Morton's neuroma (also known as intermetatarsal or interdigital neuroma) is a common cause of forefoot pain. Presents as a sharp burning sensation in the affected web space, often radiating proximally or distally between adjacent toes; more typically, it is located in the 3-4 or 2-3 intermetatarsal space, which may manifest as pain, burning, and/or numbness between the 3rd and 4th or 2nd and 3rd toes, respectively. From a pathological point of view, note that this condition is not a true neuroma per se. In other words, Morton's neuroma is not a "benign growth of nerve tissue" as any formal definition of a neuroma would imply, but represents inflammation of the nerve and/or thickening (perineural fibrosis) around it. It is generally accepted that wearing ill-fitting shoes with a tapered toe or high heels can aggravate this condition.
structure and function
The medial and lateral plantar nerves arise from the tibial nerve as it courses from the ankle to the foot and progresses to provide sensorimotor innervation to the sole of the foot (Figure 1). The medial plantar nerve is the larger of the two and normally supplies the skin and muscle groups along the vicinity of the big toe, second and third toes, as well as the medial side of the foot. This corresponds to the distribution of the median nerve in the hand. The lateral plantar nerve supplies these components to the lateral half of the fourth finger and the entire plantar surface of the fifth finger, just as the ulnar nerve does to the fingers. As these nerves course distally, they divide into the common digital nerves which then, just next to each membrane space near the metatarsal head, bifurcate into the smaller interdigital nerves which branch medially and laterally to enter the toes. the respective feet corresponding to the specific intermediary space from which the nerve comes. Unlike the hand, where anastomoses between the median and ulnar nerves are rare, in the foot, the third interdigital nerve is composed of confluent fibers from the medial and lateral plantar nerves. In about 50-85% of cases, Morton's neuroma affects this third nerve, perhaps because of its potentially larger size or because of its location in the foot among the most mobile bone structures. In the remaining cases, the second common digital nerve in the second web space is affected; there is little evidence to suggest any significant degree of nerve involvement in the 1st or 4th web space, for reasons that remain unclear.
Figure 1: Digital nerves on the plantar surface of the foot
Normally, a healthy nerve in one of these gaps looks like a piece of spaghetti. A true Morton's neuroma usually has an inflamed appearance and may be linked to the overlying intermetatarsal ligament. The neuroma itself is usually directly under the plantar skin or is only protected by a thin layer of subcutaneous tissue (Figure 2). The tissue is usually a pale yellow soft mass. Histologically, there is evidence of proliferation of fibroblasts and Schwanncell cells within extensive perivascular and subintimal fibrosis. In addition, there is demyelination, axonal damage, and hyalinized nodules (Renaut bodies) below the perineurium.
Figure 2. Location of the nerve directly under the skin (between the base of the third and fourth fingers)
The exact etiology of Morton's neuroma is unknown. The eponymous Morton himself suggested that capsulitis of the metatarsophalangeal joint was the source of the pain. While the exact etiology of the condition remains uncertain, it is thought to be related to localized repetitive strain and nerve irritation in the forefoot. However, there are also vascular, anatomical, traumatic, systemic, biomechanical and other proposals. Betts speculated that contracting the flexor digitorum brevis caused the nerve to be cut against the intermetatarsal ligament, which in turn caused inflammation. Another theory is that the enlargement of the bursa produces an anischemic effect. Finally, some authors have argued that only normal biomechanics can be responsible: shear forces are produced when the relatively mobile 4th metatarsal moves against the relatively fixed 3rd metatarsal, and the nerve can be compressed against it. the intermetatarsal ligament during the heel-lift phase of gait.
A patient with Morton's neuroma often complains of a sharp pain located between the third and fourth toes, which is made worse by wearing tight shoes or repetitive loads. The pain is usually plantar to the metatarsal heads and radiates distally to both sides of the toe; it may also radiate from the forefoot down the leg proximally. In some patients, pain is relieved by walking barefoot or taking off shoes and massaging the foot. Patients may also complain of a stone or pebble sensation under the toe or on the ball of the foot when walking, and occasionally describe associated intermittent or constant numbness along the length of the foot. interspace involved.
