What are the treatment options for Morton neuroma?

Treatment Options for Morton's Neuroma

The most effective initial treatment approach for Morton's neuroma is a trial of ultrasound-guided injection therapies before considering surgical neurectomy, as this strategy has been shown to be cost-effective and provides significant pain relief. 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 have limited utility for Morton's neuroma but help exclude other causes of forefoot pain 2

Conservative Treatment Options

First-Line Treatments

• Footwear modifications with orthoses:
  • Wider toe box shoes to reduce pressure on the affected interdigital space 4, 5
  • Metatarsal pads to spread the metatarsal heads and reduce pressure 4
  • Success rate of approximately 63% at 12-month follow-up 4

Corticosteroid Injections

• Corticosteroid injections show better outcomes than footwear modifications alone:
  • 82% of patients achieve complete or partial pain relief at 12-month follow-up 4
  • Triamcinolone acetonide is a preferred agent for injection 6
• Injection technique is critical:
  • Place small volumes (0.05-0.1 mL) beside the neuroma, not directly into it 6
  • Multiple small injections around the neuroma are preferable to a single large injection 6
  • Ultrasound guidance improves accuracy and outcomes 1

Alcohol Sclerosing Injections

• Can be used as a second-line injection therapy after corticosteroid injections 1
• A combined approach of trying both steroid and alcohol injections before considering surgery is most cost-effective 1

Surgical Treatment

• Indicated when conservative treatments fail 1, 5, 7
• Surgical options include:
  • Neurectomy (excision of the neuroma) 5, 7
  • Neurolysis (release of the nerve) 5
• Surgical approaches:
  • Dorsal approach is commonly recommended 5
  • Plantar longitudinal approach shows good pain relief (VAS score reduction from 8 to 0.4) with acceptable complication rates (7.1%) 7
  • Dorsal incisions may result in less symptomatic post-operative scars compared to plantar excision 8

Treatment Algorithm

1. Begin with footwear modifications and orthoses for 4-6 weeks 4, 5
2. If symptoms persist, proceed to ultrasound-guided corticosteroid injection 6, 4, 1
3. For patients who don't respond to corticosteroid injection, consider alcohol sclerosing injection 1
4. Reserve surgical neurectomy for patients who fail both injection therapies 1, 5, 7

Common Pitfalls and Caveats

• Direct injection into the neuroma rather than around it may cause fat and dermal atrophy 6
• Surgical complications include delayed wound healing, hypertrophic scar formation, and recurrent neuroma 7
• Failure to accurately diagnose Morton's neuroma may lead to ineffective treatment of other conditions that mimic its symptoms 2
• The evidence base for Morton's neuroma treatments remains limited, with few high-quality randomized controlled trials 8