From the Guidelines
Management of acute pain from Morton neuroma should start with conservative measures, including wearing wide, comfortable shoes, using metatarsal pads or orthotic inserts, and taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for 1-2 weeks. According to the American College of Foot and Ankle Surgeons, initial treatment options may include open-backed shoes, heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss (if indicated) 1. For immediate pain relief, NSAIDs such as ibuprofen (400-800 mg three times daily) or naproxen (500 mg twice daily) can reduce inflammation and pain. Ice application for 15-20 minutes several times daily may also help decrease inflammation.
Some key considerations in managing acute pain from Morton neuroma include:
- Relieving pressure on the affected interdigital nerve
- Reducing inflammation and pain with NSAIDs
- Modifying activities to avoid high-impact exercises during acute flares
- Considering corticosteroid injections or other interventions if conservative measures are insufficient
The most recent and highest quality study on the pharmacological management of neuropathic pain, which includes pain from Morton neuroma, recommends a stepwise approach starting with first-line medications such as secondary-amine tricyclic antidepressants (TCAs) or selective serotonin norepinephrine reuptake inhibitors (SSNRIs), and calcium channel α-d ligands such as gabapentin or pregabalin 1. However, the use of local injections of corticosteroids is not recommended as an initial treatment option 1.
In terms of specific medications, gabapentin and pregabalin have shown efficacy in several neuropathic pain conditions, including painful diabetic neuropathy and postherpetic neuralgia 1. These medications can be considered for patients who do not respond to initial treatment with NSAIDs and conservative measures. However, it is essential to carefully titrate the dosage of these medications to minimize adverse effects 1.
Overall, the management of acute pain from Morton neuroma requires a comprehensive approach that includes conservative measures, pharmacological interventions, and consideration of individual patient factors, with the goal of reducing morbidity, mortality, and improving quality of life.
From the Research
Management of Acute Pain from Morton Neuroma
Non-Surgical Treatments
- Corticosteroid and local anaesthetic injection (CS+LA) may result in little to no difference in pain, function, and health-related quality of life (HRQoL) when compared to local anaesthetic injection (LA) alone 2
- Ultrasound-guided (UG) CS+LA probably reduces pain and increases function when compared to non-ultrasound-guided (NUG) CS+LA 2
- Corticosteroid injection has shown a statistically significant reduction in mean visual analogue scale (VAS) for pain, with 50% success at 12 months 3
- Other non-operative treatment modalities, such as alcohol injection, extra-corporeal shockwave therapy (ESWT), radiofrequency ablation (RFA), cryoablation, capsaicin injection, botulinum toxin, orthosis, and YAG laser therapy, have shown statistically significant improvements, but with limitations to their application 3
Surgical Treatments
- Plantar incision neurectomy (PN) may result in little to no difference in satisfaction and adverse events when compared to dorsal incision neurectomy (DN) 2
- Operative treatment has shown better outcomes in terms of patients' satisfaction and pain improvement, but more and better randomized controlled trials (RCTs) are required to confirm these results 4
Comparison of Treatments
- A prospective, double-blinded, randomized, placebo-controlled trial found no significant difference in pain and function improvement between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) 5
- The effectiveness of corticosteroid injection for the treatment of Morton's neuroma is still unclear, and more research is needed to determine the best treatment options 2, 3, 5