Treatment of Morton's Neuroma
For Morton's neuroma, begin with ultrasound-guided corticosteroid injections (0.05-0.1 mL triamcinolone acetonide placed beside, not into, the neuroma), which provide complete or partial pain relief in 82-90% of patients and are more cost-effective than proceeding directly to surgery. 1, 2, 3
Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis with appropriate imaging:
- Obtain radiographs first to exclude alternative causes of webspace pain including osteoarthritis, Freiberg's infraction, and stress fractures 4
- Proceed to ultrasound or MRI after negative radiographs, as both demonstrate high sensitivity (ultrasound 90%, MRI 93%) for detecting Morton's neuroma 5, 4
- Ultrasound offers the advantage of real-time clinical correlation during examination 5, 4
First-Line Treatment: Corticosteroid Injections
The optimal injection technique involves:
- Inject 0.05-0.1 mL of triamcinolone acetonide beside the neuroma, not directly into it, to minimize risk of fat and dermal atrophy 1
- Use multiple small injections around the neuroma rather than a single large intralesional injection 1
- Place injections in the upper subcutis adjacent to the neuroma, just beneath the dermis 1
Expected outcomes:
- 82-90% of patients achieve complete or partial pain relief with corticosteroid injections 2, 6
- Steroid injections demonstrate significantly better patient satisfaction (p < 0.01) compared to footwear modifications alone at 1,6, and 12-month follow-up 6
Second-Line Treatment: Alcohol Sclerosing Injections
If corticosteroid injections fail to provide adequate relief:
- Consider ultrasound-guided alcohol sclerosing injections as the next step before proceeding to surgery 3, 7
- This sequential approach (steroid followed by alcohol injections) is the most cost-effective strategy, with an incremental cost-effectiveness ratio of $4,401.61/QALY 3
- The steroid/alcohol selective injection strategy was dominant in 74% of simulated trials when compared to direct-to-surgery approaches 3
Alternative Conservative Options
While less effective than injections, consider these adjuncts:
- Footwear modifications with orthoses provide complete or partial relief in only 63% of patients at 12 months, significantly lower than injection therapy 6
- Capsaicin injections reduce VAS pain scores by 51.8%, though this requires further validation 7
- Hyaluronic acid injections are well-tolerated but their efficacy needs additional research 7
Surgical Intervention
Reserve surgical neurectomy for patients who fail both corticosteroid and alcohol injection therapies 3
- Surgery should not be first-line treatment given the cost-effectiveness and high success rates of injection therapies 3
- If surgery becomes necessary, consider nerve transposition rather than standard resection, as limited evidence suggests potentially better long-term outcomes 8
- Dorsal incisions may result in fewer symptomatic post-operative scars compared to plantar approaches 8
Critical Pitfalls to Avoid
- Never inject directly into the neuroma itself, as this increases the risk of fat atrophy and dermal complications 1
- Do not proceed directly to surgery without trialing injection therapies first, as this is not cost-effective and exposes patients to unnecessary surgical risks 3
- Avoid relying solely on footwear modifications as initial treatment, as they demonstrate significantly inferior outcomes compared to corticosteroid injections 6
- Do not skip initial radiographs, as they are essential to exclude other causes of forefoot pain that would require different management 4
Monitoring Treatment Response
- Assess outcomes at 1 month, 6 months, and 12 months following injection therapy 6
- If symptoms persist after the first corticosteroid injection, consider adding footwear modifications at the 6-month mark before escalating to alcohol injections 6
- The probability of successful alcohol injection treatment must exceed 40% for this approach to remain more cost-effective than proceeding to surgery 3