What treatment options are available for a middle-aged woman with Morton's neuroma, experiencing pain and numbness between her toes?

Treatment of Morton's Neuroma

For a middle-aged woman with Morton's neuroma causing pain and numbness between her toes, begin with conservative management including shoe modification, orthotic insoles, and corticosteroid injections placed beside (not into) the neuroma, reserving surgical excision only for cases that fail conservative treatment after 2-3 months. 1, 2

Initial Conservative Management

Footwear and Mechanical Modifications

• Recommend wider shoes with lower heels to reduce mechanical compression on the affected interdigital nerve, as tight high-heeled shoes typically trigger symptoms 2
• Prescribe orthotic insoles to redistribute forefoot pressure and reduce nerve compression 2
• These modifications address the underlying mechanical etiology of this degenerative neuropathy 3

Corticosteroid Injection Therapy

Corticosteroid injections are highly effective as first-line interventional treatment, providing symptom relief in 90% of patients 4, 5

Proper Injection Technique (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

Diagnostic and Therapeutic Value

• The injection serves dual purposes: both treatment and diagnostic confirmation 2
• If the local injection provides no temporary relief, surgical treatment is not indicated 2
• This diagnostic response helps confirm the diagnosis and predict surgical outcomes 2

Diagnostic Imaging Considerations

When to Image

• Obtain weight-bearing foot radiographs first to exclude other causes including osteoarthritis, Freiberg's infraction, and stress fractures 6, 2
• Radiographs are insensitive for Morton's neuroma itself but essential to rule out alternative diagnoses 7

Advanced Imaging

• Ultrasound and MRI are the preferred modalities with high sensitivity (US: 90%, MRI: 93%) 7, 6
• Ultrasound offers the advantage of real-time clinical correlation during examination 7, 6
• Use advanced imaging after negative radiographs if diagnosis remains uncertain 6

Alternative Infiltrative Therapies

While corticosteroids remain first-line, other agents show promise:

• Capsaicin injections produce VAS score reduction of 51.8% 5
• Alcohol sclerosing injections and hyaluronic acid are well-tolerated but require further research 5
• All infiltrative therapies demonstrate good safety profiles with no serious adverse events reported 5

Surgical Intervention

Indications for Surgery

• Reserve surgery only for patients who fail conservative treatment after 2-3 months 2
• Lack of temporary relief from diagnostic injection predicts poor surgical outcomes 2
• Surgical excision of the neuroma can produce dramatic pain relief when appropriately selected 3

Surgical Approach

• The most common procedure is excision of the pseudo-neuroma using a dorsal approach 2
• Limited evidence suggests transposition of the transected nerve may yield better long-term results than standard resection 8
• Dorsal incisions may result in fewer symptomatic post-operative scars compared to plantar excision 8

Common Pitfalls to Avoid

• Never inject directly into the neuroma itself - this increases complications without improving outcomes 1
• Do not proceed to surgery without first attempting conservative measures including properly administered corticosteroid injections 4, 2
• Avoid recommending surgery if diagnostic injection provides no relief, as this predicts poor surgical outcomes 2
• Do not overlook footwear modification - this addresses the mechanical cause and many patients improve with this alone 2, 3

Clinical Context

Morton's neuroma typically affects the third web space in middle-aged women, representing a mechanically-induced degenerative neuropathy rather than a true neuroma 2, 3. The condition affects approximately 4% of the general population and causes significant functional impairment 5. The high success rate (90%) of conservative treatment with corticosteroid injections makes this the clear first-line approach 4, with surgery reserved as a definitive option only after conservative failure.