Management of Morton's Neuroma
Conservative treatment with corticosteroid injections should be the first-line therapy for Morton's neuroma, with small volumes (0.05-0.1 mL) of triamcinolone acetonide injected beside (not into) the neuroma, achieving symptom relief in approximately 90% of patients. 1, 2
Diagnostic Confirmation
Before initiating treatment, proper diagnosis must be established:
- Obtain radiographs first to exclude other causes of webspace pain including osteoarthritis, Freiberg's infraction, and stress fractures 3
- Proceed to ultrasound or MRI after negative or equivocal radiographs, as both demonstrate high sensitivity (ultrasound: 90%, MRI: 93%) for detecting Morton's neuroma 4, 3
- Ultrasound is preferred when available, as it allows clinical correlation during the examination 4, 3
Treatment Algorithm
First-Line: Conservative Interventional Treatment
Corticosteroid injection technique (the critical details that determine success):
- Inject beside the neuroma, not into it - place the injection just beneath the dermis in the upper subcutis adjacent to the neuroma 1
- Use small volumes: 0.05-0.1 mL of triamcinolone acetonide per injection site 1
- Multiple small injections around the neuroma are preferable to a single large injection directly into it 1
- This approach achieves symptom relief in 90% of patients 2
Critical pitfall to avoid: Direct injection into the neuroma carries higher risk of fat and dermal atrophy 1. The injection should be placed beside the neuroma, not within it.
Alternative Conservative Options
If corticosteroid injections are contraindicated or patient preference dictates:
- Capsaicin injections produce VAS score reduction of 51.8% 5
- Alcohol sclerosing injections are well-tolerated, though require further research for definitive efficacy 5
- Hyaluronic acid injections show promise but need additional evidence 5
Surgical Intervention
Reserve surgery for the 10% who fail conservative treatment 2:
- Neuroma excision through dorsal approach is the standard surgical technique 6
- Surgical removal can produce dramatic pain relief when conservative measures fail 7
- Careful patient selection and pre-operative counseling are essential for success 6
Refractory Cases After Surgery
For recurrent Morton's neuroma after failed surgery:
- Peripheral nerve stimulation is an emerging option, with case reports showing near-complete resolution of chronic foot pain in less than 12 months 8
- This neuromodulatory treatment remains underutilized but represents a promising intervention for refractory cases 8
Key Clinical Pearls
- Morton's neuroma is not a true neuroma but rather fibrosis of the nerve caused by pressure or repetitive irritation 6
- The condition most commonly affects the third intermetatarsal space in middle-aged women 7
- Compression test of the affected web space is quite specific for diagnosis 7
- No serious adverse events have been reported with infiltrative treatments 5