What May Lie Beneath Insurance Denials On Alcohol Injections For Morton`s Neuromas And The ABIM Foundation`s Choosing Wisely Website

Choosing Wisely (https://www.choosingwisely.org/ ) is an initiative of the American Board of Internal Medicine (ABIM) Foundation. The purpose of the initiative, according to the ABIM Foundation, is to “promote conversations between clinicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.”¹ Medical specialties create recommendations for clinicians and patients that “represent specific, evidence-based recommendations clinicians and patients should discuss.” ¹ The website exists primarily as a patient resource.

The American Podiatric Medical Association’s (APMA) Clinical Practice Advisory Committee (CPAC), for which I perform duties as a liaison, has recently crafted clinical recommendations for consideration by the ABIM. This process included reviewing past, relevant submissions made by various lower extremity specialists.

Upon reviewing previous submissions that are on the ABIM website, I encountered contradictions with established podiatric practice guidelines and therapies. I became particularly concerned upon learning of instances of private insurers denying coverage based on clinical recommendations found on the ABIM site despite its explicit advisory: “Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions.”¹ I have personally encountered this treatment denial in my private practice.

The denied coverage decision could be attributed to a submission by the American Orthopedic Foot and Ankle Society (AOFAS), which reads: “Don’t use alcohol injections for Morton’s neuromas,” with the following rationale: “Alcohol can permanently damage the nerve, but without effective pain relief. At five-year follow-up, alcohol injection for Morton’s neuroma has both a high recurrence rate and a high rate of complications, including bruising, scar formation, dysesthesia, severe pain, and infection.”1

AOFAS's submission cites two sources. The first and more relevant source is an article by Gurdezi and colleagues.² In a 5-year review of alcohol injections for Morton’s neuromas, 16 of 45 (36%) patients treated with alcohol injections required surgical excision while 13 of 45 (29%) remained symptom-free.²

The study noted that “Injection therapy is sometimes seen as a less traumatic option, but one-third of our patients described either immense pain at the time of injection (despite the use of local anesthetic), significant bruising, prolonged pain lasting weeks, or paresthesia in adjacent toes.”²

The second and more obscure article cited was titled, “Effect of glycerol on peripheral nerve: an experimental study.”³ This study by Rengachary and colleagues was based on the injection of rat sciatic nerves with glycerol, and they examined the histology at 1 or 3.5 weeks. The application of this study to the AOFAS's recommendation was unclear.

Contrarily, multiple studies show favorable results for the use of alcohol injections for Morton’s neuromas. Dockery’s landmark research showed promising results in 100 patients with success rates of 89 percent at an average follow-up of 13 months.⁴ For reference, this study used 3 to 7 injections of 4% alcohol injections given at 5- to 10-day intervals.⁴ The most frequent complaint was transient post-injection neuritis following the initial injection.4

Fanucci and colleagues found total or partial symptomatic relief at 10 months in 90 percent of the patients who had ultrasound-guided 30% alcohol injections.⁵ No post-procedure complications occurred but approximately 15 percent of the patients experienced temporary plantar pain.⁵

Hughes and coworkers showed similar results to those of Fanucci and colleagues.⁶ The study by Hughes and coworkers consisted of 101 patients treated with an average of 4.1 injections and there was a mean follow-up of 21.1 months.⁶ Partial or total symptomatic relief occurred for 94 percent of the patients with 84 percent relating complete relief.⁶ The mean Visual Analogue Score (VAS) for pain decreased from 8 to 0.5. A temporary increase in pain occurred in 17 cases (16.8 percent) but with no significant complications.⁶

Finally, Hyer and colleagues evaluated 4% alcohol injections in six patients with eight neuromas.7 The patients received between three to nine injections weekly and the average follow-up was 346 days. The VAS decreased from 7.5 ± 1.14 to 1.38 ± 2.39 with a mean reduction of 6.13, a 73 percent improvement. No complications occurred in the study.

The unreferenced research detailing these positive patient outcomes after alcohol injections more than offsets the recommendation reference. The reference for the ABIM site’s recommendation on alcohol injections for Morton’s neuromas is from an AOFAS journal.

Given that many podiatric physicians routinely utilize alcohol injections in the treatment of Morton’s neuromas, it is rational to perceive the AOFAS's position on the use of alcohol injections as yet another salvo in an ongoing turf war against podiatric physicians.

Notwithstanding their claim to have utilized supportive evidence in formulating their recommendation, the research cited was weak by the standards accepted by the medical community. Yet the AOFAS Evidence-Based Medicine Committee “reviewed the scientific literature on each statement and presented draft statements with supporting evidence to the committee for discussion.”¹

While it is true that patients receiving alcohol injections for Morton's neuromas may not experience 100 percent relief of symptoms, the research shows the therapy as a reasonable conservative option. The AOFAS's recommendation, “Don’t use alcohol injections for Morton’s neuromas,” is not rooted in evidence-based medicine and undermines the credibility of the podiatric profession, narrowing viable options for the patient.

References

1. https://www.choosingwisely.org/
2. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton’s neuroma: a five-year follow-up. Foot Ankle Int. 2013;34(8):1064-1067.
3. Rengachary SS, Watanabe IS, Singer P, Bopp WJ. Effect of glycerol on peripheral nerve: an experimental study. Neurosurgery. 1983:13(6):681-688.
4. Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg. 1999:38(6):403-408.
5. Fanucci E, Masala S, Fabiano S, et al. Treatment of intermetatarsal Morton’s neuroma with alcohol injection under US guide: 10-month follow-up. Eur Radiol. 2004;14(3):514-518.
6. Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol. 2007;188(6):1535-1539.
7. Hyer CF, Mehl LR, Block AJ, Vancourt RB. Treatment of recalcitrant intermetatarsal neuroma with 4% sclerosing alcohol injection: a pilot study. J Foot Ankle Surg. 2005;44(4):287-291.