Morton's neuroma

Interdigital neuroma more commonly known as Morton's neuroma or "foot neuroma" is an entrapment of a nerve that passes into the toes of the foot. The nerve gets entrapped or “pinched” by the metatarsal bones, which are the bones just behind the toes.

Morton's neuroma causes:

• Shoes that are too narrow
• Shoes with very flimsy soles
• High heel shoes
• Foot structure particularly those with very flat feet
• Occupations that require a lot of bending in the forefoot such as those work "low to the ground" such as plumbers or electricians forcing them to kneel and therefore bend their forefoot for long periods of time

This condition can be very painful. Typically, a person will be walking in shoes (although the condition can be painful out of shoes as well), and will develop a sharp pain just behind the third and fourth toes. The pain may be so severe that some have described it as a "knife being stabbed into the forefoot".

Below is a picture of the primary Morton's neuroma location, represented by the red arrow, (but not the only site as this pain may also appear in between the other metatarsal heads) for neuroma pain. This is the true Morton's neuroma.

Morton's neuroma diagnosis

This pain may then radiate into the toes and manifest itself as overt pain, numbness, tingling or burning. This is the most common location for Morton's neuroma, but this condition can also affect the other toes as well. On occasion this pain may also travel backwards further into the foot.

Many people will relate that they can feel a “clicking” in the affected area. This is actually the nerve moving up and down between the pressures of the adjacent metatarsal bones. (As a side note, recreating this "clicking" pain by squeezing the foot side to side is the classic Morton's neuroma test, known as Mulders sign.

It is important to note that you can have a neuroma without a positive Mulders sign.) People find that if they remove their shoes and rub the area for a couple of minutes, the pain will subside, only to return once they start walking again.

conditions that mimic Morton's neuroma

Other conditions that occur in this area of the foot may mimic neuroma pain with no actual neuroma present. A bursitis in between the two metatarsal bones may put pressure on the nerve and create neuroma type pain. Click here for more information on bursitis and its relationship to neuroma.

Secondly, a condition called capsulitis may also give similar symptoms as a true interdigital neuroma. Click here for more information on capsulitis and its relationship to neuroma.

Additionally, a metatarsal stress fracture may also create similar symptoms.

Lastly, metatarsalgia pain can be mistaken for neuroma. Click here for more information on metatarsalgia and its relationship to neuroma.

Diagnosis of a neuroma is usually made on clinical grounds. Unlike most soft tissue lesions, for some reason an MRI can be deceiving in making the diagnosis. I can tell you from personal experience that over the years I have had patients who had a negative MRI for neuroma and I went in and removed a neuroma. I think most doctors who treat this condition on a regular basis will tell you the same thing.

A diagnostic ultrasound tends to be a bit more reliable but again can be problematic in making a diagnosis.

Below is a short (15 second) video demonstrating how the nerve gets irritated and then enlarges from this irritation.

There are a number of treatments for Morton's neuroma depending on the severity.

• Sometimes, just identifying a certain pair of shoes that sets off the pain and no longer wearing them will eradicate the problem.
• Anti-inflammatory medication can be helpful, but this should be considered temporary relief and should not be considered for long-term treatment, as there are potential systemic problems with taking this type of medication for long periods of time.
• Orthotics- a foot specialist (podiatrist) may recommend an orthotic device, which is a sophisticated arch support, custom made to the structure of the patient’s foot. The purpose of which is to control the abnormal structural components of the foot, which are contributing to the condition.

  Many times a Morton's neuroma pad can be built into the orthotic which then attempts to spread apart the adjacent metatarsal bones and thereby remove the pressure on the nerve, thus reducing pain.

  I generally reserve this type of neuroma treatment for patients who are not candidates for other types of treatment. This type of therapy is the most conservative type available for this condition. For more information on orthotics and Morton's neuroma, click here.

