What are the first‑line treatments to relieve pain from Morton's neuroma?

First-Line Treatment for Morton's Neuroma Pain

Start with corticosteroid injections placed beside (not into) the neuroma using small volumes (0.05-0.1 mL) of triamcinolone acetonide at multiple points around the lesion. 1

Conservative Management Approach

Initial Treatment: Corticosteroid Injections

• Corticosteroid injections are the primary first-line treatment, with a 90% success rate in symptom relief 2
• The injection technique is critical: inject just beneath the dermis in the upper subcutis adjacent to the neuroma, not directly into it 1
• Use multiple small injections (0.05-0.1 mL each) around the neuroma rather than a single large injection 1
• This approach effectively alleviates symptoms in 9 out of 10 patients 2

Critical Technical Points

• Avoid direct intralesional injection as this increases risk of fat and dermal atrophy 1
• Ultrasound guidance improves accuracy and outcomes, allowing real-time clinical correlation during the procedure 3, 4
• The procedure can be repeated if initial treatment fails, often leading to complete symptom remission 4

Diagnostic Confirmation Before Treatment

Before initiating treatment, confirm the diagnosis:

• Ultrasound (90% sensitivity) or MRI (93% sensitivity) are the preferred imaging modalities 3, 5
• Obtain radiographs first to exclude other causes of webspace pain (osteoarthritis, Freiberg's infraction, stress fractures) 5
• Ultrasound has the advantage of allowing dynamic examination and clinical correlation 3

Alternative Infiltrative Options

If corticosteroid injections fail or are contraindicated:

• Capsaicin injections produce a 51.8% reduction in VAS pain scores 6
• Alcohol sclerosing injections are well-tolerated with good efficacy 6
• Hyaluronic acid injections show promise but require further research 6
• Radiofrequency thermal neurolysis can be considered as a second-line minimally invasive option 4

When to Consider Surgery

• Reserve surgical options only if conservative infiltrative treatments fail 2, 7
• Minimally invasive treatments significantly reduce the need for subsequent surgery 4
• Surgical excision is typically performed through a dorsal approach when necessary 7

Common Pitfalls to Avoid

• Do not inject directly into the neuroma - this causes higher risk of complications including fat atrophy and skin changes 1
• Do not proceed to surgery without attempting corticosteroid injections first, given the 90% success rate 2
• Monitor for temporary pain at injection site, fat atrophy, and skin changes post-injection 1