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So a little bit bit bit about metasia, there is a bit of a um an overlap with some of the forefoot, deformity stuff that was mentioned in the diabetic uh in the rheumatoid forefoot. Um But I think it's worth mentioning. It's a slightly different angle anyway. And um the more you hear it, the more you might actually remember it without having to specifically revise it. So, ok, can everybody see that change to plan? Yeah, I'm assuming no news is good news. So I'll carry it on but we can, we can see two stop plan. Perfect. Lovely. Thanks. I'll carry on. I said, let me know if it, if it stops somewhere on the line. So look at obviously the cause is um how people present with it, investigations, management, differential diagnosis and sort of one of the more important ones are a bit about Norton's neuro specifically at the end. So definition is pain in the fall for under one or more metatarsal heads. Um And the causes are I'm not sure this is necessarily the most helpful way of looking at it, but this is the way it seems to be looked at in the papers and the textbooks. So it's probably what the examiners will be. Um, wanting to hear if they examine you bearing in mind that you don't get examined by foot and ankle surgeons or foot and ankle cases. So, um the same applies for the other stuff too. So, primary causes due to the anatomical characteristics of the metatarsals that affect their relations to one another and the rest of the foot. So length, discrepancy, first ray insufficiency. So, we've heard about hu valgus and hypermobile, first T and T joints, um congenital deformities of the, of the met heads. Um and then further back, equinus, gastroc ta tightness, cavus foot, congenital metatarsal equinus deformities, et cetera. CTV. Um So, primary causes the causes. You can see that um there we go, you've got a long path, potentially pathologically long, second metatarsal on the left. And you've certainly got a um pathologically short fourth metatarsal on the the right and that affects how the pressure is distributed um throughout the metatarsal heads, 1st and 5th and most important. But 2nd, 3rd and 4th, absolutely do um um take um their sharing, distributing the weight. So any imbalance is going to cause pain and potentially other problems. So, secondary causes caused by conditions that increase meal loading via indirect mechanisms. So, hyperextension of the first MTP joints due to chronic sinusitis, as we've heard in rheumatoid arthritis, though it can happen in other inflammatory opathy like gout or psoriasis. Um plant plate rupture, um first ray off loading. So, anything that's painful metatarsal head abnormalities, freiburg's trauma um and then equinus neurological deformities. Um further um further approximately um potentially metatarsal ma union as well. So, um secondary causes. Here we go. Um Anybody you wanna shout out and say what they think these two on the left to begin with on the correct classic vs on the rheumatoid, on the right rheumatoid on the right. There we go. Common things are common. So, iatrogenic causes first metatarsal osteotomy. Um may cause excessive shortening or elevation and therefore um over the overloads, the um middle race, lateral me osteotomy um may result in again shortening elevation, depression, delayed or non union, which is pain reduced, extension, isolated excision of the meal and health school was overloaded with the rest. Sorry, I'll just shut the window. There are people scaffolding outside the room. I thought they finished. There we go. We can hopefully hear better. Now. Um isolated decision to base the proximal find because in theory also induce low transfers, although much less than if you take out the um metatarsal head. So there we go. Um That'll be a possibly a Wilson's type osteotomy. We don't do any of the any of those anymore. It's not been fixed and that one's more of a Chevron, but it's still somehow managed to shorten, probably was a bit short to begin with and then shortened more. Um You can see that one's even worse on the left. So, um, history worth going through some specifics that is worth asking about. So the usual, obviously where it hurts, where it starts, where it goes to when it started, how it started, how it's progressed, any history of altered sensation, any, any deformity that they've noticed and some patients will be upfront and tell you that and some will even say, oh yes, my wife or husband or whoever noticed that my ankle going in at the back as well, but a lot won't notice hind foot deformity for obvious reasons. Um, so, um, the, any past medical history, they've got, um, er, family history, I mean, CMT is a