• Cortisone injection of the area can also be very helpful. Some doctors will inject cortisone in an effort to reduce the inflammation of Morton's neuroma.
• Denatured alcohol injections- 4% denatured alcohol injections given in a series, attempts to sclerose, or deaden the nerve. My preferred treatment is multiple injections of denatured alcohol. Anywhere from one to seven injections repeated on a weekly basis are necessary. I have found the success rate to be in the 80-85 percent range.
• Cryosurgery- another nonsurgical option that has become available in recent years is the use of cryosurgery. As it relates to neuroma, the growth is "frozen" via the insertion of a probe into the area of the neuroma. This freezing of the neuroma deadens the nerve thus eliminating the pain. The procedure is an office procedure performed under local anesthesia.

  I think it is important to point out that this procedure is best performed under ultrasound guidance. Most foot specialists are very familiar with Morton's neuroma and think they can isolate the nerve just because "they know where it is". This is not necessarily true. Injecting blindly increases the chances of complications including missing the nerve entirely, freezing by mistake, an artery or a vein or perhaps even the interossei muscle that runs between the metatarsal bones all of which can lead to more pain and problems.

  By using ultrasound guidance, two very important issues are addressed. One is that there is truly a neuroma and two, the nerve is actually frozen and not another structure in the area. There may be some mild post procedure discomfort that should be relieved with a mild analgesic.

  Below is a video of the procedure.

• MIND procedure- within the last few years a new procedure called "minimally invasive nerve decompression" or MIND has been developed. This type of surgery is a minimally invasive procedure where a very small incision is made, special surgical instruments designed solely for this procedure are then introduced into the surgical site and instead of excising the neuroma, the pressure exerted on the neuroma mass is relieved (decompressed) by simply cutting the transverse metatarsal ligament.

  The idea here is that even though the nerve is enlarged, if there is no pressure on it from other surrounding structures, in this case the transverse metatarsal ligament(the ligament that attaches to the adjacent metatarsal bones and helps hold them taught) and adjacent metatarsal bones, then there should be no pain. by cutting this ligament the two adjacent metatarsal bones which usually aggravate the formation of neuroma are separated slightly thus relieving the ongoing pressure on the nerve.

  It is my understanding that preliminary studies have demonstrated a success rate at least equal to surgical excision with the obvious benefits of less pain post-operatively and quicker return to normal shoes and activity.

• Surgery- when all else fails, surgical excision is usually recommended. This is an out patient procedure where the entrapped nerve is removed. As with any surgery there are potential complications and your doctor should explain these to you.

  The two biggest complications are misdiagnosis of the Morton's neuroma; the nerve is removed and the patient still has pain, or the surgeon removes what he perceives to be the nerve but by mistake removes a vein or tendon. The second, more common complication is not resecting enough of the nerve and being left with what we call a stump neuroma. The patient will continue having pain while eradication of this new problem becomes much more difficult.

  As a side note to surgical excision of neuromas, podiatry has always been a leader and innovator of minimal incision surgery, the art of surgical correction of a problem using a minimum amount of dissection and thus trauma to the surgical site. This type of surgery obviously leads to a less painful post operative experience and quicker overall healing time.
  
  
  
  

  MORTON'S NEUROMA SURGERY

  
  
  

  Excision of the neuroma is usually made through the top of the foot, even though the neuroma occurs on the bottom of the foot. This is done to avoid scarring on the bottom of the foot which can end up being very painful.

  The procedure itself may be done on an out patient basis. The patient is able to ambulate immediately afterwards with nothing more than a surgical shoe.
  

  
  

  Frequently Asked Questions

  What is Morton’s neuroma?

  Morton’s neuroma is an entrapment of a nerve between the metatarsal bones, most commonly between the third and fourth toes. The compressed nerve becomes irritated and enlarged, causing sharp forefoot pain, burning, tingling, or numbness.

  What causes Morton’s neuroma to develop?

  Narrow shoes, high heels, flimsy soles, and repetitive forefoot bending can irritate the nerve. Foot structure—especially very flat feet—also increases pressure between the metatarsal bones, making nerve entrapment more likely.

  What symptoms should I look for?

