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Morton Neuroma Last Updated: July 11, 2001 Rate this Article Email to a Colleague Synonyms AND related keywords: Morton metatarsalgia AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Author: Richard G Bowman II, MD, Rehabilitation AND Electrodiagnostic Director, Physical Medicine AND Rehabilitation, Pain Management, The Center for Pain Relief Coauthor(s): John Baird, MD, Director for Pediatrics AND Neuromuscular Rehabilitation, Department of Physical Medicine AND Rehabilitation, Siskin Hospital for Physical Rehabilitation Richard G Bowman II, MD, is a member of the following medical societies: American Medical Association Editor(s): Robert J Kaplan, MD, Assistant Professor, Department of Physical Medicine AND Rehabilitation, Rehabilitation Institute of Chicago, Northwestern Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Michael T Andary, MD, MS, Residency Program Director, Associate Professor, Department of Physical Medicine AND Rehabilitation, Michigan State University College of Osteopathic Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine AND Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; AND Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine AND Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center INTRODUCTION Section 2 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Background: Morton neuroma is a perineural fibrosis AND nerve degeneration of the common digital nerve occurring most frequently between the third AND fourth metatarsal heads. Morton neuroma is not a true neuroma but, rather, fibrosis due to repetitive irritation of the nerve. Morton first described this condition in 1876: Patients complain that, as they walk, they are suddenly seized with an agonizing pain at the outer border of their forefoot. They have to stop still AND stand on their good foot; they take their shoe off AND rub the painful area. After some minutes the pain ceases, but the foot becomes warm AND stays so for several hours. When the pain has gone, they are able to walk comfortably. They may experience two attacks in a week then none for a year. Recurrences are very variable AND tend to become more frequent. Between attacks, there are no symptoms OR physical signs. Pathophysiology: See the Background section above. Frequency: In the US: Morton neuroma is a common disease entity of the foot, affecting males more often than females. Morton neuroma occurs most frequently between the third AND fourth metatarsals (ie, third web space), but it also is found in the second web space. Infrequently, Morton neuroma is observed in the first AND fourth web spaces. Two neuromas rarely coexist on the same foot. Other diagnoses should be considered when 2 OR more areas of tenderness are present. Internationally: Incidence is presumed to be the same internationally as in US. Sex: The female-to-male ratio is 5:1, perhaps as a result of narrow shoes, worn more commonly by females. Age: Highest prevalence of Morton neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient. CLINICAL Section 3 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography History: Obtaining an accurate history is important to making the diagnosis of Morton neuroma. Possible reported findings provided by the patient with Morton neuroma include the following: The most common presenting complaints include pain AND dysesthesias in the forefoot AND corresponding toes adjacent to the neuroma. Pain is described as sharp AND burning. Numbness often is observed in the toes adjacent to the neuroma AND seems to occur along with episodes of pain. Pain typically is intermittent, as episodes often occur for minutes to hours at a time AND have long intervals (ie, weeks to months) between a single OR small group of multiple attacks. Some patients describe the sensation as "walking on a marble." Massage of the affected area offers significant relief. Narrow tight high-heeled shoes aggravate the symptoms. Physical: Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal AND plantar interspace with the other hand may elicit characteristic pain. Pain localized only to the plantar aspect of the web space also may be consistent with Morton neuroma. Many sources acknowledge that the examination in Morton neuroma frequently is negative. Most often, sensation is wholly intact AND maneuvers are unsuccessful in reproducing the characteristic pain. Palpation of the actual neuroma seldom is successful. Most clinicians focus both on the history AND on the lack of additional findings that might suggest other disorders. Careful palpation of the metatarsal heads AND shafts may help to differentiate stress fractures OR metatarsal head osteonecrosis from Morton neuroma. Palpation of the metatarsophalangeal (MTP) joints may reveal tenderness indicating metatarsalgia (eg, when the tenderness is primarily on the plantar surface only) OR MTP synovitis (eg, when the joint is tender with palpation). Pain from MTP synovitis