classic one but I mean, diabetes is, is, um, genetic as well. He valgus, as we've heard, um, smoking obviously relevant for um, largely operative reasons. Um, so on examination, look for their gates. Um, where are they, are they using their rockers normally or not? Um, often they're not, um, a foot shape, particularly for CS or C vs, um, hind foot alignment, plantar toe deformities. And I haven't actually mentioned it. I put it on a slide that I should have done looking at their shoes as well as has already been mentioned previously to see the wear pattern in, in the, in the, um, any insoles they've got on the inside. But also, um, on the outside. Interesting fact, I was in a complaint resolution meeting about stuff that was largely nothing to do with me. A patient was admitted under my care and one of her issues was saying that her, er, elderly mother had, uh, ended up with quite bad sort of equina. Ca ca equina varus deformity. As she's been admitted, she didn't have a problem beforehand. Like, well, I actually think she probably had a minor one beforehand that nobody really noticed and, um, she's just got a lot worse in bed in hospital with a lot of muscle wasting and contractures are not moving. And what I don't know about that. And I've brought her shoes in to show that, you know, her, her feet will look perfectly normal, amazing thing to have done. And I looked at the shoes and, uh, actually, no, she's got to wear on the outside of her heels. So she was, in fact in a, in a bit of v in her hind feet. Oh, my shoes do that too. Well, there we go. It, I just told you it was often genetic. So, so there you go. She was quite impressed with that and, er, was much more amenable to listening to explanations of the other stuff. So there you go. Looking in shoes can be helpful, um, feel any, obviously the usual stuff, whether it's tender, anywhere, specifically the dorsal and plantar aspects of the MTP joints and the IP joints and the web spaces, neurovascular examination is always useful. There we go. So somebody bright spot want to tell me what the difference is between the, um, these two pictures, apart from the obvious that one's black and white and one isn't, they aren't, my pictures is the one on the left, uh, Charcot and the one, the one on the right, sort of like a question. Well, before you come to any conclusions, just say what you can see. Ok. So, uh, on, on the left, uh, the clinical photograph of the other side of the foot uh which shows a grossly swollen forefoot, uh especially on the plantar aspect. Um I can only see 44 toes in total. And on the right is another clinical photograph of the other side of the foot with a uh callosity on the plantar aspect of the, I believe the 2nd 3rd uh metatarsal heads and also uh there is swelling of this part of the foot as well. Yeah, it's interesting. So it's, it's sort of a bit foreshortened. So, so um certainly the the the metatarsal heads look quite relatively prominent. So you, you've seen callosum, one, maybe one, maybe two metatarsal heads on the left. Yeah, about the right quite as well, maybe not as obvious call, sorry, on the, on the left you can see one or maybe two, but on the right, he went the wrong way around. It is my fourth day out of four being on call on the right one you can see probably just second me head. Um on the left one. What can you see? How many do you think? Yeah, there's multiple, multiple. So it's probably an isolated problem on the right. May, you know, you can argue about that, but it might be a fibroids, it might be a long second metatarsal. Whereas on the left it's more likely to be a global problem, like maybe rheumatoid or something. Um I suspect that fifth toe is actually clawed up out of the way rather than actually missing. Um But yeah. Ok. So, um there we go, do what you normally do. I mean, I tend to er er examine most of the, the foot and ankle passively rather than actively cos I get more information from that crepitus is always um useful um pain obviously. And then whether the deformities are flexible or fixed cos that not necessarily an issue with diagnosis, but more in terms of um potential, what potentially, what you're gonna do with the surgery. Ankle dorsal flexion is important because of, as we mentioned before, for overload from um equinus um in the ankle. So, could somebody explain um to people uh who ha aren't in the know um what silver skills test is, which is helpfully illustrated. Uh I think uh well, this test um uh basically differentiates uh I mean, you're looking for uh reasons for ankle tightness um in dorsiflexion and you want to um establish whether it's coming from the achilles tendon alone or whether there's a gastric