  Many people feel a sharp, stabbing pain just behind the toes that may radiate into the digits. Tingling, burning, numbness, or a “clicking” sensation when squeezing the forefoot are also common signs of a neuroma.

  Are there other conditions that mimic Morton’s neuroma?

  Yes. Bursitis, capsulitis, metatarsal stress fractures, and metatarsalgia can all produce similar symptoms. These conditions may irritate the nerve without a true neuroma being present, so proper evaluation is important.

  How is Morton’s neuroma treated?

  Treatment ranges from shoe changes, anti-inflammatory measures, and orthotics to cortisone injections, alcohol sclerosing injections, cryosurgery, or minimally invasive decompression. When conservative care fails, surgical excision of the neuroma may be recommended.
  
  
  

  REFERENCES

  Mayo Clinic

  Harvard Health

  Cleveland Clinic
  
  
  
  

  Questions I Have Answered From Visitors

  Submission from: Dot
  Location: Bishop Auckland, Co Durham, UK

  Q: "I had my stitches out on the 31st dec 2014 my wound site has not healed and its a bit swollen and red its also weeping at the moment I am on antibiotics but they finish tomorrow the 29th jan been on them 7 days do I leave the dressing on or off or do you think there is something else going on with the wound?"

  A: Hi Dot, since your surgeon has you on antibiotics, he or she suspects an infection. However, the fact that you are still experiencing redness, swelling, and weeping suggests a few possibilities:

  • Antibiotic Efficacy: You may be on the incorrect antibiotic for the specific bacteria present, or the seven-day course may be insufficient for a surgical site infection.
  • Deep Suture Reaction: Even if the surface stitches are out, you likely have deep sutures that dissolve over time. Occasionally, the body has a reaction to these, causing a "deep suture abscess" that looks very similar to an infection.
  • Incision Tension: Foot incisions are under significant tension, which can naturally delay the healing process and work against closure.

  The best course of action is to contact your surgeon immediately for an exam. Delay in treatment can lead to a more severe infection or a hypertrophic (unsightly) scar.

  Marc Mitnick, DPM

  Visitor: Karen
  Location: California

  Visitor Question:

  I had a neurectomy for a neuroma in December of 1993 to relieve pain from between the 3rd and 4th toes on the left foot. The surgery was performed on the bottom of the foot (the scar runs from right under the toes, starting with the middle of the second toe and running to the 4th toe - where the scar ends at the 4th toe, is still completely numb; however, the toe itself is not numb anymore), those two toes remaining numb for many, many years - no pain - no problem, until yesterday when the 3rd toe started hurting excruciatingly so upon walking. It hurts to the point where I'm limping. The scar doesn't hurt. There is no pain in the 4th toe, only the 3rd. There is no bruising, no other marks, no swelling, nothing. It hurts where the pad of the toe is down to the bottom of the toe, but definitely not the scar. The pain is hard to describe - sort of a combination of being sharp and very ouchy (which gets worse the longer/further I walk). I'm sitting in a chair right now, and the toe is kind of achy and throbbing. I do not wear heels - I don't wear tight fitting shoes, and I don't wear thinly soled shoes (I gave all that up when I had the surgery). I don't remember a lot about the surgery because it was 23 years ago, and I had just had a baby via C-section 3 weeks earlier - I've been perfect until yesterday, and am getting concerned b/c of the increase in the amount of pain only since yesterday. I'm definitely going to have to be seen for this, but wanted to try to get an idea of what might be wrong for when I talk to the doctor. I wasn't even really sure where to start, so I appreciate being able to email someone for a little help :-)

  Doctor's Response:

  Hi Karen,

  Obviously I cannot make a diagnosis without examining you, but my first thought would be a recurrence of the neuroma.

  Nerve tissue is one of the few body tissues that regenerate over time. The "second" time around the symptoms do not have to be exactly as your original symptoms of 23 years ago, so just because the fourth toe does not hurt, does not mean it is not a neuroma.

