Morton's neuroma
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Morton's neuroma, also referred to as Morton neuroma or interdigital neuralgia, is a painful compression syndrome of the common plantar digital nerve within the forefoot. It most commonly affects the third interphalangeal space, between the third and fourth metatarsal bones, and less frequently the second space. Despite its established name, the lesion is not a typical nerve tumor. Its essence consists of chronic mechanical irritation, perineural fibrosis, and thickening of the nerve. Characteristic symptoms include burning metatarsal pain, numbness of the toes, and the sensation of a pebble in the shoe. Diagnosis is primarily based on the clinical presentation, with ultrasonography or magnetic resonance imaging helping to confirm the diagnosis and rule out other causes of metatarsalgia. Treatment usually begins with footwear modification, forefoot offloading, and conservative therapy.
Morton's neuroma - where does it come from
Morton's neuroma develops as a result of repetitive compression and stretching of the nerve running between the metatarsal heads. During walking, the nerve moves adjacent to the deep transverse metatarsal ligament. Chronic overload of this area can lead to nerve ischemia, damage to its sheaths, edema, and the deposition of fibrous tissue around the nerve fibers.
The most common location in the third interdigital space is associated with the anatomical structure of the forefoot. The nerve in this area is relatively thick, has limited mobility, and is sometimes formed by the junction of branches of the medial and lateral plantar nerves. This increases its susceptibility to compression.
Contributing factors include:
- narrow footwear, which brings the metatarsal heads closer together and reduces the space available for the nerve;
- high heels, which shift body weight to the forefoot;
- running, dancing, racquet sports, and other activities causing repetitive stress on the metatarsus;
- transverse flatfoot and abnormal plantar pressure distribution;
- hallux valgus, hammer toes, and instability of the metatarsophalangeal joints;
- limited ankle mobility and contracture of the gastrocnemius muscle and Achilles tendon complex;
- excessive pronation or supination of the foot;
- past injuries and procedures within the forefoot.
The lesion usually develops gradually. Initially, pain appears only during prolonged walking or when using certain shoes. Persistent compression can lead to increasingly frequent symptoms, also in regular footwear.
Morton's neuroma - how to recognize
A typical symptom is paroxysmal, burning, or shooting pain in the plantar aspect of the forefoot. The discomfort often radiates to adjacent toes. Patients also describe numbness, tingling, an electric shock-like sensation, and the feeling of a fold in a sock or a pebble under the foot.
A characteristic course includes:
- worsening of pain during walking, running, and standing on tiptoes;
- a clear association of symptoms with tight footwear or high heels;
- relief after removing the shoe, resting, and massaging the forefoot;
- minimal or invisible external changes;
- periodic radiation of pain to the third and fourth toes, less commonly to the second and third toes.
During the examination, the doctor applies pressure to the interphalangeal space while simultaneously squeezing the forefoot. Reproduction of pain, paresthesias, or a palpable click is referred to as Mulder's sign. Its absence remains possible, especially with a small lesion.
Ultrasound allows visualization of hypoechoic thickening of the nerve, assessment of the interphalangeal bursa, and performing a dynamic examination during compression. Magnetic resonance imaging is useful in cases of atypical symptoms, suspicion of multiple lesions, plantar plate instability, or discrepancies between the clinical examination and ultrasound. An X-ray is mainly used to assess bone structure and rule out a stress fracture, degenerative changes, and deformities.
Differential diagnosis includes, among others:
- interphalangeal bursitis;
- plantar plate injury;
- inflammation or instability of the metatarsophalangeal joint;
- metatarsal stress fracture;
- necrosis of the metatarsal head;
- nerve compression at another location;
- polyneuropathy, lumbar radiculopathy, and pain of vascular origin.
The presence of a thickened nerve on imaging requires correlation with symptoms, as some of these lesions remain asymptomatic.
Morton's neuroma - which footwear worsens symptoms
The greatest pain intensity is caused by shoes that combine a narrow toe box, a rigid sole, and an elevated heel. A tapered toe box compresses the metatarsal bones, while the heel increases pressure under their heads. This creates conditions conducive to mechanical irritation of the nerve during each step.
Symptoms may be worsened by:
- stiletto heels and other high-heeled shoes;
- pumps with a tapering toe;
- tight dress shoes;
- athletic footwear that is too short;
- climbing and cycling shoes that tightly grip the forefoot;
- models with a hard edge running over the painful space;
- worn-out footwear, asymmetrically worn down, or lacking stability;
- insoles that take up excessive space and increase pressure on the toes.
