What are the treatment options for Morton's neuroma?

Treatment Options for Morton's Neuroma

A trial of ultrasound-guided injection therapies is the most cost-effective first-line treatment for Morton's neuroma when conservative management fails, before considering surgical neurectomy. 1

Diagnosis and Evaluation

Morton's neuroma is a common, painful disorder of the foot characterized by fibrosis of the digital nerve, typically located in the third or second intermetatarsal space. It is caused by pressure or repetitive irritation leading to thickening of the nerve 2.

Diagnostic imaging options include:

• MRI: Highly sensitive (87%) and specific (100%) for Morton's neuroma diagnosis 3
• Ultrasound: Comparable sensitivity to MRI (90% vs 93%) with better specificity (88% vs 68%) 3

Treatment Algorithm

1. Conservative Management (First-Line)

• Footwear modifications:
  • Wider toe box shoes
  • Lower heel height
  • Custom orthoses
  • Metatarsal pads to spread the metatarsal heads

2. Injection Therapies (When Conservative Management Fails)

• Corticosteroid injections:

  • High efficacy in reducing pain 4
  • 82% of patients report complete or partial relief at 12 months 5
  • Significantly better patient satisfaction compared to footwear modifications alone 5

• Alcohol sclerosing injections:

  • Well-tolerated option 4
  • May be used after corticosteroid injections in a sequential approach

• Other injection options:

  • Capsaicin: Reported to produce a 51.8% reduction in pain scores 4
  • Hyaluronic acid: Well-tolerated but requires further research 4

3. Surgical Management (When Injection Therapies Fail)

• Surgical neurectomy:
  • Reserved for cases that fail to respond to injection therapies
  • Approaches include dorsal or plantar incisions
  • Dorsal incisions may result in less symptomatic post-operative scars 6

Evidence-Based Approach

Cost-effectiveness analysis shows that a sequential approach of trying ultrasound-guided injections before surgery is more cost-effective than proceeding directly to surgical neurectomy 1. The most cost-effective strategy involves:

1. Trial of corticosteroid injections
2. If unsuccessful, trial of alcohol sclerosing injections
3. Surgical neurectomy only if both injection approaches fail

This approach yields an incremental cost-effectiveness ratio of $4,401.61/QALY compared with no treatment 1.

Practical Considerations

• Injection technique: Ultrasound guidance improves accuracy and outcomes
• Monitoring: Follow-up at 1,6, and 12 months to assess response
• Expectations: Patients should understand that multiple treatment modalities may be necessary

Potential Pitfalls and Caveats

1. Misdiagnosis: Morton's neuroma symptoms can overlap with other foot conditions like metatarsalgia or stress fractures
2. Incomplete response: Some patients may require multiple injections or combination therapy
3. Post-surgical complications: Persistent pain, numbness, or scarring can occur after surgical neurectomy
4. Recurrence: Even after successful treatment, symptoms may recur with continued mechanical irritation

The evidence strongly supports a stepped approach to treatment, starting with conservative measures, progressing to injection therapies, and reserving surgery for refractory cases. This approach optimizes both clinical outcomes and cost-effectiveness.