What are the treatment options for Morton's neuroma or metatarsalgia?

Treatment Options for Morton's Neuroma and Metatarsalgia

The most effective treatment approach for Morton's neuroma and metatarsalgia begins with conservative measures including proper footwear, orthotic devices, and corticosteroid injections, with surgical intervention reserved for cases that fail to respond to conservative management. 1, 2

Conservative Management Options

Footwear Modifications and Orthotics

• Use appropriately fitting footwear that cushions the feet and redistributes pressure, particularly for patients with neuropathy or increased plantar pressures 3
• For patients with bony deformities (hammertoes, prominent metatarsal heads, bunions), extra wide or deep shoes are recommended 3
• Custom-molded shoes may be necessary for severe bony deformities including Charcot foot that cannot be accommodated with commercial therapeutic footwear 3
• Felted foam in combination with appropriately fitting footwear can be considered when offloading devices are not available 3

Injection Therapy

• Corticosteroid injections are highly effective as first-line interventional treatment, with studies showing symptom relief in up to 90% of patients with Morton's neuroma 4
• Ultrasound-guided injections improve accuracy and effectiveness of treatment 1
• For persistent cases, chemical neurolysis with alcohol or radiofrequency thermal neurolysis can be considered as minimally invasive alternatives before surgery 1

Physical Therapy

• Mechanical Diagnosis and Therapy (MDT) approaches using repeated end-range movements matched to the patient's directional preference have shown promising results in some cases 5
• Addressing mechanical factors is crucial, as mechanical metatarsalgia has been identified as a risk factor for symptom recurrence after treatment 6

Surgical Options

For Morton's Neuroma

• Surgical removal should be considered only when conservative measures fail to provide adequate pain relief 2
• Minimally invasive ultrasound-guided procedures can significantly reduce the need for subsequent surgery in patients with persistent symptoms 1

For Metatarsalgia in Diabetic Patients

• For neuropathic plantar metatarsal head ulcers where non-surgical offloading fails, consider:
  • Achilles tendon lengthening in combination with an offloading device (Conditional recommendation; Moderate evidence) 3, 7
  • Metatarsal head resection in combination with an offloading device (Conditional recommendation; Low evidence) 3, 7
• For neuropathic hallux ulcers where non-surgical treatment fails, joint arthroplasty in combination with an offloading device may be beneficial 3, 7
• For neuropathic plantar ulcers on metatarsal heads 2-5 where non-surgical treatment fails, metatarsal osteotomy combined with an offloading device can be considered 3
• Digital flexor tenotomy is strongly recommended for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity 3

Diagnostic Considerations

Imaging

• MRI is a sensitive and reliable method for evaluating Morton's neuroma with high sensitivity (87-93%) and specificity (68-100%) 3
• Ultrasound is also effective for diagnosis, with comparable sensitivity to MRI (83-96% vs 82-96%) and better specificity in some studies 3
• For plantar plate tears associated with metatarsalgia, MRI shows higher diagnostic accuracy than ultrasound 3

Special Considerations for Diabetic Patients

• Proper fitting of orthotic devices is essential to prevent pressure sores and ulceration at fracture sites 8, 7
• For patients with diabetes and neuropathic plantar forefoot or midfoot ulcers, non-removable knee-high offloading devices are recommended as first-line treatment 3
• When non-removable devices are contraindicated or not tolerated, removable knee-high or ankle-high offloading devices should be considered 3
• Conventional footwear or standard therapeutic footwear should not be used over an offloading device 3

Treatment Algorithm

1. First-line treatment: Proper footwear, orthotic devices, activity modification, and anti-inflammatory medications 1, 2
2. Second-line treatment: Corticosteroid injections (ultrasound-guided when available) 4, 1
3. Third-line treatment: Chemical neurolysis (alcohol injection) or radiofrequency thermal neurolysis for Morton's neuroma 1
4. Fourth-line treatment: Surgical intervention when conservative measures fail 2
   • For Morton's neuroma: surgical removal of the neuroma 2
   • For metatarsalgia in diabetic patients with ulcers: appropriate surgical procedure based on location and nature of the problem 3