Initial Treatment for Morton's Neuroma
The initial treatment for Morton's neuroma should be ultrasound-guided corticosteroid injection with triamcinolone acetonide (0.05-0.1 mL) placed beside—not into—the neuroma, combined with appropriate footwear modifications. 1, 2
Primary Treatment Approach
Corticosteroid Injection as First-Line Therapy
Ultrasound-guided steroid injections are superior to blind injections and should be the preferred initial interventional approach, providing statistically significant greater pain relief at 45 days, 2 months, and 3 months compared to blind injection. 2
Corticosteroid injections achieve symptom relief in approximately 90% of patients when used as first-line treatment after conservative measures fail. 3
At 12-month follow-up, 82% of patients treated with steroid injections had complete or partial pain relief, compared to only 63% with footwear modifications alone. 4
Proper Injection Technique
Inject 0.05-0.1 mL of triamcinolone acetonide in multiple small volumes around the neuroma, not directly into it, to minimize risk of fat and dermal atrophy. 1
The preferred technique involves injecting just beneath the dermis in the upper subcutis adjacent to the neuroma. 1
Multiple small injections around the neuroma are preferable to a single large injection directly into it. 1
Role of Footwear Modifications
Footwear modifications with orthoses should be used concurrently with steroid injections, though they are less effective when used alone. 4
While shoe modifications alone provide some benefit (63% relief at 12 months), combining them with steroid injections yields superior outcomes. 4
Diagnostic Confirmation Before Treatment
Imaging Requirements
Obtain radiographs first to exclude other causes of webspace pain such as osteoarthritis, Freiberg's infraction, and stress fractures. 5
After negative or equivocal radiographs, proceed to ultrasound or MRI for definitive diagnosis, both showing high sensitivity (ultrasound: 90%, MRI: 93%). 6, 5
Ultrasound has the advantage of allowing clinical correlation during examination and can guide the injection procedure. 6
Cost-Effectiveness Considerations
A trial of ultrasound-guided injection therapies is more cost-effective than proceeding directly to surgical neurectomy, with an incremental cost-effectiveness ratio of $4,401.61 per quality-adjusted life year. 7
The steroid/alcohol selective injection strategy (trying steroid injections first, then alcohol sclerosing injections if needed, before considering surgery) is the most cost-effective approach. 7
Common Pitfalls to Avoid
Do not inject directly into the neuroma itself, as this increases the risk of fat and dermal atrophy. 1
Do not skip radiographs before advanced imaging, as they are essential to exclude other treatable causes of forefoot pain. 5
Avoid blind injections when ultrasound guidance is available, as they provide inferior short-term pain relief and higher rates of skin side effects. 2
Treatment Algorithm
Confirm diagnosis with radiographs to exclude other pathology, followed by ultrasound or MRI if needed 6, 5
Initiate ultrasound-guided corticosteroid injection (triamcinolone acetonide 0.05-0.1 mL beside the neuroma) 1, 2
Combine with footwear modifications and orthoses 4
Reassess at 1 month, 3 months, and 6 months for treatment response 2
Consider alcohol sclerosing injections if steroid injections fail before proceeding to surgery 7
Reserve surgical neurectomy only for patients who fail conservative injection therapies 3, 7