What are the treatment options for Morton neuroma?

Treatment Options for Morton's Neuroma

Ultrasound-guided injection therapies should be considered as first-line treatment for Morton's neuroma when conservative management fails, as this approach is more cost-effective than proceeding directly to surgical neurectomy. 1

Diagnostic Approach

• Ultrasound and MRI are the preferred imaging modalities for diagnosing Morton's neuroma, with high sensitivity (US: 90%, MRI: 93%) 2, 3
• Ultrasound has the advantage of allowing clinical correlation during examination 2, 3
• Radiographs are insensitive for diagnosis of Morton's neuroma but useful to exclude other causes of webspace pain 2

Treatment Algorithm

First-Line Conservative Treatments

• Footwear modifications and orthoses
  • Wide toe box shoes to reduce compression of the neuroma 4, 5
  • Metatarsal pads to spread the metatarsal heads and reduce pressure 4
• While footwear modifications alone can provide relief (63% of patients report complete or partial relief at 12 months), they are less effective than steroid injections 4

Second-Line Treatments

• Corticosteroid injections

  • Triamcinolone acetonide is a preferred agent 6
  • Injection technique: place small volumes (0.05-0.1 mL) beside the neuroma in the upper subcutis, not directly into the neuroma 6
  • Multiple small injections around the neuroma are preferable to a single large injection 6
  • 82% of patients report complete or partial relief at 12 months with steroid injections 4

• Alcohol sclerosing injections

  • Can be used after steroid injections if pain persists 1
  • A combined approach of trying both steroid and alcohol injections before surgery is the most cost-effective strategy 1

Surgical Options (for refractory cases)

• Surgical neurectomy when conservative treatments fail 1, 5, 7
  • Dorsal incision approach may result in less symptomatic post-operative scars compared to plantar excision 8
  • Nerve-sparing microneurosurgical procedures are being developed to reduce the risk of stump neuromas 7

Treatment Effectiveness

• A trial of ultrasound-guided injection therapies before surgery is more cost-effective than proceeding directly to surgical neurectomy 1
• The most cost-effective approach is a sequential strategy of steroid injections followed by alcohol injections if needed, with surgery reserved for non-responders 1
• This sequential approach yields an incremental cost-effectiveness ratio of $4401.61/QALY compared with no treatment 1

Potential Complications

• Direct injection into the neuroma may cause higher risk of fat and dermal atrophy 6
• Surgical complications include recurrence of symptoms and development of painful stump neuromas 7, 8
• Monitor for potential side effects of injections including fat atrophy, skin changes, and temporary pain at injection site 6

Follow-up Recommendations

• Evaluate response to conservative treatment after 1-3 months 4
• If initial conservative measures fail, proceed to injection therapy 1, 4
• Consider surgery only after failure of both footwear modifications and injection therapies 1, 7