What medications are used to treat pain associated with Morton's neuroma?

From the Guidelines

For Morton neuroma pain, the most effective treatment approach involves a combination of pharmacologic and non-pharmacologic interventions, with gabapentinoids, such as pregabalin, being a viable option for managing neuropathic pain, as supported by high-quality studies 1.

Treatment Options

• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg every 6-8 hours) or naproxen (220-440mg every 8-12 hours) are typically the first-line medications for reducing inflammation and pain.
• Acetaminophen (500-1000mg every 4-6 hours, not exceeding 4000mg daily) can also help manage pain but doesn't address inflammation.
• For more severe pain, prescription-strength NSAIDs or a short course of oral corticosteroids may be considered to reduce inflammation.
• Topical treatments like diclofenac gel applied to the painful area 3-4 times daily can provide localized relief with fewer systemic side effects.
• Gabapentin or pregabalin may be beneficial for patients with prominent nerve pain, as they have been shown to be effective in treating neuropathic pain in other conditions, such as diabetic peripheral neuropathy 1.

Additional Considerations

• Proper footwear, rest, ice, and orthotic inserts can complement medication therapy and provide additional relief.
• If pain persists despite medication, corticosteroid injections directly into the affected area might be recommended before considering surgical options.
• It is essential to weigh the potential benefits and risks of each treatment option, considering the individual patient's medical history, age, and other factors, to determine the most appropriate course of treatment.

From the Research

Medications for Pain in Morton's Neuroma

• The primary outcome for treatments of Morton's neuroma is pain, with secondary outcomes including function, satisfaction, health-related quality of life (HRQoL), and adverse events (AE) 2.
• Nonsurgical treatments such as corticosteroid and local anaesthetic injection (CS+LA) have been compared to local anaesthetic injection (LA) alone, with low-certainty evidence suggesting little to no difference in pain and function between the two 2.
• Ultrasound-guided (UG) CS+LA has been shown to probably reduce pain and increase function compared to non-ultrasound-guided (NUG) CS+LA, with moderate-certainty evidence 2.
• Other nonsurgical treatments, including alcohol injection, extra-corporeal shockwave therapy (ESWT), radiofrequency ablation (RFA), cryoablation, capsaicin injection, botulinum toxin, orthosis, and YAG laser therapy, have shown statistically significant improvements in pain, but with limitations to their application 3.
• Corticosteroid injections have been found to provide satisfactory outcomes in patients with Morton's neuroma, with maximal pain reduction between 1 week and 3 months after injection, although almost 30% of patients eventually underwent operative treatment 4.
• Medium-term results of corticosteroid injections have shown that the injection remained effective in 36% of patients at a mean follow-up of 4.8 years, with a positive outcome at 1 year being reasonably predictive of a prolonged effect from the injection 5.
• A randomized controlled trial found no significant difference in pain and function improvement between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) 6.

Adverse Events

• Adverse events associated with CS+LA include mild skin atrophy, hypopigmentation of the skin, and plantar fat pad atrophy, while LA has been found to have no adverse events 2.
• UG CS+LA has been found to result in little to no difference in AE compared to NUG CS+LA, with AE including depigmentation or fat atrophy 2.
• Surgical treatments, such as plantar incision neurectomy (PN) and dorsal incision neurectomy (DN), have been found to have AE including hypertrophic scarring, foreign body reaction, missed nerve, artery resected, wound infection, postoperative dehiscence, deep vein thrombosis, and reoperation with plantar incision due to intolerable pain 2.