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Morton’s Neuroma

What Is A Morton's Neuroma?

A Morton’s neuroma is thickening of the tissue around the interdigital nerve that runs between the metatarsal bones down to the toes.

Despite the name, it is not a true neuroma (tumour of the nerve). Instead there is thickening and scarring (fibrosis) around the nerve.

The incidence of Morton’s neuroma is roughly 9 times greater in women than men. It is more common in middle age. It almost never occurs between the 1st and 2nd or 4th and 5th metatarsals. The most frequent site of a Morton’s neuroma is between the 3rd and 4th metatarsal heads.

Illustration of A - normal interdigital nerves B - a Morton's neuroma between the 3rd and 4th metatarsal bones

Illustration of A – normal interdigital nerves B – a Morton’s neuroma between the 3rd and 4th metatarsal bones

What Can Cause It?

The exact cause and mechanism of injury is still not clearly understood. Amongst surgeons it is felt to be due to repetitive microtrauma, irritation and excessive pressure around the nerve.

The anatomy of the foot may also predispose to the development of Morton’s neuroma. The space between the metatarsal heads 2 & 3, and 3 & 4 is quite narrow.

Radiograph (x-ray) of the foot demonstrating the narrow space between 2nd and 3rd as well as 3rd and 4th metatarsal heads

Radiograph (x-ray) of the foot demonstrating the narrow space between 2nd and 3rd as well as 3rd and 4th metatarsal heads

Anything that causes increased pressure and irritation of the nerve may lead to the development of Morton’s neuroma such as:

  • Wearing of high heels
  • Tight calf muscles 
  • Wearing tight constrictive shoes
  • Trauma – after a metatarsal fracture
  • Abnormal foot biomechanics/anatomy such as in high arched feet
  • Swelling in the webspace such as ganglion, lipoma or bursitis
  • Secondary to other foot problems (transfer metatarsalgia)

Occasionally, problems in adjacent structures can result in local inflammation which irritates the interdigital nerve and reproduces symptoms similar to a Morton’s neuroma. It is extremely important to rule out any other pathology as treating the Morton’s neuroma (including surgery) may fail to alleviate symptoms as the real underlying problem has not been treated.

Local problems that can mimic Morton’s neuroma include:

What Are The Symptoms?

Pain is the commonest symptom of Morton’s neuroma.

The pain can be present in many different forms for example it may be:

  • Burning in nature
  • Sharp
  • Shooting
  • Aching
  • Cramp

There may also be tingling or numbness of the toes.

Some patients also describe “clicking” in the foot which may or may not be painful.

Symptoms are worse wearing tight fitting shoes and high heels. Symptoms are relieved by taking off shoes and massaging the foot.

On examination there will be tenderness on palpation of the webspace (positive web space compression test). Sometimes it is possible to “feel” the neuroma (Mulder’s click). There may be numbness or altered sensation in the toes.

Examination will also look to see how tight the calf muscles are, and whether there are signs of callosities and any other foot problem that may be the cause of the symptoms.

What Investigations May Be Required?

Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.


Plain radiograph (x-ray)

Plain radiographs are a quick and effective way of ruling out any other foot condition that may be causing symptoms similar to Morton’s neuroma.

Plain radiographs (x-rays) may demonstrate the following conditions that can cause forefoot pain:


Ultrasound

Ultrasound is requested in almost all cases. It is quick, effective and safe. It helps to confirm the diagnosis of Morton’s neuroma and also treat the condition by undertaking an image guided injection of local anaesthetic. All patients are recommended to undergo this before considering surgery.

An ultrasound scan will also pick up other pathologies that are not visible on an x-ray such as:

  • Lesser MTP joint synovitis (inflammation)
  • Intermetatarsal bursitis
  • Lesser MTP joint arthritis
  • Other soft tissue tumour/swelling
  • Stress fracture

MRI

MRI is a useful investigation when x-rays and an ultrasound scan appear normal. It is also useful in patients who have recurrent symptoms post surgery. It provides excellent high definition static images.

MRI is particularly useful in assessing:

  • Cartilage damage
  • Reactive bone changes (stress response)
  • Synovitis (inflammation and fluid in the joint)
  • Damage to the plantar plate
  • Internal scar tissue
  • Other pathology
An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint

An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint

An MRI in combination with a small injection can help confirm any injury to the plantar plate (if there is a tear, fluid leaks out of the 2nd MTP joint, see image below), it can also confirm any stress lesions in the bone itself. If the underlying diagnosis is not clear an MRI can be a useful investigation.

MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule

MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule

Can The Problem Get Worse?

