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Mortons Neuroma) Less commonly, can occur between 2nd and 3rd MTP Ultrasound vs Palpation Guidance Santiago et al: Compared to a blind injection, ultrasound guidance provides a statistically significant improvement at some stages of the follow-up (45 days, 2 and 3 months) [2] Indications Contraindications Absolute Anaphylaxis to injectates Overlying cellulitis, skin lesion or systemic infection Relative Can be treated with less invasive means Hyperglycemia or poorly controlled diabetes Lack of symptom improvement with previous injection Procedure Equipment Sterile prep (including chloraprep, chlorhexadine, iodine, etc) Ultrasound with sterile probe cover Gloves Needle Local anesthesia: typically 23-25 gauge, 1.5 inch Injection: 25-27 gauge, 1-1.5 inch needle Syringe: 5-10 mL Gauze Ethyl Chloride Bandage Injectate Local anesthetic Corticosteroid/ injectate Ultrasound Findings Best evaluated using a superficial linear transducer Hypoechoic mass greater than 5 mm measured in short axis is usually found in symptomatic Mortons neuroma Long axis view: Neuroma has a more fusiform appearance Can see continuity of the neuroma with the interdigital nerve (somewhat oblique to the nearby metatarsal bone) Sonographic Tinels Sign Squeeze the neuroma between the transducer and the operators opposite thumb