The diagnosis of symptomatic forefoot neuroma from a clinical diagnostic protocol for podiatric assessment

Abstract

There is limited evidence reporting the epidemiology of forefoot neuroma (FFN) in the general population of the United Kingdom (UK). Consequently, estimated incidence or prevalence are not known although the condition is considered common in the National Health Service (NHS) and private health care sectors. Therefore, there is a need to determine the extent of this condition to inform appropriate healthcare provision. Furthermore, it is thought that an accurate and timely diagnosis would improve the patient experience and use of pathways through the NHS. A specific set of symptoms, associated with FFN, has been consistently documented in the literature. Despite this, the optimal method for FFN diagnosis is challenging and anecdotally highly variable between clinicians; currently no reliable or valid clinical diagnostic protocol exists for the diagnosis of symptomatic FFN in podiatric practice. Therefore, there is a need to develop a clinical diagnostic protocol and to determine its reliability and validity. It was anticipated that accurate diagnosis will inform more targeted service planning and promote effective clinical decision making on the management options available to address participant reported symptoms.
Three sequential studies were designed and delivered within a local NHS podiatry service line. In study one, the clinical pathways were reviewed and the numerical values of individuals accessing the local podiatry service for a forefoot assessment were defined. Study two developed a clinical assessment protocol (FNCAP) with agreed expert consensus for the diagnosis of FFN. Through study three, the content validity and reliability of FNCAP for the diagnosis of FFN was established.
The findings of this thesis validate the estimated regional incidence and prevalence rates of symptomatic persons registered to the podiatry service line. However, records provided little insight into the diagnostic methods used to identify FFN from other forefoot pathology. This led to the development of a clinical diagnostic protocol from expert consensus for FFN. Through the Delphi study, six themes related to the clinical diagnosis of FFN: location of pain, non weight-bearing sensation, weight-bearing sensation, observations, clinical tests and imaging were identified. The themes were integrated such that 21 recommendations were identified and refined to form a clinical diagnostic protocol for FFN. The diagnostic test study indicated that there is content validity for the items that form FNCAP. The intra-rater reliability tests for the FNCAP revealed a ‘moderate’ threshold of agreement value. The sensitivity (100%) and specificity (95.6%) scores for FNCAP were high and indicated the FNCAP could be useful for diagnosing FFN in most cases. Feasibility testing of the FNCAP has indicated some usefulness in diagnosing FFN but further investigations are required to determine the FNCAP applicability in clinical practice.

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Identifiers

ORCID for Charlotte Dando: orcid.org/0000-0002-6954-4212

ORCID for Catherine Bowen: orcid.org/0000-0002-7252-9515

ORCID for Lindsey Cherry: orcid.org/0000-0002-3165-1004

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