What are the treatment options for Morton's neuroma?

Morton's Neuroma Treatment

Begin with ultrasound-guided corticosteroid injections as first-line treatment after conservative measures fail, using small volumes (0.05-0.1 mL) of triamcinolone acetonide injected beside—not into—the neuroma, which provides symptom relief in approximately 90% of patients. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with imaging:

• Obtain radiographs first to exclude other causes of webspace pain including osteoarthritis, Freiberg's infraction, and stress fractures 3
• Proceed to ultrasound or MRI after negative radiographs, as both demonstrate high sensitivity (ultrasound 90%, MRI 93%) for detecting Morton's neuroma 4, 3
• Ultrasound offers the advantage of real-time clinical correlation during examination 4, 3

Treatment Algorithm

First-Line: Conservative Measures

• Footwear modifications with orthoses should be attempted initially, though steroid injections demonstrate superior patient satisfaction at all follow-up intervals 5
• At 12 months, 82% of steroid injection patients achieved complete or partial pain relief versus 63% with footwear modifications alone 5

Second-Line: Corticosteroid Injections

Injection technique is critical:

• Inject 0.05-0.1 mL of triamcinolone acetonide beside the neuroma, not directly into it 1
• Use multiple small injections around the neuroma rather than a single large intralesional injection 1
• Place injections just beneath the dermis in the upper subcutis adjacent to the neuroma 1
• Direct intralesional injection carries higher risk of fat and dermal atrophy 1

Clinical outcomes:

• 90% of patients experience symptom relief with corticosteroid injections 2
• This approach is significantly more effective than footwear modifications alone (p < 0.01) 5

Third-Line: Alternative Injection Therapies

If corticosteroid injections fail:

• Consider alcohol sclerosing injections, which demonstrate good tolerability though require further research for optimal protocols 6
• Capsaicin injections produce VAS score reduction of 51.8% 6
• Hyaluronic acid injections show promise but need additional evidence 6
• A sequential steroid/alcohol injection strategy is the most cost-effective approach before proceeding to surgery, with an incremental cost-effectiveness ratio of $4,401.61/QALY 7

Fourth-Line: Surgical Neurectomy

Reserve surgery for patients who fail injection therapies:

• Surgical excision through dorsal approach is the standard technique 8
• Ultrasound-guided injection therapies are cost-effective compared to proceeding directly to surgery and should be trialed first 7
• In probabilistic sensitivity analysis, the selective injection strategy was superior in 74% of 10,000 simulated trials 7

Critical Pitfalls to Avoid

• Never inject directly into the neuroma—this increases risk of fat atrophy and dermal changes 1
• Do not skip radiographs—they are essential to exclude other pathology despite being insensitive for Morton's neuroma itself 4, 3
• Avoid proceeding directly to surgery without trialing injection therapies, as this is not cost-effective 7
• Monitor for injection complications including fat atrophy, skin changes, and temporary pain at the injection site 1

Monitoring and Follow-Up

• Assess outcomes at 1 month, 6 months, and 12 months after initiating treatment 5
• If symptoms persist at 6 months, consider adding steroid injections to footwear modifications or progressing to alternative injection therapies 5
• No serious adverse events have been reported with infiltrative therapies 6