On direct examination, the patient's foot usually appears normal, with no signs of bursitis, swelling, or other abnormality. On palpation, the usual location of the pain is in the space between the metatarsal heads. Interdigital skin sensation may decrease.
A useful test for Morton's neuroma is the "lateral compression" or compression test: when the forefoot is compressed by the examiner's hands, a painful or palpable "Mulder click" can be produced due to uncomfortable subluxation of the neuroma between the heads of the metatarsals.
There is no sine qua non test for Morton's neuroma. It is usually a clinical diagnosis, made through consistent findings elucidated through history and physical examination. However, imaging tests are needed to rule out its differential diagnoses. Occasionally, an x-ray may show lateral deviation of the finger due to metatarsophalangeal joint instability or capsulitis, arthritic changes in the adjacent joint, or even a stress fracture of one metatarsal. MRI and ultrasound can confirm Morton's neuroma, but they are not very high in sensitivity and specificity. Injection of local anesthetics can also confirm the diagnosis of a Morton's neuroma, producing rapid (albeit temporary) improvement in symptoms.
The incidence of Morton's neuroma is unknown. What is known is that the incidence is approximately 5 times higher in women than in men. The left and right feet are equally affected. The typical patient is about 45 years old.
Most chronic forefoot pain is NOT a result of Morton's neuroma. Other more common sources of metatarsalgia (the medical term for pain in the forefoot) are peripheral neuropathy (probably due to diabetes); metatarsal stress fractures; MTP joint synovitis or other inflammation; and trauma. In addition, Freiberg infraction (avascular necrosis of the metatarsal head), tarsal tunnel syndrome, infection, and tumors should be considered. A complete physical examination is essential to differentiate between these possible diagnoses.
Foot pain in patients with diabetes can be a harbinger of complications. A history of diabetes, therefore, should prompt an especially detailed examination.
Treatment Options and Outcomes
Nonsurgical treatment is the best initial approach. The patient should be instructed to wear shoes with wide toe caps and low heels; A metatarsal pad or custom orthosis can also be used to relieve pressure. The use of anti-inflammatory drugs can be empirically justified for pain relief. Physical therapy modalities such as ultrasound or electrical stimulation may help, but studies demonstrating their effectiveness are lacking. An intermetatarsal injection that supplies the neurovascular bundle can help confirm the diagnosis with the addition of a local anesthetic, and a corticosteroid in the cocktail can help produce lasting relief.
If a patient does not improve with nonsurgical measures over time and if all other potential sources of pain have been eliminated as diagnostic possibilities, surgery may be indicated. Various treatments are currently employed, including formal resection of the nerve proximal to the area of fibrosis. Another option is simple surgical release of the intermetatarsal ligament and removal of scar tissue. Although resection is considered more definitive, transection of the nerve results in permanent numbness of the foot and can lead to a troublesome recurrent ("True") neuroma if the remaining stump grows back and becomes symptomatic. So there continues to be disagreement about which operation is best.
In addition to what are considered the standard risks of any orthopedic procedure, such as infection, wound healing complications, or blood clots, there are some complications that are specific to this procedure and need to be considered. These include persistent or worsening pain if this is not the cause of the patient's problem or if the nerve stump grows back and becomes uncomfortable. Complex regional pain syndrome (formerly known as reflex sympathetic dystrophy) can also occur in rare cases. These specific complications are relatively rare, but they can be difficult to manage if they occur.
Risk Factors and Prevention
There are no clear risk factors as the exact etiology is unknown. Tight, ill-fitting shoes and shoes with high heels are likely to contribute to the development of Morton's neuroma and should be avoided if possible.
Related historical information
Stigler's law of eponymy states that no scientific discovery has ever been named after its original discoverer. In fact, Stigler's Law was described without credit by Robert K. Merton! This law applies here, as this condition is not named after its original discoverer. Although Morton associated his name with this disorder (because he was the first to write about the symptoms), it was Betts who first correctly described the pathology. To complicate that eponym, Dr. Morton who gave this pathology its name was Thomas Morton, rather than Dudley Morton, the last author of the historical text "The human foot: its evolution, physiology and functional disorders".