  Very few surgeons remove neuromas through a plantar incision simply because of the chance of scarring and the pain associated with the scar. Evidently that is not the source of your pain, simply because if you were to have had pain from the scar, it would have begun years ago.

  Now I cannot predict if this pain will continue or not (there is a chance that by the time you read this response, the pain may have subsided), but if it does continue, you will need to see a foot specialist.

  If there was no history of trauma to the forefoot, and the pain kind of occurred spontaneously, then I would be leaning towards a neuroma.

  Other possibilities would include capsulitis and intermetatarsal bursitis, both of which you can read about on this site. (use the Search Box on the Home Page)

  Now, if you walked into my office and I determined it was a recurrence of a neuroma, the first thing I would offer you would be a series of denatured alcohol injections which attempt to sclerose or deaden nerve tissue. Even though you could also consider a cortisone injection, I think denatured alcohol injections is a more permanent approach to the possibility of neuroma.

  If you are looking for an even more conservative approach to the problem, you could consider adding a metatarsal pad to your shoes. This pad attempts to "spread" the metatarsal bones, which then takes pressure off the neuroma and reduces pain. It is not a cure, but it is a simple way to reduce pain without any invasive procedures.

  Surgery in this case could be very difficult as looking for a regrowth of a neuroma is like looking for a needle in the haystack in many cases because of the small size of the offending nerve. Your doctor might consider an MRI or ultrasound to see how large, (or small) a neuroma you may have.

  If your pain persists and you have to seek medical attention and the diagnosis ends of being one of neuroma, start with the most conservative means first and see what happens.

  Marc Mitnick DPM

  DISCLAIMER: This information is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

  Visitor Name: Missy

  Location: Ohio, United States

  ---

  Question: Two Neuromas

  Hi, I have 2 neuromas in my left foot. They are very painful and I have tried the anti-inflamatory injections and the series of 7 alcohol injections and started the alcohol injections again but decided to quit after the 2nd because I was seeing no results from them.

  The doctor recommends removing the neuromas but says they can not be removed at the same time because of running the risk of injury to an artery? Does this sound right? MRI revealed that the neuromas are 8-10mm's at the 2nd and 3rd IMS djd 1st mpj and sessmoids. Capsulitis 1-4 mpj.

  I am going for a second opinion because I just really do not want the surgery, but am sick of dealing with this. It has been going on for 1 1/2 years. It is getting in the way of my working out because of the pain. What would you recommend and does what the 1st doctor says make sense?

  ---

  RESPONSE

  Hi Missy,

  I would recommend the surgery if nothing else has helped and you are in a lot of pain.

  The notion of worrying about the artery, in my opinion, is a bunch of nonsense. Why would he subject you to two hospital visits and two rounds of anesthesia?

  Key Observation: The biggest issue when you remove two adjacent neuromas is that enough room be left between the two incisions, so that the skin in between does not necrose (start to die because of lack of blood flow to the skin). Over the years I have removed adjacent neuromas at the same time and have never had a problem.

  Go get that second opinion. You'll likely find that addressing both at once is a standard and safe approach when handled correctly.

  Marc Mitnick DPM

  DISCLAIMER

  
  

  Persistent pain after neuroma surgery

  Visitor name: Tracy

  Location: Not provided

  Visitor's question

  I had three neuromas removed from my right foot in June 2008. The pain has gradually gotten worse. I saw my doctor last week who gave me a cortisone shot, which has made it even worse.

  I cannot put weight on it and it burns, stings, and throbs. Do you know what is wrong? If so, what can be done? Thank you.

  Doctor's answer

  Hi Tracy,

  More than likely you have what is known as a stump neuroma, which means not all of the entrapped nerve was originally removed. This is a somewhat common problem.

  See if your doctor gives denatured alcohol injections — they are usually better for this type of problem than cortisone injections.

  Additionally, I would recommend an MRI with contrast to make sure there is not some other problem going on in that part of your foot.