is aggravated with forced toe flexion. Subtle joint swelling also may coexist with MTP synovitis. Tenderness localized to the second MTP joint, along with swelling AND warmth, may be, in rare cases, an early presentation of Freiburg osteochondrosis. Causes: See History section above. Various factors have been implicated to precipitate Morton neuroma, but the exact cause is not understood entirely. Morton neuroma is known to develop as a result of chronic nerve stress AND irritation. Poorly fitting AND constricting shoes (ie, small toe box) often contribute to development of this condition. Women who wear high-heeled shoes for a number of years OR men who are required to wear constrictive shoe gear are at risk for Morton neuroma. Another theory of causation involves individuals who have excessively pronated OR unstable feet, as these malformations may cause increased movement AND nerve irritation between the toes. DIFFERENTIALS Section 4 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Other Problems to be Considered: Stress fracture of the neck of the metatarsal Rheumatoid arthritis AND other systemic arthritis conditions Hammer toe Metatarsalgia (plantar tenderness over the metatarsal head) Neoplasms Metatarsal head osteonecrosis Freiburg osteochondrosis Ganglion cysts Intermetatarsal bursal fluid collections True neuromas Quick Find Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Click for related images. Related Articles Continuing Education CME available for this topic. Click here to take this CME. Patient Education Click here for patient education. WORKUP Section 5 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Lab Studies: No lab studies are indicated for diagnosis of Morton neuroma. Imaging Studies: Results of plain films are normal in Morton neuroma. Ultrasound, though not often used, may detect Morton neuroma but has questionable reliability. Computed tomography (CT) scan has been used but may not be as sensitive as magnetic resonance imaging (MRI). MRI, while not needed in most cases for establishing diagnosis of Morton neuroma, has been studied widely. Sensitivity of 87% AND specificity as high as 100% have been reported. Asymptomatic neuromas may occur AND confound accurate diagnosis. Indications exist that Morton neuromas smaller than 5 mm in diameter may not be significant clinically AND that other diagnoses may be excluded carefully before diagnosis of a symptomatic Morton neuroma is made with such a small lesion. Imaging with T1 weighting in a coronal plane is recommended for best visualization. In addition, on T2 imaging, the low signal of a Morton neuroma may help differentiate it from a true neuroma, ganglion cyst, OR intermetatarsal bursal fluid collection. Contrast enhancement usually is demonstrated with Morton neuromas. Other Tests: Electromyography AND nerve conduction study (EMG/NCS) of Morton neuroma is not used often because of the technical difficulty in performing the test, requiring needle stimulation of the common digital nerve AND pickup on the adjacent toe OR toes, which may be of short distance. Surface stimulation results most often in volume conduction through the skin to the pickups because of the short distance involved AND the large amount of stimulation needed to penetrate the deep tissue separating the nerve from the skin surface. Histologic Findings: Tissue biopsy is neither needed nor recommended for Morton neuroma. TREATMENT Section 6 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Rehabilitation Program: Physical Therapy: Treatment strategies for Morton neuroma range from conservative to surgical management. The conservative approach to treating Morton neuroma may benefit from the involvement of a physical therapist. The physical therapist can assist the physician in decisions regarding the modification of footwear, which is the first step to treatment. Recommend soft-soled shoes with a wide toe box AND low heel (eg, an athletic shoe). High-heeled narrow nonpadded shoes should not be worn, as they aggravate the condition. The next step in conservative management is to alter alignment of the metatarsal heads. One recommended action is to elevate the metatarsal head medial AND adjacent to the neuroma, thereby preventing compression AND irritation of the digital nerve. A plantar pad is used most often for elevation. Have the patient insert a felt OR gel pad into the shoe to achieve the desired elevation of the above metatarsal head. Other possible physical therapy treatment ideas for patients with Morton neuroma include cryotherapy, ultrasound, deep tissue massage, AND stretching exercises. Ice is beneficial to decrease the associated inflammation. Phonophoresis also can be used, rather than just ultrasound, to decrease pain AND inflammation further. Surgical Intervention: Surgical excision of the area of fibrosis in the common digital nerve may be curative when conservative measures are unsuccessful. Common adverse outcomes include dysesthesias radiating from a painful nerve stump after surgical excision of the Morton neuroma. Dysesthesias may be treated as any other dysesthetic pain. (See the Medication section.) Consultations: If surgical intervention is needed, consultation with an orthopedic surgeon specializing in foot AND ankle surgery is recommended. Other Treatment (injection, manipulation, etc.): A more aggressive approach involves injection of the Morton neuroma. Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the web space, in line with the MTP joints. Advance the needle through the mid web space into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located. Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid AND 2 mL of anesthetic. The anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad. Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible. MEDICATION Section 7 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Dysesthesias may be treated as any other dysesthetic pain. Tricyclic antidepressants, such as amitriptyline at 10-25 mg PO qhs, may be tried. If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective. Drug Category: Tricyclic antidepressants -- A complex group of drugs that have central AND peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, AND they block the active re-uptake of norepinephrine AND serotonin.Drug Name Amitriptyline (Elavil) -- Analgesic for certain chronic AND neuropathic pain. Low doses, 10-25 mg qhs, may provide pain relief from burning AND tingling occurring at rest but function only as an adjunct to definitive treatment. Adult Dose 10-25 mg PO qhs Pediatric Dose Not recommended Contraindications Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, AND urinary retention Interactions Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, AND disulfiram Pregnancy D - Unsafe in pregnancy Precautions Caution in cardiac conduction disturbances AND history of hyperthyroidism, AND renal OR hepatic impairment; avoid use in elderly patients Drug Category: Anticonvulsants -- Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants).Drug Name Gabapentin (Neurontin) -- Neuromembrane stabilizer useful in pain reduction with dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors. Adult Dose 300-1200 mg PO qhs OR divided bid/tid Titrate up starting at 300 mg qhs changing dose q3d up to therapeutic effect; not to exceed 3600 mg/d Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, 300 mg tid on day 3) Pediatric Dose Not recommended Contraindications Documented hypersensitivity, renal failure, AND patients using other anticonvulsants Interactions Antacids may reduce bioavailability of gabapentin significantly (administer at least 2 h following antacids); may increase norethindrone levels significantly Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in severe renal disease FOLLOW-UP Section 8 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Deterrence/Prevention: General prevention includes ensuring that shoes fit properly. Recommend wearing of well-padded low-heeled shoes with wide toe box. No other preventative techniques are recommended. Complications: Chronic pain may develop when treatment is unsuccessful for patients with Morton neuroma. Postoperative complications, such as dysesthesias, are possible when surgery is performed to remove the neuroma. Possible complications following corticosteroid injections may include plantar fat pad necrosis AND transient numbness of the toes. Prognosis: Prognosis for recovery is good with conservative treatment; however, patients still may require surgical intervention. Some patients who undergo surgery report as high as 50% recurrence rate. This number is likely to be reduced significantly with proper presurgical diagnosis. Patient Education: Patients should be well informed about proper footwear. MISCELLANEOUS Section 9 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Medical/Legal Pitfalls: The most common condition misdiagnosed as Morton neuroma is metatarsophalangeal (MTP) joint synovitis. When pain occurs in the third interspace, the clinician may misdiagnose the condition as Morton neuroma instead of MTP synovitis, which may manifest very much like Morton neuroma. MTP synovitis is distinguished from Morton neuroma by subtle swelling around the joint, pain localized mainly within the joint, AND pain with forced toe flexion. Palpation of the MTP joint is performed best with a pinching maneuver from the dorsal AND plantar aspects of the joint to elicit tenderness of the joint. Other conditions often misdiagnosed as Morton neuroma include the following: Stress fracture of the neck of the metatarsal Rheumatoid arthritis AND other systemic arthritis conditions Hammer toe Metatarsalgia (ie, plantar tenderness over the metatarsal head) Less common conditions that have overlapping symptoms with Morton neuroma include the following: Neoplasms Metatarsal head osteonecrosis Freiburg osteochondrosis Ganglion cysts Intermetatarsal bursal fluid collections True neuromas