From the Guidelines
Morton's neuroma-bursitis complexes in the left second and third intermetatarsal spaces should be treated with a combination of conservative measures initially, prioritizing the reduction of pressure on the affected area and management of pain and inflammation. The treatment approach should involve wearing wide, comfortable shoes with a low heel and adequate toe box, using metatarsal pads or cushioned insoles to redistribute pressure away from the neuroma, and taking over-the-counter anti-inflammatory medications like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily with food) for 1-2 weeks to reduce pain and inflammation 1.
Initial Management
- Apply ice to the affected area for 15-20 minutes several times daily
- Rest and avoid high-impact activities that worsen symptoms
- Consider physical therapy focusing on foot stretching and strengthening exercises to help manage symptoms
Diagnostic Imaging
For diagnostic purposes, MRI is believed to be a sensitive and reliable method to evaluate patients with metatarsalgia and Morton’s neuroma, with a sensitivity of 87%, specificity of 100%, accuracy of 89%, PPV of 100%, and NPV of 60% in surgically treated patients 1. Increased fluid within the intermetatarsal bursa, which suggests bursitis, is well demonstrated on MRI, making it a valuable tool in the diagnosis and treatment planning of Morton's neuroma-bursitis complexes.
Further Treatment
If the initial measures do not provide relief within 4-6 weeks, consider corticosteroid injections administered by a healthcare provider. For persistent cases, custom orthotics might be necessary. Surgery is typically reserved for cases that don't respond to conservative treatment after 6-12 months, emphasizing the importance of exhausting non-surgical options before considering surgical intervention. Morton's neuroma involves thickening of tissue around nerves leading to the toes, causing pain, burning, and numbness, while the associated bursitis involves inflammation of the small fluid-filled sacs that cushion the bones, tendons, and muscles near the joints.
From the Research
Morton's Neuroma-Bursitis Complexes
Morton's neuroma-bursitis complexes within the left second and third intermetatarsal spaces are a common pathology affecting the forefoot, characterized by fibrosis of the nerve due to pressure or repetitive irritation 2.
Causes and Treatment Options
The condition is caused by thickness of the digital nerve, located in the third or second intermetatarsal space, leading to pain and discomfort 2. Treatment options for Morton's neuroma include:
- Orthotics
- Steroid injections
- Surgical excision, usually performed through a dorsal approach 2
- Infiltrative treatment, such as capsaicin, corticosteroids, sclerosing solutions, and hyaluronic acid injections, which have been shown to be effective in reducing pain related to Morton's neuroma 3
Efficacy of Treatment Options
Studies have evaluated the efficacy of different treatment options for Morton's neuroma, including:
- Alcohol injection, which has been shown to have limited long-term effectiveness, with only 29% of patients remaining symptom-free at 5-year follow-up 4
- Corticosteroid injections, which have been reported to have a high level of efficacy in reducing pain related to Morton's neuroma 3
- Surgical interventions, such as neurolysis and neurectomy, which have been shown to have higher incidences of complete pain relief and complete patient satisfaction outcomes compared to injection treatment 5
Clinical Recommendations
Clinical recommendations for the treatment of Morton's neuroma include a protocol of stepped care, starting with patient education and foot-wear or insole changes, followed by corticosteroid injections and, finally, surgery 6. The choice of treatment should be based on individual patient needs and preferences, and should take into account the potential risks and benefits of each option 6.