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Morton's Neuroma

(Also known as Morton's Interdigital Neuroma, Morton's Metatarsalgia, Morton's Neuralgia, Plantar Neuroma, Intermetatarsal Neuroma)
What is a Morton's neuroma?
Morton's neuroma is a condition characterized by localized swelling of the nerve and soft tissue located between two of the long bones of the foot (metatarsals), which can result in pain, pins and needles, or numbness in the forefoot or toes.
The foot comprises of many small bones, five of which are the long bones known as the metatarsals which are situated beside each other. Between these bones are nerves (known as the interdigital nerves) which supply the toes.
During certain activities, particularly weight-bearing activities (e.g. walking or running) a compressive force, is sometimes placed on the interdigital nerves and surrounding soft tissue, between the metatarsal bones (this is often the case with tight fitting shoes or flat feet). If this force is repetitive enough and beyond what the nerve and soft tissue can withstand, swelling to the nerve and soft tissue may occur. This may result in pain, tenderness, pins and needles or numbness in the forefoot or toes. When this happens, the condition is known as a Morton's neuroma.
A Morton's neuroma most commonly occurs between the 3rd and 4th metatarsal bones. It is more common in women than men and can sometimes affect both feet at the same time.

Causes of a Morton's neuroma

A Morton's neuroma commonly occurs due to repetitive weight bearing activity (such as walking or running) particularly when combined with tight fitting shoes or excessive pronation of the feet (i.e. "flat-feet"). The condition is also more common in patients with an unstable forefoot allowing excessive movement between the metatarsal bones. A Morton's neuroma can also result due to certain foot deformities, trauma to the foot, or the presence of a ganglion or inflamed bursa in the region which may place compressive forces on the nerve.

Signs and symptoms of a Morton's neuroma
Patients with a Morton's neuroma typically experience a sharp, shooting or burning pain, usually at the base of the forefoot or toes, which radiates into the two affected toes. Sometimes the pain may also radiate into the foot. The pain is often associated with pins and needles and numbness.
Pain is usually increased by forefoot weight bearing activities (such as running), with narrow-fitting footwear, or with high heeled shoes. It is usually painful to firmly touch the affected region and, in chronic cases, pain and sometimes an audible click, may be heard when squeezing the foot and toes together with the hand. Often a localized area of swelling may be evident at the site of injury.

Diagnosis of a Morton's neuroma
A thorough subjective and objective examination from a physician is usually sufficient to diagnose a Morton's neuroma. Investigations such as an X-ray, ultrasound, MRI, CT scan or bone scan may sometimes be used to assist with diagnosis, assess the severity of the injury and rule out other conditions.

Treatment for a Morton's neuroma

Treatment for a Morton's neuroma may initially involve a change in footwear to loose fitting shoes, low heels or the prescription of orthotics (particularly if poor foot posture has contributed to the condition). Regular icing and the use of anti-inflammatory medication may also help to reduce inflammation in the initial stage of injury or when inflammatory signs are present.
One of the most important components of treatment for a Morton's neuroma is that the patient rests sufficiently from any activity that increases their pain (crutches may be required). Activities which place large amounts of stress through metatarsals should also be avoided, particularly excessive weight bearing activity such as running, jumping, standing or walking excessively (especially up hills, on uneven surfaces or with the majority of weight on the forefoot). Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities and weight bearing forces is indicated provided there is no increase in symptoms. This should take place gradually over a period of time with direction from the treating therapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing resulting in the condition becoming chronic.
The use of padding underneath the forefoot and toe region can help to unload the affected area and is usually effective in reducing symptoms. Nerve stretching or gliding exercises as prescribed by a physiotherapist may sometimes be indicated when abnormal nerve tightness has been identified.
In chronic cases, a corticosteroid injection may provide the relief of symptoms required to allow rehabilitation to be facilitated. Surgical excision of the Morton's neuroma may be necessary if adequate relief is not gained from conservative measures.
Patients with a Morton's neuroma should perform pain-free flexibility, strengthening and balance exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as balance, soft tissue flexibility and strength are quickly lost with inactivity. The treating therapist can advise which exercises are most appropriate for the patient and when they can be commenced.
In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating therapist provided there is no increase in symptoms. The use of orthotics, correct footwear or metatarsal padding during this phase of rehabilitation, and, as an ongoing form of injury prevention, may be indicated.

Prognosis of a Morton's neuroma
Patients with a Morton's neuroma usually make a full recovery with appropriate management. Return to activity or sport can usually take place in weeks to months and should be guided by the treating therapist, podiatrist and / or specialist. In patients with severe or chronic cases which have failed to respond to conservative treatment recovery times may be longer. In these cases, further intervention, such as corticosteroid injections or surgical excision of the neuroma may be indicated.

Contributing factors to the development of a Morton's neuroma
There are several factors which can predispose patients to developing a Morton's neuroma. These need to be assessed and corrected (where possible) with direction from a therapist. Contributing factors may include:
  • inappropriate footwear (particularly tight shoes or high heels)
  • poor foot posture (e.g. "flat feet")
  • forefoot instability
  • poor flexibility (particularly of the ankle joint, the subtalar joint or the calf muscles)
  • inappropriate or excessive training
  • poor biomechanics
  • certain foot deformities
  • local trauma
  • the presence of a ganglion or inflamed bursa in the area

Therapy for a Morton's neuroma
Therapy treatment is vital in all patients with a Morton's neuroma to hasten healing and ensure an optimal outcome. Treatment may comprise:
  • footwear advice
  • prescription of orthotics
  • the use of metatarsal padding
  • soft tissue massage (to the calf and plantar fascia)
  • joint mobilization (to the ankle, subtalar joint, midfoot and forefoot)
  • ice or heat therapy
  • electrotherapy (e.g. ultrasound)
  • corrective taping
  • the use of crutches
  • exercises to improve strength, flexibility and balance
  • neural stretches
  • biomechanical assessment and correction
  • education
  • activity modification
  • a graduated return to activity plan

Other intervention for a Morton's neuroma
Despite appropriate management, some patients with a Morton's neuroma do not improve adequately and may require other intervention. The treating doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, ultrasound, CT scan, MRI or bone scan, corticosteroid injections or referral to an orthopaedic specialist to consider the option of surgery to remove the neuroma, or any other procedure which may help to relieve the condition. Often the involvement of a podiatrist is required to ensure appropriate footwear is being worn along with the prescription of appropriate orthotics to unload the metatarsal region.