What are the treatment options for Morton's neuroma?

Treatment Options for Morton's Neuroma

For patients with Morton's neuroma, a trial of ultrasound-guided injection therapies is recommended as first-line treatment when conservative management fails, as this approach is more cost-effective than proceeding directly to surgical neurectomy. 1

Diagnostic Approach

• MRI and ultrasound are the preferred imaging techniques for diagnosing Morton's neuroma, with high sensitivity (MRI: 93%, ultrasound: 90%) 2
• Ultrasound has the advantage of allowing dynamic examination and direct clinical correlation during assessment 3
• Radiographs are insensitive for diagnosing Morton's neuroma but help exclude other causes of webspace pain such as osteoarthritis, Freiberg's infraction, and stress fractures 3

Conservative Treatment Options

• First-line treatments:

  • Footwear modifications with orthoses (wider toe box, low heels) 4
  • Activity modifications to reduce pressure on the affected area 5

• Injection therapies:

  • Corticosteroid injections provide better short-term results compared to footwear modifications alone (82% vs 63% complete or partial relief at 12 months) 4
  • Ultrasound-guided ethanol injections show promising results with a success rate of over 82% per single injection (defined as freedom from pain in daily activities) 6
  • A combined approach of steroid injections followed by alcohol sclerosing injections (if needed) before considering surgery is the most cost-effective treatment strategy 1

Surgical Options

• Surgical intervention should be considered when conservative treatments fail 5
• Surgical options include:
  • Neurectomy (excision of the nerve) - typically performed through a dorsal approach 5
  • Nerve transposition - may yield better long-term results than standard resection 7
  • Neurolysis (freeing the nerve from surrounding tissue) 7

Treatment Algorithm

1. Initial conservative management:

   • Footwear modifications with orthoses 4
   • Activity modifications 5

2. If conservative management fails:

   • Progress to ultrasound-guided injection therapy 1
   • Begin with corticosteroid injections 4
   • Consider alcohol sclerosing injections if steroid injections fail 1, 6

3. If injection therapies fail:

   • Consider surgical neurectomy, preferably through a dorsal approach to minimize symptomatic post-operative scarring 7, 5

Important Considerations

• Ultrasound-guided injection therapies should be tried before surgical neurectomy as they are more cost-effective 1
• Higher percentage ethanol (70%) and improved localization techniques (using fluoroscopic and electroneurographic guidance) may improve outcomes of alcohol injections 6
• Patients should be informed that while treatments can provide significant relief, some mild pain may persist, particularly during sports activities 6
• The evidence base for Morton's neuroma treatments remains limited, with few high-quality randomized controlled trials available 7