Morton's neuroma, medial and lateral plantar nerves, digital nerves, intermetatarsal ligament, perineural fibrosis, metatarsalgia
Perform a lateral compression test and obtain a Mulder click, described in the patient presentation.
table of contents
Over-the-counter nonsteroidal anti-inflammatory medications, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), can reduce swelling and relieve pain. Try ice massage. Regular ice massage may help reduce pain.What is the new treatment for Morton neuroma? ›
New Treatments for Morton's Neuroma
Shockwave therapy.is a non-surgical and non-invasive treatment option that has an 85% success rate. By targeting areas with high-intensity pressure waves, shockwave therapy accelerates the body's natural healing process.
- Activity modification.
- Anti-inflammatory medications.
- Corticosteroid injection.
- Changing your footwear (Avoid wearing shoes that are narrow, tight or high heels. ...
- Trying custom orthotics (shoe inserts)
- Icing the inflamed area.
Most patients are surprised to find out that one of the key contributing factors to these conditions, including Morton's neuroma is a condition called 'Ankle Equinus'. Ankle equinus occurs when the ankle joint lacks flexibility, particularly, the upward movement of 'toes-to-shin' (dorsiflexion).What aggravates Morton's neuroma? ›
High-heeled shoes can aggravate a Morton's neuroma. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve. You should seek evaluation from an orthopaedic surgeon if you have continued pain or discomfort in your forefoot.Is Voltaren gel good for Morton's neuroma? ›
Anti-inflammatory treatment – A Morton's Neuroma is commonly associated with swelling and inflammation which can be painful. Anti-inflammatory therapy such as Voltaren can be useful.How do you shrink Morton's neuroma naturally? ›
Morton's neuroma inserts and proper footwear are among the most effective remedies for treating a neuroma naturally. Practices such as osteopathy and reflexology also help to ease symptoms. Finally, consider local treatments (arnica, clay, etc.).What is the gold standard treatment Morton's neuroma? ›
Radiofrequency ablation and/or cryotherapy ablation procedures or neurolytic injections are excellent treatments for Morton neuroma, especially when done under ultrasound guidance.Does gabapentin help Morton's neuroma? ›
Some anticonvulsant medications such as Gabapentin or Lyrica, can help with the nerve pain from Morton's neuroma. While the exact mechanism of action is unknown these medication are effective.Is walking bad for Morton's neuroma? ›
You can still take up walking with a neuroma as long as your foot is protected and relieved from as much pressure as possible.
If the personal quality of life has been reduced and pain is severe, and if conservative treatment is unsuccessful, surgery is an option. If the size is less than 0.8 cm, surgery can be used to save the nerve (neurolysis). If Morton's neuroma swelling is too severe, the nerve will need to be removed (neurectomy).Do toe spreaders help Morton's neuroma? ›
Toe spacers can help reduce Morton's Neuroma by decreasing pressure on the affected nerves and providing support for the foot's natural arch.How do you treat a neuroma in the ankle? ›
Injections of corticosteroids and anti-inflammatory medications are often successful in treating pinched nerves. Other treatment methods include orthotics or special padding inserts for shoes. In more severe cases, surgery may be recommended to relieve the pressure on the nerve.Is Morton's neuroma linked to MS? ›
Neurological conditions like MS and diabetes are also linked to Morton's neuroma due to the underlying disease process. Dancers are especially prone to developing the condition and we have experience in treating particularly young people in this field.What is extremely painful Morton's neuroma? ›
Morton's neuroma may feel as if you are standing on a pebble in your shoe or on a fold in your sock. Morton's neuroma involves a thickening of the tissue around one of the nerves leading to your toes. This can cause a sharp, burning pain in the ball of your foot.What not to do with Morton's neuroma? ›
- Wearing high-heeled shoes.
- Wearing narrow shoes.
- Skipping your workout.
- Wearing the wrong athletic shoes.
- Never alternating your workout.
- Don't ignore foot pain.
Morton's neuroma is a common, paroxysmal neuralgia affecting the web spaces of the toes, typically the third (Thomson 2001). The pain is significant and often debilitating to the extent that patients become apprehensive and anxious about walking or even putting their foot to the ground.What can be mistaken for Morton's neuroma? ›
- Stress fracture of the neck of the metatarsal.
