If I were a clinician getting ready to inject steroid in the intermetatarsal space of a patient believed to have a Morton neuroma, my awareness of the study by Thomson et al. would justify the concern that “evidence-based medicine” was being followed. Dr. Thomson and his coauthors have clearly shown that an injection of steroid with a local anesthetic has a significantly greater likelihood of improving a patient’s “foot health” for at least three months than if a local anesthetic without steroid were injected.

     The conclusion that steroid injection in a patient with Morton neuroma provides a statistically significant benefit is not shocking. However, the study by Thomson et al. illustrates the amount of work required to develop a Level-I clinical study on even a relatively simple clinical condition such as a Morton neuroma. A previous study by Saygi et al.1 compared steroid injection therapy with shoe modifications and orthoses. That study used simpler outcome measurements and was retrospective. The conclusions of Saygi et al. also supported the benefit of steroid injection over the control treatment, but they did not achieve the same level of evidence as in the highly structured study by Dr. Thomson and his team.

     In addition to the demonstration of the exceptional work required for Level-I studies, two other issues to be noted are the selection of outcome measurements for foot and ankle conditions and the use of ultrasonographic imaging for the diagnosis and localization of the steroid injection used to treat a Morton neuroma.

     The outcome measurement tools used in the study by Thomson et al. included a Foot Health Thermometer, which is a foot-oriented derivative of a general health assessment tool (the EQ-5D) used in the United Kingdom. The study by Thomson et al. also used secondary outcomes tools including the Manchester Foot Pain and Disability Schedule (MFPDS), a visual analog scale (VAS) for pain, and the Multidimensional Affect and Pain Survey (MAPS).