NEMIS, um, play plays a part as well by doing the, by bending the knee to 90 degrees, you eliminate the gastric NEMIS component. And if there is still tightness present, that means it's coming from the achilles tendon. Yeah, I N95 percent. Right. But um, so yeah, if you're assuming that the ankle dorsiflexion is limited due to tight posterior structures, it may not be, you might have um anterior osteophytes, for example. but assuming that you've eliminated that, um then yes, then you're trying to find out whether it's the achilles as a whole because that's, um that's a, um is comprised of both fibers from the soleus and the gastroc or whether it's a gastroc mostly, um it doesn't have to be flex to 90 degrees. They need just enough, 30 or so enough to take the, um to effectively take the um uh the tightness out of the er, equation. Um So you're effectively solely testing uh soleus with um gas with the knee flex. Um And if it's still tight then then it's the whole achilles. That's the problem rather than the gastroc itself. Um molders test. Um We can talk a bit more about that but effectively, um you um squeeze the metatarsal heads 1st and 5th from um the relevant medial or lateral sides and then um er, put some upward pressure in the um plantar aspect of whichever web space. You think they might have a um Morton's neuroma and um then you'll feel a, feel a click or, and, or elicit pain. But I think I've got a diagram of that later on. So there we go x-rays, as we've said before, should be mandatory weight bearing. And uh for the foot, you need the lateral as well. Most places will um not do um a lateral foot view unless you specify and won't do the weight bearing unless you specify. Um I'm lucky our place due for elective for our, in our elective clinic at least. So, um ultrasound can be really, really useful. Um I tend to combine mine with injections cos I'm usually fairly certain um of my diagnosis if, if before I send it and I'm lucky to work very closely with some excellent M SK radiologists who, if I've got the, um, the diagnosis slightly wrong, we'll just, um, er, amend it and ask the patient if they'd like them to, er, inject it a bit that actually it's causing the problem. Um, rather than the, what I said it might be and we'll carry on. So that's quite useful. Um And that will partly treat it and partly diagnose it. Um MRI can be useful if you're not really sure clinically exactly what the problem is. Um, spec ct um a bit more of a hassle. Um But if you've got a patient who can't have an MRI for any reason, it can be useful, um Just tell the patient to bring a good book with them because it takes the whole morning or afternoon to happen. Um So conservative management as we've, you know, again, this has been mentioned before today. Um Rocker bottom shoes are helpful if they've got, um, uh to put a bit less pressure on the metatarsals high toe box, if you've got the clawed up toes, um, metatarsal bar again, um, can be helpful, podiatry. I mean, people, you know, ii big diabetic foot interest. So I work very closely with podiatrist, but, um, whilst they might not be able to get NHS podiatry unless they're neuropathic for any reason. Um, or, or diabetic, um, people, the people will pay sometimes. So again, if, uh, if they ask, it's worth mentioning that you can have podiatry sort of every month or six weeks or whatever to, um, to bribe the callus and that might be enough for somebody who is elderly or haven't got the time to have surgery or whatever. Um, and they can provide some more specific padding than just insoles as well. Um If you do, if, if you do think they've got a tight ta or a tight calf physios can be really helpful. Um, so I had one recently that was really tight bi later and he also had Helix Valgus and I was just a bit worried that if she was that tight, he wasn't even getting to plan a grade that, um, the Helix Valgus Correction would be doomed to failure so she went off to physio for slightly grudgingly, but it did actually help quite a bit. So, um, I've done the correction now a couple of weeks ago, so I hope it works. Um, so if they've, again, if they've exhausted all of the above, then, um, operative management really depends on the anatomy. You essentially fix what's causing the problem. Oh, if you can. So, as with a lot of things you've got, you've got osteotomy, you've got fusion excision, um use excision, arthroplasty and soft tissue maneuvers depending on what's relevant. So you can shorten what's too long. Uh with a vial osteotomy, you can uh do that with a DM mo if you are happy with burs in um places you can't see them. Um And you can do a, so that's the vial, that's somebody with a um uh doing a