What are the treatment options for Morton's neuroma?

Treatment Options for Morton's Neuroma

A sequential approach of trying ultrasound-guided injections before considering surgical neurectomy is the most cost-effective and clinically effective treatment strategy for Morton's neuroma when conservative management fails. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Plain radiographs are recommended as initial imaging to exclude other causes of forefoot pain (stress fractures, osteoarthritis, Freiberg's infraction) 2
• Ultrasound has high sensitivity (90%) and specificity (88%) for diagnosing Morton's neuroma and allows for dynamic examination 2
• MRI without contrast (sensitivity 87%, specificity 100%) is useful when ultrasound results are equivocal or multiple neuromas are suspected 2

Treatment Algorithm

First-Line Conservative Management

1. Footwear modifications and orthoses

   • Wear loose-fitting shoes, roomy cotton socks, and padded slippers 3
   • Keep feet uncovered in bed to avoid pressure on toes 3
   • Use appropriate orthotic devices

2. Physical therapy approaches

   • Mechanical Diagnosis and Therapy (MDT) has shown promising results with rapid improvement in some cases 4
   • Regular walking to help blood circulation, though excessive walking/standing may worsen symptoms 3
   • Cold therapy: soaking feet in icy water and massage for temporary pain relief 3

Second-Line Treatment: Infiltrative Therapy

If conservative management fails, ultrasound-guided injections should be attempted before surgery:

1. Corticosteroid injections

   • High efficacy in reducing pain 5
   • 82% of patients showed complete or partial relief at 12-month follow-up 6
   • Significantly better patient satisfaction compared to footwear modifications alone 6

2. Other infiltrative options

   • Alcohol sclerosing injections - well tolerated but requires further research 5
   • Capsaicin injections - reported to produce a 51.8% reduction in pain scores 5
   • Hyaluronic acid injections - well tolerated but needs additional research 5

The most cost-effective approach is a sequential strategy of trying corticosteroid injections followed by alcohol sclerosing injections before considering surgery 1.

Third-Line Treatment: Surgical Management

When conservative and infiltrative treatments fail:

• Surgical neurectomy (excision of the neuroma) 7
• Typically performed through a dorsal approach 7
• Should be reserved for cases that don't respond to less invasive treatments

Clinical Considerations and Pitfalls

• Important caveat: Asymptomatic neuromas can be incidental findings on MRI in up to 4% of individuals, so imaging findings must correlate with clinical symptoms 2
• Differential diagnosis: Intermetatarsal bursitis can mimic or coexist with Morton's neuroma and should be distinguished on imaging 2
• Cost-effectiveness: A trial of ultrasound-guided injection therapies yields an incremental cost-effectiveness ratio of $4,401.61/QALY compared to no treatment, making it significantly more cost-effective than proceeding directly to surgery 1
• Treatment success factors: Careful clinical examination, appropriate patient selection, and proper pre-operative counseling are key to successful management 7

By following this stepped approach from conservative measures to injections and finally surgery only when necessary, clinicians can provide the most effective and cost-efficient care for patients with Morton's neuroma.