What are the symptoms and treatment options for Morton's neuroma?

Symptoms of Morton's Neuroma

Morton's neuroma presents with paroxysmal pain, burning sensations, numbness, and tingling in the forefoot, typically affecting the third webspace between the toes, often so severe that patients become anxious about walking or bearing weight. 1, 2

Clinical Presentation

Primary Sensory Symptoms

• Pain is the hallmark symptom, described as sharp, burning, or shooting pain in the ball of the foot that radiates into the affected toes 3, 1
• Paresthesias and dysesthesias manifest as tingling, numbness, or abnormal sensations in the webspace, most commonly the third intermetatarsal space 3, 1
• Burning sensations are frequently reported, particularly with weight-bearing activities 1
• Pain typically worsens with tight or fashionable footwear and improves with shoe removal 1

Distribution Pattern

• The third webspace (between third and fourth toes) is most commonly affected, followed by the second webspace 3, 1
• Symptoms follow a predictable pattern affecting the adjacent sides of two toes rather than an entire toe 3

Functional Impact

• Severe functional impairment occurs, with patients experiencing difficulty with weight-bearing activities 4
• Limitation in appropriate footwear due to pain and discomfort significantly affects daily activities 4
• The pain can be so debilitating that patients develop anxiety about walking or placing their foot on the ground 2

Diagnostic Examination Findings

Physical Examination

• Compression test of the affected webspace is highly specific for diagnosis - squeezing the metatarsal heads together while palpating the webspace reproduces symptoms 1
• Tenderness is localized to the specific intermetatarsal space 3

Imaging Confirmation

• Ultrasound and MRI are the preferred diagnostic modalities, with high sensitivity (ultrasound: 90%, MRI: 93%) according to the American College of Radiology 5, 6
• Ultrasound allows real-time clinical correlation during examination 5, 6
• Radiographs should be obtained first to exclude other causes of webspace pain such as osteoarthritis, Freiberg's infraction, and stress fractures, though they are insensitive for diagnosing Morton's neuroma itself 5, 6

Treatment Approach

First-Line Conservative Management

• Corticosteroid injections are highly effective, with symptom relief achieved in 90% of patients (9 out of 10) in recent studies 4
• The British Journal of Dermatology recommends injecting 0.05-0.1 mL of triamcinolone acetonide beside (not into) the neuroma using multiple small injections rather than a single large injection 7
• Orthotics and footwear modifications should be implemented 3

Additional Infiltrative Options

• Capsaicin injections produce VAS score reduction of 51.8% 8
• Alcohol sclerosing injections and hyaluronic acid are well-tolerated alternatives, though require further research 8
• No serious adverse events have been reported with infiltrative therapies 8

Surgical Consideration

• Surgical excision through a dorsal approach is reserved for cases where conservative treatment fails 3
• Surgery can produce dramatic pain relief when conservative measures are insufficient 1

Important Clinical Caveats

• This is not a true neuroma but rather fibrosis of the digital nerve caused by repetitive pressure or irritation 3
• Middle-aged women who frequently wear fashionable, tight shoes are at highest risk 1
• The condition affects approximately 4% of the general population 8