diagram of somebody doing a DM MO. And uh then you can do a B RT osteotomy and elevate the metatarsal if you think that's the problem. So if say, for example, somebody's had a fracture that's healed um with uh some apex, dorsal angulation, um you can take a wedge out and then put a little screw in. And as you can see, um there's less force on that metatarsal head. Um There we go, we've talked about first T MT joint instability or arthritis. Um And you can dial in the form of correction there. So that's a lapidus along with an aching and I'm almost certain. So somebody's done something to the, er, um, soft tissues in the first web space because those, um, uh, sesamoids are now nicely underneath the metatarsal head. Again. Um, first MTP joint, um, again, either arthritis or a deformity correction, you confuse that. Um, I mean, you've already heard about that and then the IP IP Js again, you can do deformity correction and you've, you've heard about that and, er, wires and, er, very soft tissue things. So there we go. Excision. So this is one that, um, again, somewhat controversial. Um, my views on excision for deformity correction in lesser toes is that it's very good. Um, I would tend to try and do a vial osteotomy and keep the joint as a joint in a, a younger patient with, um, with more demand. Um, but if there's frank arthritis, you know, if there's really bad arthritis in the joint, particularly on the pharyngeal side, which is less common, um, or they are older or they've, they've already had previous surgery. Um, then I would tend to do a, um, a stains be type procedure ie um, excision of, um, er, part or most of the proximal phalanx. Um, there are various ways to do this. The simplest one is probably the way I do it, which is to, um, lop it off, um, and stick a wire down as a metatarsal head. I don't even do anything as fancy as attaching the um, uh, the extensor tendon ends down to the flexor tendon. Um, I was taught to do it um, without the wire, um, and doing something very fancy, which I can't even remember how it works. Now, when you put the, the flexor tendons through the, er, drill hole in the metatarsal head, I think I tried it once and, er, independently and gave it up as a bad job. I tend to have to have very few problems after my stayings used to be just a simple excision and wiring frankly, um metatarsal head excision, uh controversial. Um The issue is if you effectively, I've not got anything to walk on then. So it's really, I certainly would only um do an isolated metatarsal head excision in the presence of, of osteomyelitis. And in that case, if it's, if it's all o often it's very crumbled and soft by then anyway. So, um you're not actually doing any more harm than the infections already done by just tidying it up and um removing any residual infection, assuming it's a, more of a, more of a metatarsalgia um problem. Um Then yes, I have done a few Kates KK, not any as a consultant for them, but I did a few as a training. Um It's actually described as, as all five metatarsal heads, but the modified version that I was taught was largely for rheumatoid patients that are low demand. Um Their fat pad tends to migrate distally. So you fuse the first MTP joint that has already been discussed and then you um have a um a um an elliptical incision um to er remove the other metatarsal heads in that keep their cascade and then you er excise that soft tissue and then pull it back down and you're f to be putting the fat back down under the remains of the um distal metatarsals and it can work well for some people, but to be used very sparingly, I think. Um So there we go. Soft tissues. I've already mentioned um uh flexible, extensive transfers. Again, it's not something I do very often. Um, extensive lengthening autotomy again, I was taught to Z lengthen them and, you know, and, and cobble them back together again with a scruffy bit of two OV. Um I've stopped doing that now. I kind of still Z lengthen them because there's more of a chance that one bit will sit next to the other bit and sort of vaguely heal back together again. Um For Edl, I'll just cut Edb and I haven't had any problems that I don't, that I can remember with cock up toes because I've stopped repairing them. So I think that's quite helpful and um I've had one, I think that didn't like the floppy toe and that, yeah. So I think it's worth um, again, that would be slightly controversial to say in a, um uh in a Viber. So I'd probably stick to saying I'd take length and then I'd repair it afterwards. But as I said, I don't, to myself, um, flexo tenotomy if the, um, deformity is fully flexible in a younger person. Um, I do a flexo toomy. Um, or I do them in