- Rheumatoid arthritis and other systemic arthritic conditions.
- Metatarsalgia (ie, plantar tenderness over the metatarsal head)
The good news is that mild neuromas can be managed with padding, orthopedic devices or modifying your activities that put pressure on your feet. CBD oil can help with pain management, inflammation management and neuroprotection.Will a TENS unit help Morton's neuroma? ›
Not only does T.E.N.S. help relieve pain, but the sensation felt is very pleasant and soothing and is totally controlled by the user. TENS is more commonly used in muscular and sometimes joint pain and is rarely if ever used for Morton's neuroma.
If you are suffering from Morton's neuroma, your doctor will most likely suggest some lifestyle changes, such as wearing comfortable shoes and adding an insert. To help the pain, a corticosteroid or alcohol injection may also be recommended.Is it good to massage a Morton's neuroma? ›
Massaging is a great way to reduce pain in the early stages of Morton's Neuroma. However, massaging methods that put too much pressure on the metatarsal heads can aggravate the pain by worsening the nerve compression.Are compression socks good for Morton's neuroma? ›
Yes, Compression socks decrease the pain caused by Morton's Neuroma and they may help provide temporary relief from the symptoms such as pain and swelling. In addition, compression socks also help in the recovery phase after the surgery for faster healing.How long does a Morton's neuroma flare up last? ›
On average, some experience burning, numbness, tingling, or pain for up to a couple of weeks before seeking treatment. Trying at-home conservative methods such as icing, NSAIDS, and rest can help decrease the duration of a neuroma.Does B12 help Morton's neuroma? ›
In cases of nerve damage such as neuralgia, neuritis, Morton's neuroma, and peripheral neuropathy, injections of a concentrated B12 dose directly surrounding the affected nerve has been shown to promote nerve regeneration and diminish pathologic nerve pain.How long does it take Morton's neuroma to heal without surgery? ›
Normally within 4 weeks a client can expect to feel symptoms reducing when they have their foot posture corrected naturally using the AllNatural System at Foot Posture Centres. There are some cases where the Morton's neuroma has become chronic and injection therapy or even surgery (last resort) may be required.What does gabapentin do to feet? ›
A very small percentage of people taking Neurontin may experience swelling of the hands, feet, ankles, or other extremity locations. Shallow or labored breathing may also occur. These are potentially life threatening reactions and medical help should be sought immediately.Is Morton's neuroma a form of neuropathy? ›
Morton neuroma is a compressive neuropathy of the interdigital nerve in the forefoot due to compression and constant irritation at the plantar aspect of the transverse intermetatarsal ligament. It is not a true neuroma as the condition is degenerative rather than neoplastic.What is the best massage for Morton's neuroma? ›
Massaging the foot can be helpful, but deep pressure between the metatarsal heads will only aggravate the condition and must be avoided. Spreading the metatarsal heads is the best way to massage a foot with Morton's Neuroma without causing further damage.What makes neuroma worse? ›
The symptoms may be worse when you move your foot or wear tight or high-heeled shoes. It often gets worse over time.