Morton’s neuroma are sometimes seen as an incidental finding on ultrasound scans when treating another foot condition. Therefore not all Morton’s neuromas are painful. Of those patients that have a painful neuroma, a significant proportion will respond well to non operative measures (see below).

Having said that, Morton’s neuroma is a condition that can become chronic and fail to respond to non operative treatment. Surgery is reserved for this group of patients.

Non-Operative Treatment Options

Non-operative management aims at relieving pain.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.


Insoles & orthotics

An insole with a metatarsal dome pad just proximal to the neuroma


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can sometimes decrease discomfort.


Footwear Modification

The use of comfortable and wide fitting shoes with a small or no heel.


Physiotherapy

Stretching tight calf muscles will help reduce the forces going across the forefoot. This can help reduce pain from a Morton’s neuroma.

Injections For Morton's Neuroma

There are a number of treatments that involve an injection or series of injections for the treatment of Morton’s neuroma. At The London Foot And Clinic we only use local anaesthetic and steroid.


Image guided steroid and local anaesthetic injection

This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.

The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.

We carry out all injections only after ultrasound confirmation that there is indeed a Morton’s neuroma present. Most injections are performed under ultrasound image guidance to make sure the needle is in the correct spot. A mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is then injected around the Morton’s neuroma. Undertaking the injection in this manner ensures the best outcome clinically as there is no doubt about the placement of the needle and subsequent injection.

The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.

Injections are not repeated less than 6 monthly intervals. Repeating injections can also weaken local tissue and cause complications such as:

  • Skin discolouration
  • Skin thinning
  • Fat atrophy

Please read here for more information regarding injections and possible complications.

Please ensure someone is available to drive you home after the injection as the foot may hurt for a few days after the injection.


We do not use alcohol or sclerosants at The London Foot and Ankle Clinic.

It has been suggested that injecting these substances in and around the nerve will damage the nerve sufficiently to eliminate symptoms. Our experience and concern is that the alcohol will cause excessive scarring and if anything make symptoms worse and any open surgery more complicated.

For the very same reasons we do not use crysosurgery. This involves destroying the nerve by freezing it. While some patients may claim to get better using these techniques the complication and failure rates are unacceptably high in our opinion.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

Surgery involves an incision over the top of the foot between the metatarsal bones. Some surgeons carry out the operation through the sole of the foot however in our experience this results in a painful and thickened scar and quite a lot of discomfort in the immediate post-operative period while the wound heals.

Traditionally surgery for Morton’s neuroma involves identifying the nerve and cutting (resecting) it proximal to the point where it is irritated/injured (the neuroma).

This should result in relief of pain, but does leave permanent numbness along the distribution of the nerve. This does not usually cause any problems.

Illustration of a foot - resecting the Morton's neuroma will leave numbness between the toes (red)

Illustration of a foot – resecting the Morton’s neuroma will leave numbness between the toes (red)

Some surgeons advocate releasing a ligament (intermetatarsal) over the Morton’s neuroma and freeing the nerve of local scar tissue. This may be suitable for certain patients and can discussed with your surgeon Mr Malik.

The operation is carried out under a general anaesthetic and is usually done as a daycase procedure which means you will not have to stay in the hospital overnight.

The success of surgery is variable. Around 75% of patients feel happy with the outcome and have a pain free foot.

It is important to make sure that the underlying diagnosis is correct and that the pain is not from another pathology but actually from Morton’s neuroma.

If the pain is truly arising from the irritated nerve (Morton’s neuroma) then surgery will probably be successful. However a variety of conditions cause forefoot pain (metatarsalgia) and this needs to investigated carefully and treated.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.

Potential complications of non-operative treatment include:

  • Worsening pain

Complications can occur as with any type of surgery. Please see foot and ankle complications for more detailed explanation of post surgical complications.

Potential complications of operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Recurrence of the condition
  • Wound healing problems 
  • Complex regional pain syndrome
  • Need for further surgery
  • Persistent pain and symptoms

Note – this list is not exhaustive and is meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

You will have a bandage applied similar to this during the operation.

Post operative bandage of the foot

Post operative bandage of the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

Post operative stiff soled shoe

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

High elevation of the foot and ankle post surgery

High elevation of the foot and ankle

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and redressed if necessary.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence range of motion exercises of the lesser toes immediately after surgery and continue for 6 weeks.  After two weeks start intrinsic foot muscle strengthening exercises.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

Typical appearance of Morton's neuroma excision wound at 6 weeks post surgery

Typical appearance of Morton’s neuroma excision wound at 6 weeks post surgery

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

When can I wear normal shoes?

This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.

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