Treatment of Morton's Neuroma in the Foot
For Morton's neuroma causing foot pain, begin with conservative management using footwear modifications and corticosteroid injections, with steroid injections showing superior initial results (82% pain relief at 12 months) compared to footwear modifications alone (63% relief). 1
Initial Conservative Management
First-Line Interventions
- Start with corticosteroid injections combined with local anesthetic as the primary treatment, as this approach demonstrates significantly better patient satisfaction and pain relief compared to footwear modifications alone at 1,6, and 12-month follow-up intervals 1
- Prescribe extra-depth or wide shoes to accommodate forefoot width and reduce pressure on the intermetatarsal spaces 2, 3
- Consider customized pressure-relieving orthoses, though evidence shows limited efficacy when used as monotherapy 1, 4
Ultrasound-Guided Diagnosis and Treatment
- Use ultrasound for accurate diagnosis, as it provides high sensitivity (87% on MRI, with US approaching similar accuracy) and can guide subsequent interventions 2, 5
- MRI demonstrates 93% sensitivity and 68% specificity for Morton's neuroma detection, with gadolinium contrast improving soft-tissue visualization 2
- Ultrasound-guided corticosteroid infiltration allows precise delivery to the affected interdigital nerve, typically at the third intermetatarsal space 5
Second-Line Minimally Invasive Treatments
When initial conservative measures fail after 6 months:
- Consider ultrasound-guided chemical neurolysis with alcohol as a minimally invasive option that can achieve significant and potentially long-lasting pain reduction 5
- Radiofrequency thermal neurolysis represents another ultrasound-guided alternative for persistent symptoms 5
- These procedures can be repeated if initial treatment fails, often leading to complete symptom remission and significantly reducing the need for subsequent surgery 5
Surgical Management
Indications for Surgery
- Persistent symptoms despite 6-12 months of conservative and minimally invasive treatments 4, 6
- Debilitating pain that prevents weight-bearing or normal ambulation 7
Surgical Approach
- Perform neurectomy through a dorsal approach, as this is associated with fewer wound complications compared to plantar incision 4, 6
- Resect the neuroma as proximally as possible to include plantar digital branches 6
- For recurrent neuromas, a plantar approach may be more appropriate 6
Expected Outcomes
- Success rates for neurectomy rarely exceed 83%, making thorough preoperative counseling essential 6
- Limited evidence suggests nerve transposition may yield better long-term results than standard resection, though data is insufficient 7
Special Considerations for High-Risk Patients
Diabetic Patients
- Perform comprehensive foot examination including assessment of protective sensation using monofilament testing 2
- Evaluate for peripheral arterial disease by checking lower-extremity pulses, capillary refill time, and ankle-brachial index if pulses are diminished 2
- Refer diabetic patients with loss of protective sensation or peripheral vascular disease to foot care specialists for ongoing surveillance 2
- These patients require more frequent monitoring due to increased risk of complications from any foot pathology 8
Common Pitfalls to Avoid
- Do not rely solely on footwear modifications as initial treatment, as steroid injections demonstrate statistically superior outcomes 1
- Avoid delaying imaging when clinical diagnosis is uncertain, as ultrasound or MRI can confirm the diagnosis and guide treatment 2, 5
- Do not proceed directly to surgery without attempting minimally invasive ultrasound-guided treatments, which can obviate the need for operative intervention in many cases 5
- Ensure proper patient counseling about realistic surgical expectations, as success rates are imperfect even with optimal technique 6
- In diabetic patients, never overlook concurrent foot deformities or loss of protective sensation that may complicate treatment 2, 8