diabetic, um, diabetic neuropath, but that's a whole other, um, discussion. Um, and then the hindfoot, you know, if you think that's causing the problem and, um, they've got, you've, you've assessed them with a silver skilled, uh, test, you can either do a gastroc release if you, if you think it's the, uh, gastroc, that's the main problem or a formal ta lengthening. There we go. There's a stray type release on the left. Obviously in a dead person, you wouldn't make that kind of incision in a live person. Made the mistake of show it. Yeah. Anyway, um, or on the, um, so postmedial gastroc release, um, on the, er, right. And that can be done under local anesthetic. I have to say I've only ever seen the right on youtube, so I've not done it myself. Um, and go ta release. I made a mistake of, um, showing this to a bunch of vascular surgeons that I was teaching a couple of weeks ago in the CAD lab and forgot to point out, er, or, or make obvious, er, what I thought was obvious that the fact that these are all stab incisions. But of course, this bit was, um, the skin's been removed. So they were merely making a huge, great um incision, but it was quite good to be able to see where they made the cuts. Um So, yeah, um er, ideally they would be more, slightly more transverse than the, the most distal one. There you start about, it's about an inch, you start about an inch above the insertion um at the, er, calcaneum and then about another 22 to 2.5 centimeters um approximately and again, for the third cut. Um traditionally your slides are probably not moving. What are they not on the screen? Is it says excision, you know, you are on cast one? Oh OK. That's odd. Has that, has that now moved or not? No? Oh, that's annoying. OK. Is it, it's moving for me? OK. For me as well. Oh, well, maybe somebody suggested if you click the screen, then it stops. Oh OK. OK. I'll reha hang on. Yeah, mister be, it's actually quite a common problem on me if you simply um close your screen and then log back in again, it will, it'll be fine, I think. Yeah. OK. Well, thanks that somebody's right. Hang on now. I need to figure out what I'm doing and reha um uh right there we go. So there we go. Yes. Um So yeah. Um traditionally you use one medial uh sorry, two medial and one lateral. Um I in theory, it's um better with the spiral fibers of the um, uh, of the achilles. Um, in practice, I don't think it makes that much difference and in theory you could do it the other way, depending on whether you're trying to, if the patient had a, um, varus or Valgus hindfoot. But, um, small print. So there we go. And you can get as good a release as this. Um, quite often. Um, it's one of those ones where you don't want to push it too much and make the achilles completely froy that said it happens every now and again, I've done it once. Well did, I haven't done it but a patient, I was doing a achilles length thing for, for a, I think it was a hindfoot correction. Um, unfortunately, um, came out of the boot and did a bit too much after six weeks and ended up completing it and then having to spend longer and wedges. Um, but he was fine in the end. So, um, differential diagnosis, uh MS neuroma of which more in a minute. Bursitis, arthritis, seso itis stress fracture. I think you can probably add a few more to that. So on to Mortons the anatomy. So, um, I don't know about you, but I tend to draw these for patients a bit, although not as well as this. So if I'm feeling particularly bad, I will look up a pic this picture on youtube or, or, um, Google or something. Um, so essentially you've got, um, median later plantar nerves um coming from the tibial nerve. So the neurovascular bundle behind the posterior malleolus and then you have um them splitting up into the branches that form the digital arteries and um where they come back to. So where they branch, there's maybe a bit of a bulge and may and that's generally speaking worthy um metatarsal hence are closest. And that's the theory of vague theory of how they happen in the first place. But it's a bit like um any um um trapped nerve um saying with a carpal tunnel, no, you know, a lot of it's hydrogenic, you don't really know what's happened in the first place. Cos anatomy is anatomy. Um But uh it can happen after, after trauma, if there's some in other inflammation for any other reasons can happen in rheumatoid, again, pick what um the carpal tunnel, um sort of high risk things and it's about the same for Morton's. So, um there we go, that's the anatomy. So you've got the um transverse intermetatarsal ligament that holds them all together and the Mortons in your ovaries deep to that. So it's on the plantar aspect. Um and again, can be very small