One of the most effective exercises for Morton's Neuroma is toe stretching. This involves stretching the toes and the bottom of the feet to reduce tension and alleviate pain.Can barefoot shoes help Morton's neuroma? ›
Zero-Drop shoes are beneficial for Morton's neuroma sufferers due to the reduction of the forces on forefoot caused by the heel of the foot being higher than the toes.Do you have to wear a boot after Morton neuroma surgery? ›
The recovery time for an excision of Morton's neuroma is generally short. For the first two weeks after Morton's neuroma treatment you will be required to wear a post operative boot or sandal that allows you to walk without putting excessive pressure on the foot.What happens if you leave a Morton's neuroma untreated? ›
If a Morton's Neuroma goes untreated a few things can occur. First, symptoms can worsen making a Morton's Neuroma more painful and potentially more difficult to treat. Second, permanent numbness can develop. Again a neuroma is a thickening or swelling of a normal nerve.Are you awake for Morton's neuroma surgery? ›
What is Morton's neuroma surgery? In most cases the operation is performed under general anaesthetic (whilst you are asleep). Alternatively, you can have a spinal or regional anaesthetic, which just numbs the leg.What do podiatrists think of toe spreaders? ›
“I recommend toe separators to almost all my patients,” says podiatrist Emily Splichal, DPM. “I find that they're a great way to stretch the small muscles around the toes as well as the toes themselves.” Toe Spacers Aren't Just for Pedicures—This Simple Tool Can Ease Your Foot...Does foot neuroma ever go away? ›
Expected Duration. A Morton's neuroma will not disappear on its own. Usually, the symptoms will come and go, depending on the type of shoes you wear and how much time you spend on your feet. Sometimes, the symptoms will go away completely.What is the success rate of neuroma surgery? ›
Surgical excision of Morton neuroma has a fairly low success rate that may range from 55% to about 85%, depending on factors like expertise of the surgeon and nature of procedure employed.What is the prognosis for Morton's neuroma? ›
Morton's neuroma is treatable, but if it's not treated promptly it can lead to permanent nerve damage. Your doctor will ask you how the pain started and physically examine your foot. They'll put pressure on the ball of your foot and move your toes to see where you have pain.What are the early signs of MS in feet? ›
Numbness or tingling: “Numbness and tingling — especially that comes and goes in the hands or feet — is a common symptom,” says Dr.
Morton's Neuroma is a related condition that is becoming more and more common among individuals with fibromyalgia. This is a condition that is characterized by severe pain in the feet, which makes any type of exercise or other activity that requires them to be on their feet extremely difficult.Is it common to have Morton's neuroma in both feet? ›
In the majority of Morton's neuroma cases, only one nerve is affected. It's uncommon to find two neuromas in the same foot or even neuromas in both feet; only around 10-15% of patients have bilateral Morton's neuroma. However, these do sometimes occur.Is Morton's neuroma a disability? ›
Thankfully, for the majority of people, Morton's Neuroma is not a disability. However, Morton's neuroma can severely restrict quality of life, and limit enjoyment of passions, hobbies, recreational activities and often family life.Is Morton's neuroma a form of arthritis? ›
Morton's neuroma can be a local manifestation of a generalized disease such as rheumatoid arthritis [5, 9].What is the first line treatment for Morton's neuroma? ›
A custom orthotic with a metatarsal pad included to relieve pressure from the neuroma is usually the first line treatment.What is the home remedy for nerve pain in the foot? ›
- Soak in Warm Water and Epsom Salt. Soaking in Epsom salt can help ease the pain and discomfort associated with nerve pain. ...
- Compression Socks/Neuropathy Socks. ...
- Rest. ...
- Ice the Pain. ...
- Check Feet Daily. ...
- Avoid Alcohol. ...
- Anesthetic Lidocaine. ...
- Massage Your Feet.
Use ice packs or an ice massage and raise the foot and ankle at or above heart level. This will help reduce swelling. Heat may be used before doing stretching and strengthening activities prescribed by your doctor, health care provider, or athletic trainer. Use a heat pack or a warm soak.Does walking aggravate Morton's neuroma? ›
A neuroma can be very painful. It is a growth of nerve tissue between the third and fourth toes that can cause burning, pain, tingling, and numbness in the ball of the foot and between the toes. Walking can be painful with this condition, especially if you do not have the right shoes.What is the strongest drug for nerve pain? ›
What's the best painkiller for nerve pain? Tricyclic antidepressants like amitriptyline and anti-epileptic drugs like gabapentin and pregabalin are very effective at treating nerve pain.Does Vicks Vapor Rub help neuropathy pain? ›
Vicks VapoRub also has other popular off-label uses—and these have more support than use of the product on the feet to improve a cough. Vicks is sometimes used on the feet to relieve neuropathy pain, treat toenail fungus, and soften callouses.
Capsaicin is used to help relieve a certain type of pain known as neuralgia (shooting or burning pain in the nerves). Capsaicin is also used to help relieve minor pain associated with rheumatoid arthritis or muscle sprains and strains.Will Icy Hot help Morton's neuroma? ›
Applying ice then heat, known as contrast therapy, is another treatment for Morton's neuroma. This treatment involves alternating between ice packs and heating pads.