What are the treatment options for Morton neuroma?

Treatment Options for Morton's Neuroma

The most effective initial treatment for Morton's neuroma is a stepwise approach starting with conservative measures including footwear modifications and corticosteroid injections, with surgical intervention reserved for refractory cases. 1

Diagnostic Approach

• Imaging:
  • Ultrasound: 90% sensitivity, 88% specificity (preferred initial imaging)
  • MRI: 87% sensitivity, 100% specificity 1

Treatment Algorithm

First-Line Conservative Treatments

1. Footwear Modifications and Orthoses

   • Wide toe box shoes
   • Low-heeled shoes
   • Custom orthotic insoles to reduce pressure on the affected nerve

2. Corticosteroid Injections

   • More effective than footwear modifications alone
   • 82% of patients achieve complete or partial pain relief at 12 months with steroid injections compared to 63% with footwear modifications 2
   • Ultrasound guidance improves accuracy of injection

Second-Line Treatments

1. Ultrasound-guided Pulsed Radiofrequency
   • Promising option before considering surgery
   • Provides successful pain control in approximately 60% of patients
   • Allows comfortable walking in 80% of patients 3

Surgical Options (for refractory cases)

1. Neurectomy (excision of the nerve)

   • Dorsal approach preferred over plantar approach to avoid painful hyperkeratotic scarring 4
   • Highly effective for pain relief but results in permanent numbness in the affected web space
   • Consider only after failure of conservative treatments

2. Nerve Transposition

   • May yield better long-term results than standard resection 5

Treatment Effectiveness

• Steroid injections provide better short-term outcomes than footwear modifications
• At 12-month follow-up, the difference between steroid injections and footwear modifications becomes less statistically significant 2
• A sequential approach of trying ultrasound-guided injections before surgery is more cost-effective than proceeding directly to surgical neurectomy 1

Important Considerations

• Morton's neuroma is not a true neuroma but rather perineural fibrosis of an intermetatarsal plantar nerve 6
• Most commonly affects the third intermetatarsal space, followed by the second 4
• Surgical neurectomy provides definitive treatment but results in permanent sensory deficit in the affected web space
• Post-surgical complications include painful scarring (particularly with plantar approach) and persistent neuroma pain

Follow-up Recommendations

• Evaluate response to conservative treatment at 1 month, 6 months, and 12 months
• If no improvement after 3-6 months of conservative management, consider advancing to next treatment option
• Post-surgical follow-up should assess pain relief, sensory changes, and scar formation