Morton's Neuroma

A Patient's Guide

Morton's neuroma, also known as interdigital neuroma or interdigital neuritis, is a painful condition affecting the ball of the foot, most commonly between the third and fourth toes. This condition is characterized by the thickening of the tissue around one of the nerves leading to the toes. As the nerve becomes compressed, it can cause sharp, burning pain in the ball of the foot. Some patients describe the sensation as feeling like they are standing on a pebble in their shoe or having a fold in their sock. This condition predominantly affects middle-aged women but can occur in anyone who engages in activities that put excessive pressure on the feet, such as running or wearing high-heeled shoes. Understanding Morton's neuroma is essential for timely diagnosis and treatment, which can significantly improve quality of life.

Symptoms and Signs

The symptoms of a Morton's neuroma can vary in severity and may come on gradually. The primary symptom is pain, often described as sharp or burning, in the ball of the foot. This pain can radiate into the toes, most commonly affecting the third and fourth toes. Patients often report that the pain worsens with activity or while wearing tight shoes, particularly high heels.

In addition to pain, other symptoms may include:

Numbness or Tingling: Some individuals experience a sensation of numbness or tingling in the affected toes, which can be intermittent or persistent.
Swelling: While less common, some patients may notice swelling in the area between the toes.
Cramping: Foot cramps can accompany the pain and discomfort, particularly after prolonged periods of walking or standing.
A Feeling of a Lump: Although there is no visible lump, some people feel as though they have a lump or pebble under the ball of their foot.

The symptoms often start subtly and may initially be relieved by removing tight footwear or massaging the foot. However, as the condition progresses, the pain can become more severe and persistent, significantly affecting daily activities and mobility.

Assessment

When diagnosing Morton's neuroma, healthcare providers typically begin with a thorough medical history and physical examination. During the physical exam, the doctor will palpate the foot to identify the specific area of pain and may perform a specific manoeuvrer to reproduce the symptoms and elicit a 'Mulder's click'. Several diagnostic tests and procedures may be used to confirm the diagnosis although not all are neccessary:

Ultrasound: This imaging technique is particularly useful for visualizing soft tissues and can help identify the thickened nerve characteristic of Morton's neuroma.
MRI (Magnetic Resonance Imaging): An MRI can provide detailed images of the foot's structures and is often used if the diagnosis is unclear or if surgery is being considered.
X-Rays: While X-rays do not show soft tissue changes, they may be performed to rule out other conditions, such as fractures or arthritis, that could be causing the symptoms.
Diagnostic Injections: A local anaesthetic may be injected into the affected area to see if it temporarily relieves the pain. This can help confirm the diagnosis of Morton's neuroma.
Nerve Conduction Studies: In some cases, additional tests like nerve conduction studies might be conducted to rule out other nerve-related conditions.

Non-invasive Treatment

The treatment for Morton's neuroma typically starts with conservative measures aimed at relieving pressure on the affected nerve. These non-invasive treatments may be highly effective, especially if the condition is diagnosed early.

Footwear Modification: Wearing shoes with a wide toe box and low heels can reduce pressure on the affected area. Avoiding high heels and tight shoes is crucial.
Orthotic Devices: Custom orthotic inserts can provide additional support and cushioning, redistributing pressure away from the neuroma.
Padding: Placing pads in the shoe can help relieve pressure on the ball of the foot.
Activity Modification: Reducing activities that exacerbate the symptoms, such as running or high-impact sports, can help manage pain.
Medications: Over-the-counter pain relievers, such as ibuprofen or paracetamol, can help reduce pain and inflammation.
Physiotherapy: Stretching and strengthening exercises can improve foot mechanics and alleviate symptoms.

Invasive Treatment

When conservative options fail to adequately control symptoms, advanced treatment of injections or surgery may be offered. Options will depend upon your goals and the severity of disease:

Injections: Corticosteroid injections are used to reduce pain and inflammation. They are typically provide long-term effective in over half of patients who have not improved with non-invasive treatment. They work best on small neuromas which explains why either symptoms recur or you may be offered surgery over injection therapy.
Neurectomy: In cases which have failed other treatments, surgery may be offered as a final option. Neurectomy involves removing the affected portion of the nerve. While effective, it carries the risk of developing a stump neuroma or permanent numbness in the toes.

Summary

Morton's neuroma is a common but often misunderstood condition that can cause significant pain and discomfort in the ball of the foot. Early recognition and treatment are key to managing symptoms and preventing progression. With a combination of conservative measures and, if necessary, more invasive treatments, most individuals with Morton's neuroma can find relief and return to their normal activities. If you suspect you have Morton's neuroma, it is important to consult with a healthcare professional to determine the best course of action based on your specific condition and needs.