointment to get your foot and ankle pain under control.
Expert Podiatrists for the treatment of Neuromas servicing the areas of Northcote, Thornbury, Fitzroy, North Fitzroy, Carlton, North Carlton, Alphington, Fairfield, Brunswick, Coburg and Preston
Call The Ankle Foot and Orthotic Centre for diagnosis and advice on professional management and treatment options.
References
1.Bossley CJ, Cairney PC. The intermetatarsophalangeal bursa–its significance in Morton’s metatarsalgia. J Bone Joint Surg Br. 1980;62-B(2):184-7.
2.Giakoumis M, Ryan JD, Jani J. Histologic Evaluation of Intermetatarsal Morton’s Neuroma. Journal of the American Podiatric Medical Association. 2013;103(3):218-22.
3.Stecco C, Fantoni I, Macchi V, Del Borrello M, Porzionato A, Biz C, et al. The role of fasciae in Civinini-Morton’s syndrome. J Anat. 2015;227(5):654-64.
4.Bianchi S. Practical US of the forefoot. J Ultrasound. 2014;17(2):151-64.
5.Cohen SL, Miller TT, Ellis SJ, Roberts MM, DiCarlo EF. Sonography of Morton Neuromas: What Are We Really Looking At? J Ultrasound Med. 2016;35(10):2191-5.
6.Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. 2000;12(2):131-42
7.Decherchi P. [Thomas George Morton metatarsalgia]. Presse Med. 2007;36(7-8):1098-103.
8.Rajput K, Reddy S, Shankar H. Painful neuromas. Clin J Pain. 2012;28(7):639-45.
9.Perini L, Borrello MD, Cipriano R, Cavallo A, Volpe A. Dynamic sonography of the forefoot in Morton’s syndrome: correlation with magnetic resonance and surgery. Radiol med. 2006;111(7):897-905.
10.Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015;25(8):2254-62.
11.Zanetti M, Weishaupt D. MR Imaging of the Forefoot: Morton Neuroma and Differential Diagnoses. Seminars In Musculoskeletal Radiology. 2005;09(03):175-86.
12.Chauveaux D, Huec JCL, Midy D. The supra-transverse intermetatarsocapital bursa: a description and its relation to painful syndromes of the forefoot. Surg Radiol Anat. 1987;9(1):13-8.
13.Lee M-J, Kim S, Huh Y-M, Song H-T, Lee S-A, Lee JW, et al. Morton Neuroma: Evaluated with Ultrasonography and MR Imaging. Korean J Radiol. 2007;8(2):148-55.
14.Kankanala G, Jain AS. The Operational Characteristics of Ultrasonography for the Diagnosis of Plantar Intermetatarsal Neuroma. The Journal of Foot and Ankle Surgery.46:213-7.
15. Fazal MA, Khan I, Thomas C. Ultrasonography and magnetic resonance imaging in the diagnosis of Morton’s neuroma. Journal of the American Podiatric Medical Association. 2012;102(3):184-6
16.Zanetti M, Weishaupt D. MR Imaging of the Forefoot: Morton Neuroma and Differential Diagnoses. Seminars In Musculos