A more beneficial choice is a model with a wide and adequately high toe box, a low heel, a stable heel counter, and a sole that allows for an even foot roll-through. There should be free space between the end of the longest toe and the front of the shoe. The toes need the ability to spread out naturally under load.
A metatarsal pad can reduce nerve compression by spreading the metatarsal heads. It is placed proximally—slightly behind the painful bone heads, rather than directly under the area of greatest pain. It is advisable to determine its placement with a physical therapist, orthopedist, or foot biomechanics specialist. A pad that is too thick or misaligned can increase localized pressure.
Footwear fit is best assessed at the end of the day, when the volume of the foot is larger. The width of a specific model, the shape of the toe box, and the actual internal length are also significant, rather than solely the size indicated by the manufacturer.
Morton's neuroma - how to relieve pain
The cornerstone of conservative treatment is reducing mechanical pressure on the nerve. Management begins with footwear modification, temporary restriction of activities that provoke pain, and correction of load distribution across the forefoot. Custom-fitted insoles and metatarsal pads can improve walking comfort, particularly in the presence of coexisting biomechanical disorders.
During an acute flare-up, the following are used:
- short-term restriction of running, jumping, and prolonged walking;
- cooling the painful area through a cloth;
- footwear with a wide toe box and a low heel;
- exercises to improve ankle joint mobility;
- gradual stretching of the calf muscles;
- training of the short foot muscles and load control;
- analgesic or anti-inflammatory medications selected by a physician, taking into account comorbidities.
Physiotherapy may include gait analysis, load pattern re-education, exercises, and work addressing mobility limitations and tissue tension. Therapy supports the improvement of foot function, although it usually does not eliminate established fibrosis around the nerve.
In the offer of Ambasada Urody, the following forms of complementary management may be associated with functional forefoot problems:
- physiotherapy and manual therapy, selected after a functional assessment of the lower limb;
- manual therapy according to the Maitland concept, utilizing controlled mobilizations and ongoing assessment of the patient's response;
- soft tissue techniques and fascial therapy, targeted at coexisting restrictions of the calf, ankle joint, and foot structures;
- neuromobilization, applied by a physiotherapist after confirming appropriate indications;
- therapeutic massage and deep tissue massage, helpful mainly for secondary myofascial overloads of the lower limb;
- INDIBA Sport and Rehabilitation, a radiofrequency therapy designed to support the rehabilitation of injuries and chronic overloads.
The methods available at the facility are supportive in nature. Qualification should precede intensive work in the immediate vicinity of the painful nerve, as strong pressure on the forefoot may exacerbate neuropathic symptoms. INDIBA, massages, and manual techniques must be treated as components of an individualized rehabilitation program rather than a proven method for eliminating perineural fibrosis.
If symptoms persist, a physician may suggest an injection of a local anesthetic and a glucocorticosteroid, preferably under ultrasound guidance. The procedure often provides short-term pain relief, although the duration of the effect varies. Radiofrequency ablation, cryoablation, and alcohol injections have also been described, but the quality of evidence for these methods remains limited, and qualification requires specialist consultation.
Morton's neuroma - when is surgery needed
Surgical treatment is considered when properly conducted conservative treatment for several months brings insufficient improvement, and pain limits walking, work, sleep, or sports activity. Before surgical qualification, consistency between symptoms, clinical examination, and imaging diagnostics should be confirmed, and coexisting forefoot deformities must be assessed.
The primary surgical methods include:
- nerve decompression, consisting of cutting the deep transverse metatarsal ligament and increasing the space for the nerve;
- neurectomy, which is the excision of the altered segment of the nerve;
- procedures correcting forefoot biomechanics, performed in selected cases of coexisting deformity or instability.
The dorsal approach usually allows for earlier weight-bearing on the foot and reduces the risk of a painful plantar scar. The plantar approach provides direct access to the nerve, but the scar is located in the weight-bearing area during walking. The choice of technique depends on the clinical picture, the anatomy of the lesion, and the surgeon's experience.
Permanent reduction of sensation in the adjacent surfaces of the toes is expected following a neurectomy. Possible complications include healing impairment, infection, hematoma, scar tenderness, chronic pain, and stump neuroma. Recurrence of symptoms may result from leaving behind a portion of the altered nerve, scar tissue formation, the development of a stump neuroma, or a prior misdiagnosis of the pain source.
Postoperative rehabilitation includes wound protection, gradual increase in weight-bearing, swelling control, restoration of mobility, and correction of biomechanical factors. Return to activity depends on the type of surgery, tissue healing, and the patient's functional demands.
