Morton’s Neuroma

A Morton’s neuroma is a very common entity seen in my practice. Specifically, a Morton’s neuroma refers to thickening of the outer surrounding sheath of the nerve present in the 3rd interdigital space (between toes 3 and 4).

There are a few theories that explain why the 3rd space is the most common place to see this pathological entity, and hence why it even has its own eponym (Morton’s). The first theory being there is increase mobility between the two metatarsals where the nerve exists and this can lead to irritation and enlargement of the nerve as the bones rub against the nerve tissue. Another theory is that the common digital nerve in this area is predisposed to being large in general because it receives branches from two different nerves (derives from the medial and lateral plantar nerves).

Symptoms of a Morton’s neuroma include pain, irritation, numbness and tingling in the ball of the foot. Many have also described the sensation of walking on a rolled-up sock or the sensation of a pebble on the bottom of the foot. Symptoms can worsen with heels, narrower shoes and walking barefoot (lack of cushioning). Symptoms are typically relieved with wider shoes, massage of the foot and walking on more cushioned surfaces (like carpet).

Both conservative and surgical treatment options exist for Morton’s neuroma. Conservative treatment is attempted first.

Conservative treatment options include activity modification, shoe modifications (wider shoes), orthotics, and cortisone injections. Cortisone injections work exceedingly well and offer both diagnostic and therapeutic properties. The injection is diagnostic because it is injected around the area of the suspected neuroma, and if the patient’s symptoms dissipate or disappear, then that is further evidence that a Morton’s neuroma is present. The injection is therapeutic because if performed correctly, and if the suspecting neuroma is actually present, then there should be relief for the patient. 

Cortisone injections work well but must be performed in concert with other modalities such as activity modification, wearing appropriate shoes, orthotics and oral medications (anti-inflammatories).

Surgical management of a Morton’s neuroma is reserved for cases in which there has been unsatisfactory response to conservative treatment and the pathology is having an impact on activities of daily life or athletics. 

In my hands there are two choices for surgical treatment.

The first would be a procedure called neurolysis. This is a procedure whereby surrounding tissues (like the “deep intermetatarsal ligament”) are released to relieve pressure being placed on the nerve. This can be performed in cases in which the neuroma is not very large. 

For larger, more diseased cases of nerve entrapment, a small portion of the nerve needs to be removed and this is called a “neurectomy”. After a neurectomy procedure, most patients will experience permanent numbness in the affected webspace; however, this is usually not noticeable.

Recovery involved immediate weight bearing in a surgical shoe following surgery until the incision heals, which usually takes about two weeks. Transition back to regular sneakers is then gradually made.

If you think you are suffering from a Morton’s neuroma, please contact Dr. Lonny Nodelman at District Foot and Ankle, located in Alexandria, Virginia for a consultation to see what your personalized treatment options are.