Who to refer and what treatment is recommended for a patient with Morton's neuroma?

Management and Referral for Morton's Neuroma

For Morton's neuroma, initial conservative treatment should be attempted with appropriate footwear, metatarsal pads, and NSAIDs, followed by referral to podiatry or orthopedics for specialized interventions including corticosteroid injections, and if necessary, surgical management through neurectomy or neurolysis. 1

Diagnostic Approach

Morton's neuroma is a common cause of forefoot pain characterized by fibrosis of the digital nerve, typically affecting the third or second intermetatarsal space. Proper diagnosis involves:

• Clinical examination:

  • Positive squeeze test (pain with lateral compression of the forefoot)
  • Pain at interphalangeal joints and metatarsal heads
  • Pain with metatarsophalangeal joint (MPJ) extension 2
  • Paroxysmal neuralgia affecting the web spaces of the toes 3

• Imaging confirmation:

  • MRI or ultrasound is recommended for confirmation
  • MRI has sensitivity of 87%, specificity of 100%, and accuracy of 89% 1
  • Ultrasound is also reliable with sensitivity of 90% and specificity of 88% 1

Treatment Algorithm

Step 1: Conservative Management (Primary Care)

• Footwear modifications:
  • Wide toe box shoes
  • Low-heeled shoes
  • Avoid tight-fitting footwear
• Orthotic devices:
  • Metatarsal pads to spread the metatarsal heads
  • Custom insoles to redistribute pressure
• Pain management:
  • NSAIDs for pain and inflammation
  • Activity modification

Step 2: Physical Therapy Referral

• Consider physical therapy with focus on:
  • Mechanical diagnosis and therapy approach
  • Repeated flexion of metatarsophalangeal joints 2
  • Stretching exercises for forefoot

Step 3: Specialist Referral (When to Refer)

• Refer to podiatry or orthopedic foot specialist when:
  • Conservative measures fail after 4-6 weeks
  • Pain significantly impacts daily activities
  • Pain scores remain high (>4/10) despite initial management

Step 4: Specialized Interventions (Specialist Management)

• Corticosteroid injections:

  • First-line invasive treatment
  • Can be performed with ultrasound guidance for accuracy

• Ethanol injections:

  • Alternative to corticosteroids
  • 70% ethanol under fluoroscopic and electroneurographic guidance shows 82% success rate 4

• Surgical options (when conservative treatment fails):

  • Neurectomy (excision of the nerve) - most common approach
  • Neurolysis (release of the intermetatarsal ligament) - effective when no macroscopic nerve thickening is present 5
  • Dorsal surgical approach preferred to minimize symptomatic post-operative scarring 1, 3

Effectiveness of Treatments

• Conservative treatment: Variable success, often temporary relief
• Corticosteroid injections: Moderate success but may require multiple injections
• Ethanol injections: Up to 82% success rate with proper technique 4
• Surgical management:
  • Neurectomy: High success rate but may result in permanent numbness
  • Neurolysis: Effective when no pseudoneuroma has developed 5

Important Considerations and Pitfalls

• Diagnostic pitfalls:

  • Similar symptoms can be caused by metatarsalgia, stress fractures, or plantar plate tears
  • MRI or ultrasound confirmation is essential before invasive treatment 1

• Treatment pitfalls:

  • Failure to try adequate conservative management before invasive procedures
  • Incomplete surgical resection leading to recurrence
  • Plantar surgical approach may result in more symptomatic scarring than dorsal approach 3
  • Permanent numbness is an expected outcome after neurectomy

• Post-treatment monitoring:

  • Even after successful treatment, some mild pain may persist during sports activities 4
  • Recurrence may require additional intervention

By following this structured approach to diagnosis, referral, and treatment, patients with Morton's neuroma can achieve significant pain relief and improved function in most cases.