What are the treatment options for Morton's neuroma?

Treatment of Morton's Neuroma

For Morton's neuroma, begin with corticosteroid injections as first-line treatment, using small volumes (0.05-0.1 mL) of triamcinolone acetonide injected beside—not into—the neuroma, which provides complete or partial pain relief in approximately 82-90% of patients. 1, 2, 3

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using:

• Ultrasound or MRI as the preferred imaging modalities, with sensitivities of 90% and 93% respectively 4, 5
• Initial radiographs to exclude other causes of webspace pain including osteoarthritis, Freiberg's infraction, and stress fractures 5
• Ultrasound offers the advantage of real-time clinical correlation during examination 4, 5

First-Line Conservative Treatment: Corticosteroid Injections

Injection technique is critical for success:

• Inject 0.05-0.1 mL of triamcinolone acetonide beside the neuroma, not directly into it 1
• Use multiple small injections around the neuroma rather than a single large injection 1
• Place injections just beneath the dermis in the upper subcutis adjacent to the neuroma 1
• Direct intralesional injection increases risk of fat and dermal atrophy 1

Expected outcomes:

• 82% of patients achieve complete or partial pain relief at 12 months 3
• 90% symptom relief reported in recent case series 2
• Significantly superior patient satisfaction compared to footwear modifications alone at all follow-up intervals 3

Second-Line Conservative Treatment: Footwear Modifications

If corticosteroid injections fail or as adjunctive therapy:

• Footwear modifications with orthoses provide complete or partial relief in 63% of patients at 12 months 3
• Combining shoe modifications with steroid injections at 6 months may improve outcomes 3
• However, supinatory insoles lack evidence for effectiveness 6

Alternative Infiltrative Therapies

When corticosteroids are insufficient or contraindicated:

• Capsaicin injections produce VAS score reduction of 51.8% 7
• Alcohol sclerosing injections are well-tolerated but require further research 7
• Hyaluronic acid injections show promise but need additional evidence 7
• All infiltrative therapies demonstrate good safety profiles with no serious adverse events reported 7

Surgical Intervention

Reserve surgery only for patients who fail conservative treatment 2, 8:

• Standard nerve excision through dorsal approach is the most common technique 8
• Transposition of the transected plantar digital nerve may yield better long-term results than standard resection, though evidence is limited 6
• Dorsal incisions may result in fewer symptomatic post-operative scars compared to plantar excision 6
• Careful patient selection and pre-operative counseling are essential for surgical success 8

Treatment Algorithm

1. Confirm diagnosis with ultrasound or MRI after excluding other pathology with radiographs 4, 5
2. Initiate corticosteroid injections using proper technique (beside, not into the neuroma) 1, 3
3. Reassess at 1,6, and 12 months 3
4. Add footwear modifications if partial response or consider at 6 months 3
5. Trial alternative infiltrative therapies (capsaicin, alcohol, hyaluronic acid) if corticosteroids fail 7
6. Refer for surgical excision only after exhausting conservative options 2, 8

Common Pitfalls to Avoid

• Injecting directly into the neuroma increases complications without improving outcomes 1
• Using large injection volumes rather than multiple small deposits 1
• Proceeding to surgery prematurely before adequate trial of conservative treatment 2
• Relying on radiographs alone for diagnosis, as they are insensitive for Morton's neuroma 4, 5