What is the treatment for Morton's (Mortons) neuroma?

Treatment of Morton's Neuroma

Conservative management with corticosteroid injections should be the first-line treatment for Morton's neuroma, with surgery reserved only for cases that fail to respond to conservative therapy.

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through appropriate imaging:

• Obtain radiographs first to exclude other causes of webspace pain including osteoarthritis, Freiberg's infraction, and stress fractures 1
• Proceed to ultrasound or MRI after negative or equivocal radiographs, as both demonstrate high sensitivity (ultrasound: 90%, MRI: 93%) for detecting Morton's neuroma 2, 1
• Ultrasound offers the advantage of allowing real-time clinical correlation during examination 2, 1

First-Line Treatment: Corticosteroid Injections

Corticosteroid injections demonstrate superior efficacy compared to footwear modifications alone, with 82% of patients achieving complete or partial pain relief at 12 months versus 63% with shoe modifications 3. More recent data confirms this approach alleviates symptoms in 90% of patients 4.

Proper Injection Technique

The technique matters significantly for outcomes and safety:

• Inject beside the neuroma, not directly into it - place the injection just beneath the dermis in the upper subcutis adjacent to the neuroma 5
• Use small volumes: 0.05-0.1 mL of triamcinolone acetonide (Kenalog) per injection site 5
• Perform multiple small injections around the neuroma rather than a single large injection directly into it 5
• Avoid intralesional injection as this increases the risk of fat and dermal atrophy 5

Expected Outcomes and Monitoring

• Monitor for potential side effects including fat atrophy, skin changes, and temporary pain at the injection site 5
• Reassess at 1 month, 6 months, and 12 months to evaluate treatment response 3
• Consider repeat injections at 6 months if initial response is incomplete, as combined approaches show better results 3

Alternative Infiltrative Therapies

If corticosteroids are contraindicated or ineffective, other infiltrative options exist:

• Capsaicin injections produce VAS score reductions of 51.8% 6
• Alcohol sclerosing injections are well-tolerated though require further research for efficacy validation 6
• Hyaluronic acid injections show promise but need additional evidence 6

All infiltrative therapies demonstrate good safety profiles with no serious adverse events reported 6.

Adjunctive Conservative Measures

While less effective as monotherapy, footwear modifications should be used alongside injections:

• Recommend shoe modifications with orthoses to reduce pressure on the affected intermetatarsal space 3, 7
• Combine with steroid injections rather than using footwear modifications alone 3

Surgical Intervention

Reserve surgery exclusively for patients who fail conservative management with corticosteroid injections 4, 7:

• Surgical excision (neurectomy) is the definitive treatment when infiltrative therapy fails 7
• Both dorsal and plantar approaches are viable, with the plantar longitudinal approach showing strong pain relief (VAS reduction from 8 to 0.4) and low complication rates (7.1%) at midterm follow-up 8
• Plantar approach advantages include technical simplicity and non-bothersome scar placement, particularly useful for adjacent webspace neuromas 8

Common Pitfalls to Avoid

• Do not inject directly into the neuroma - this increases complications without improving outcomes 5
• Do not proceed to surgery without adequate trial of conservative therapy - 90% of patients respond to injections 4
• Do not rely on footwear modifications alone as initial treatment - they are significantly less effective than corticosteroid injections 3
• Do not skip imaging confirmation - clinical diagnosis alone may miss alternative pathology 1