or can be much larger. Um If you're, if you've ever tried to take one out, it's a dancer easier to find the one centimeter ones than the two millimeter ones. Um So there we go. Um, presentation, burning ankle or cramping pain, may radiate distal proximate. I've had people complain of toe pain and complain of, you know, pain in the, um, around their, to me to, tos joints from this. They, a lot of them do actually say it feels like walking on a pebble, particularly if they're in bare feet. They do often get altered sensation in the relevant toes as they tend to worsening closed footwear, um, or uh, narrow ff er, toe box footwear. Um, they may have no symptoms. Um, well, if they're walking barefoot without shoes, um on a soft carpet because it's cushioned. So you may often cea plateaus which the patient may or may not have noticed before you pointed out to them. Um They will usually have web space tenderness and then molders tests as you men I mentioned earlier before. So you can see there you've got um um something either side of pressing on the first and the fifth metatarsal heads and then you're pressing from dorsal uh planted dorsal um oh on the um in the relevant webspace that you're trying to test um, click should be positive. Sometimes you don't always feel a click or the patient will say they felt well and you didn't. Um but sudden pain and it's something I take as a um soft positive. So, um I'd say if I think that if there's a good story for an examination for Morton's neuroma, um I usually don't do X rays because I don't really see what they're going to add, if I'm, if I'm 90% sure it's a Morton's anyway. So I will usually send them off to a friendly radiologist with an ultrasound machine and an injection full of, um, steroid and local anesthetic. They will then confirm the diagnosis. Occasionally they don't. And if it, if it isn't, it's usually a bursa intermetatarsal bursa. So they wield their, their injection and, um, yeah, often the patients will come back saying they're fine. Um Sometimes um they'll come back saying it was fine for, you know, whatever, three days and it wasn't, which is fine if they just be wary. Whereas with a lot of foot and ankle stuff, if they don't say that the injection helped at all, you need to press them because sometimes people say think that if you say the injection didn't, they, they say the injection didn't help at all, then you're more likely to operate on them. Of course, it's the reverse because if I think the patient is being genuine about that, then um we've got the wrong diagnosis, we need to look elsewhere, but they don't really understand that a lot of them even though I explain it. Um So yeah, you can get x rays if you think there's another cause for this as in, you know, general metatarsalgia or 4 ft pain MRI scans. Interesting. If you're scanning something for something else, they often show more incidentally and people can get, especially if you've, they somebody else has, has got the MRI scan ordered it and then, um told them about this patients get very upset when you say, well, actually that's fine. A lot of people actually have it. It's not symptomatic, it's not even relevant in your pain. So, yeah, that can cause problems like bone spurs on x rays. There we go. Um I have to say, I don't always find them this obvious. An MRI is when I'm looking for them, but that's quite nice. And that's again, not my picture. Somebody else had already, um, put this on the internet with, um, a nice box around it to show your, um, find a good radiologist. Um, there we go. Again. Conservative management. Um, it's interesting, isn't it? It's a, you're sort of training everything else called a good friend who hates m neuromas who tries to operate on none of them and always sends them off for insoles and physiotherapy. I quite like it cos it's a nice quick operation. Um, bit fiddly keeps me, keeps me interested. Um, and I've so far had I think one slightly unhappy patient. Um, so, yeah. Um, if they're that tight, I will send them for physiotherapy, but most of the ones I've seen with MS, I don't think they are. Um, so we go, we mention injections. Um, so interestingly there are studies that show that, um, the ultrasound guided ones are better in that they will definitively confirm the diagnosis. Um, but, um, overall don't have a, a better success rate of abolishing symptoms um than um, is that a, a surface anatomy based injection? Interestingly, um, er, there is some effort about a case series from Nottingham. Um, no, not Nottingham Leicester, sorry, er, where they inject local anesthetic and steroid, um, about 50% were fine at a year and the same cohort they followed up um to five years and