  Marc Mitnick DPM

  
  

  Persistent pain after 3rd toe amputation and stump neuroma concerns

  Visitor name: Jill S.

  Location: Milford, CT

  Visitor's question

  I spoke to you last week about my 3rd toe amputation and a nerve entrapment.

  Well, I went back to the original podiatrist who did my surgery, and I told him about your advice. He said he wanted more X-rays and an MRI done. I gave him the MRI and report from my second opinion. As I told you, they both came up showing nothing.

  Yesterday he injected more cortisone in the spot where my toe used to be. Excruciating pain there. He then said that in a month if this doesn't work, then another shot at the end of April, then perhaps surgery.

  Today I am not only in pain but worse pain from the shot on top of the regular pain. Couldn't sleep a wink last night. Have you heard of cryogenic surgery? My doctor said I have stump neuromas. I have been online researching both traditional and cryo surgery. Please give me your advice.

  Thanks again — Jill from CT

  Doctor's answer

  Hi Jill,

  As I think I had originally suggested to you, a stump neuroma was one of my thoughts. It seems to be the only logical explanation for the amount of pain that you are in. The fact that the cortisone shot made it worse does not change that suspicion.

  Cryogenic surgery is a possible treatment option for neuroma. If you go to my article on Morton's neuroma, there is a video of the procedure.

  There is a caveat here. Cryosurgery freezes the nerve and thereby deadens the tissue. Because of this, I am not sure freezing the nerve will actually reach the portion that is embedded in scar tissue.

  I think in your last post you had mentioned that you had received alcohol injections which did not help. The same rule would apply here — the injection likely did not reach the part of the nerve embedded in scar tissue.

  Although familiar with the concept of cryosurgery, I personally do not perform it, as I prefer denatured alcohol injections since they have essentially the same outcome and are a little less invasive.

  There is probably no harm in considering cryosurgery because it is relatively noninvasive, but it is my feeling that the only way you are going to end up resolving this issue is through surgery. In this surgery, the entrapped nerve has to be freed from the scar tissue and then that portion of the nerve would have to be excised.

  Marc Mitnick DPM

  
  

  Post Op Morton's Neuroma—Longer Recovery Than Normal?

  by Janine
  Austin, Texas

  QUESTION:

  I am 15 weeks since having 3 large Morton's neuromas removed from my left foot.

  Background:
  I was diagnosed with the neuromas on my left foot by X-rays done in my podiatrist's office. I went the conservative route for 8 years—cortisone shots, two pairs of custom orthotics—until I could no longer handle the pain. I had surgery on December 20th. I was off it completely for 2 days (bathroom/meals only). I elevated and iced as instructed. I have a walking boot and now I am to walk on it for 1 hour a day in regular sneakers (which I am doing). I am also taking Naproxen.

  I am just wondering if I should be healed by now. My podiatrist (whom I do trust) has told me there are 3 stages of healing and I am in the 2nd stage. I work with a nurse who told me I should get a second opinion and that I should already be out of the walking boot. My toe looks deformed, but it was raised before surgery… it looks worse now, but I am splinting it and my bunion pushes it the other way.

  Now she has me second-guessing my podiatrist.

  RESPONSE:

  Hi Janine,

  I am a little concerned, as it is virtually impossible to diagnose a neuroma with an X-ray. You would need an MRI or even an ultrasound to actually visualize a neuroma. Although it is possible to have three neuromas in one foot, I have never personally seen it; the most I have ever removed is two.

  At 15 weeks post-op, although you may not be completely healed, you should generally be further along than you appear to be. My rule of thumb in evaluating post-operative progress is simple: ask yourself, “Am I any better this week than I was last week?” If the answer is yes each week, then I know the patient is improving—some people simply take longer than others.

  If you have reached a point where you are not noticing any improvement on a week-to-week basis, that would be concerning.

  The only way to get a true assessment of what is going on (if anything) is to obtain another opinion from a podiatrist in your area. If you receive mixed signals from the second opinion, consider getting a third.

  Marc Mitnick DPM

  DISCLAIMER