From the Guidelines
Morton neuroma typically presents with sharp, burning pain in the forefoot, usually between the third and fourth toes, and is often diagnosed using imaging techniques such as MRI or US, with MRI having a sensitivity of 87% and specificity of 100% in surgically treated patients 1. The clinical features of Morton neuroma include a sensation of walking on a pebble or having a fold in their sock, with pain that worsens when wearing tight shoes or high heels and improves with rest and removing footwear. Physical examination may reveal pain with compression of the forefoot, sometimes accompanied by a clicking sensation, and numbness or paresthesia may occur in the affected toes. The condition results from thickening of tissue around an interdigital nerve, usually due to repetitive trauma or compression, and symptoms typically develop gradually and may be intermittent initially before becoming more persistent. Pain often radiates to the toes and can be exacerbated by weight-bearing activities, and initial management includes conservative measures such as wearing wider shoes, using metatarsal pads, taking NSAIDs for pain, and possibly corticosteroid injections. For persistent cases, surgical excision of the neuroma may be necessary, though this can result in permanent numbness in the affected area, and high-resolution US can approach the sensitivity of MRI in detecting Morton’s neuromas, with a pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 90%, 88%, 2.77, and 0.16 for US 1. Key points to consider in the diagnosis and management of Morton neuroma include:
- The use of imaging techniques such as MRI or US to confirm the diagnosis
- The importance of conservative management, including wearing wider shoes and using metatarsal pads
- The potential need for surgical excision in persistent cases
- The risk of permanent numbness in the affected area following surgical excision.
From the Research
Clinical Features of Morton Neuroma
- Morton's neuroma is a common pathology affecting the forefoot, characterized by fibrosis of the nerve, rather than a true neuroma 2.
- It is typically caused by pressure or repetitive irritation, leading to thickening of the digital nerve, usually located in the third or second intermetatarsal space 2.
- Symptoms of Morton's neuroma include burning or shooting pain in the webspace, extending to the toes, or a sensation of walking on a pebble, which can impact weight-bearing activities and quality of life 3.
Diagnosis and Treatment
- Diagnosis of Morton's neuroma is typically confirmed through symptoms, clinical tests, and imaging studies such as ultrasound or MRI 3.
- Treatment options for Morton's neuroma include orthotics, steroid injections, and surgical excision, usually performed through a dorsal approach 2.
- Conservative methods, such as shoe modifications and steroid injections, can be effective in managing symptoms, with steroid injections showing better results in some studies 4, 5.
Outcomes and Efficacy
- Studies have shown that corticosteroid injections can provide satisfactory outcomes for patients with Morton's neuroma, with maximal pain reduction occurring between 1 week and 3 months after injection 5.
- However, almost 30% of patients may eventually require operative treatment due to persistent pain 5.
- Ultrasound-guided corticosteroid injections have been shown to be more effective than non-ultrasound-guided injections in reducing pain and improving function 3.
- Surgical treatments, such as plantar incision neurectomy, may result in little to no difference in satisfaction or adverse events compared to dorsal incision neurectomy 3.