still over a third or better then. Um There are, there, there are some places that have injected alcohol. Um There are some series of radio frequency ablation, cryoneurolysis, shock wave therapy. Um It's all relative small print and um still, you know, either not nice, approved or certainly under restrictions. Um So um if they've done all that, they've had their injection, it abolished their pain, but it came back four months later, then you can make, you can explain about this to them and see what, see what they want to do. Um I was also taught one year at a time because it's all small stringy bits. Um And it's relatively easy to damage um one of the digital arteries at the same time as taking out the digital nerve. And if you managed, if you're doing two at once, you might manage to do this both sides of the patient's toes. And if you're unlucky, their toe will turn black and drop off. So I would rather not risk that. And when I explain it, the patients, generally speaking, don't want to risk it either often. Um I have to say I've rarely had to do, go back and do a secondary ovary the same foot for the same patient. Um I think once you've taken out the deep transverse interme tarsal ligament in what between in one web space, it sort of decompresses the whole system um for the others as well. Um So you go dorsal incision about an inch starting in the web space. So the, the, the main thing that I have to explain to people to trainees is generally that they um don't start the incision distally enough. Um So fine and divide the transverse intermetatarsal ligament and if it's one of those nice big one centimeter ones, the neuroma should pop up to meet you. Otherwise you have to sort of do a bit of sort of fling around to find stringy bits um that then have a nice Y shape to them. It's surprising. Um You think that if you pull something and the toes flex, then it is, in fact, um uh some form of flexor tendon rather than the um nerve, you can flex the toes with the nerve branch as it turns out. Um So yeah, um it's a nice, nice diagram and a nice surgical photo as well. Again, not mine pulled from somewhere off the internet, but that's what you want to see. You want to see the, the nice Y shape here. Um with the, the sort of trouser legs going up, um, to the, er, the individual, um, digital, digital nerves. Um, my rule of thumb is actually a rule of, um, uh, sort of, um, forefinger really. I've got relatively small fingers, I guess. But, um, I don't think that the ligament has been adequately, um, excised, um, or released enough unless I can get my index finger between the two metatarsal heads without wincing an agony. So that's my, that's, that's my test. And if I do that, I don't often use a, um, a need to use um a distractor like they've got in that picture. Um There we go, complications, ongoing pain, technical error. You've removed the artery, not the nerve. Um So far, I've always sent them to the lab and they've always come back with um, MS neuroma, um, wrong or incomplete diagnosis. So, either the neuroma was there but it wasn't causing the pain or the, it was, but there was something else causing pain as well. Um So that's, they're basically not gonna be happy as soon as they're out of their dressings and, and back walking on it. Um If they get, if they're happy to begin with and then the pain comes back again, sort of about six months, plus afterwards, then it's probably a stump neuroma. And this is a true neuroma as opposed to um, the MS, which technically is more of a neuritis than a neuroma if you're being picky. Um I've had one of these that said, I think an injection has cured that, but she's now symptomatic from the Mortons in the next web space. So I think I'm gonna take her back but not for a revision, but for the other web space. So, um traditionally, revisions are done by the Plantar Plantar approach. Um because scar tissue dorsally is going to be tricky and you don't need to get, you don't need to re re um divide the uh intermeal ligament. Um We don't tend to do the implant woods um for primaries because we all worry about um uh the scars not healing as well and being as tender as the neuroma. Um even if they do heal well. So metatarsalgia is pain of the metatarsal heads. The cause of divide to primary secondary and iatrogenic treatment depends on the underlying pathology. Operative management includes everything you think of really osteotomy fusion excision or soft tissue work. Morts neuroma is an important differential diagnosis and is probably quite a nice one to for them to put in the short case in the exam as well. There we go. There's a few um er references if anybody wants them. So I will stop sharing. Now.