Morton’s Neuroma: Throw the kitchen sink at it

A Mortons neuroma or an intermetatarsal neuroma is an irritation of the the nerves between the metatarsal heads in the foot, most commonly between the 3rd and 4th metatarsal heads. Firstly, it not really a neuroma at all, it is really more of a perineural fibrosis, but the word ‘neuroma’ has been used for years and the name has stuck.

Causes of a Morton’s Neuroma

The cause of a Morton’s neuroma is anything that is going to increase the pressure between metatarsal heads that can irritate the nerve. This could be standing all day at work. It could be too high of an activity level. It is more often than not related to wearing shoes that are not wide enough, increasing the pressure between the metatarsal heads. Their are also individual variations in the length and shape of the metatarsal bone that may also play a role. Obesity may also play a role in increasing the risk for this.

Clinical Features of a Mortons Neuroma

There can be three stages of symptoms in a Morton neuroma:

• First Stages: vague aching type pain (occasionally can be sharp) mostly around 3rd and 4th metatarsal heads. May feel like walking on a lump or walking on a wrinkle in socks (but there is no wrinkle there). The pain can often be relieved by taking off the footwear and massaging the area.
• Next stage: a sharp shooting pain that radiates into the toes is common.
• Later stages: that pain becomes excruciating radiates into the toes and sometimes across the top of the foot. There may also be some numbness of the toes.

A key feature of a Morton’s neuroma is a Mulder’s Click: This is done by pressing a finger in between the bottom of 3rd and 4th metatarsal heads and squeeze laterally and compress the foot around the metatarsal heads with the other hand. A positive diagnosis is present if an audible click is heard in the early stages and symptoms produced in the later stages.

X-rays are of not much help as a neuroma can not be seen (they can help rule out other causes for the pain). An ultrasound may help see the enlarged never tissues and a MRI has too many false positives to be useful (MRI finds a lot of incidental neuromas in asymptomatic people).

Differential diagnosis: plantar plate tear; plantar callus, metatarsal stress fracture; early rheumatoid arthritis

Treatment of a Morton’s Neuroma

The most important things to do for a Morton’s neuroma are to get it early by:

1. Get the diagnosis right (no point treating the wrong thing).
2. Get into wider fitting footwear, probably with a lower heel height than you normally wear.
3. Use a metatarsal pad put in the right place to separate the metatarsal heads to get pressure off them.
4. Mobilize and move the metatarsal heads. This is like a self manipulation of the metatarsal heads with your hands to stretch the tissues around the nerve and metatarsal heads.

That should take care of most cases, if it is done early enough and it has not progressed to far.

If after a few months that this has not helped and it is getting worse, then firstly make sure you are really doing the above correctly (ie the shoes really are wider and the metatarsal pad is really in the right place) and then you might want to consider injection therapy. This could be a local anesthetic, corticosteroid or a sclerosing alcohol. This is more of a symptomatic treatment and you still should be doing the 4 things above.

If that fails and it continues to get worse, you may need to consider surgery to ‘remove the neuroma’.

Forum Discussions on Mortons Neuroma

Foot orthotics for morton’s neuroma
Radiofrequency Ablation for the Management of Morton’s Neuroma
Treatment of Morton’s neuroma
Manipulation for mortons neuroma
Diagnosis of mortons neuroma
Bad Morton’s Neuroma

Personal Opinion on Morton’s Neuroma

It is so important to get it early with wider shoes and a properly placed metatarsal dome and that will generally take care of most. The problem ones tend to be the ones that are not got onto early; don’t get into wider fitting shoes early enough and the metatarsal dome is in the wrong place.

Even podiatrist’s can get a Morton’s neuroma and this one has written a book on it..

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