The aim of this article is to provide advice and self-help for people diagnosed with a Morton's Neuroma, which is a common cause of forefoot and toe pain in adults.
The information is also presented in video format below.
What is a Morton's Neuroma ?
The word neuroma comes from the Ancient Greek with 'neuro' referring to ‘Nerves’ and 'oma' meaning ‘Growth’ - so Neuroma means a Nerve Growth. 'Morton's' refers to the American surgeon who first described the condition in 1876, Thomas George Morton.
More correctly though it should be called a neurofibrosis as the condition is actually a benign fibrous thickening of the nerves between the toes. Morton's neuroma is not a malignant growth.
The condition most commonly affects the nerve between the 3rd and 4th toes and so that is where the symptoms are usually felt. However, any of digital nerves can be affected and therefore symptoms can affect any of the toes. Symptoms are always aggravated by standing and walking and will always ease at rest, when the foot is off the floor.
2) What causes a Morton's Neuroma ?
Between each toe is a digital nerve. These nerves are slippy in order to cope with the friction of the toes moving against each other when walking. If this friction becomes excessive and persistent then the nerve will start to adapt and thicken its external membrane - this is the process of fibrosis.
Of course a thicker nerve is then more likely to become squashed because it occupies more space between the toes than it should do. And it can then become inflamed and swollen which further increases its size.
So what causes this excessive friction between the toes in the first place ? The answer usually comes down to footwear. Anything that squeezes the toes together can cause a Morton’s Neuroma and shoes like the ones below are often the culprit. As a result, Morton's Neuroma has been found to be around 10 times more common in women than in men.
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| Shoes which can constrict the Toes |
While footwear is by far the most common cause, some sports and actives that involve jumping or standing on tip toes repeatedly can also cause the condition.
Dancers, particularly those who do ballet have a higher risk of developing the condition. Also, anything that alters the normal shape of the metatarsal bones can irritate the nerve and cause fibrosis, such as a fracture or osteoarthritis. An X-Ray can check the shape of the metatarsal bones.
One of the tests that clinicians use to help diagnose the condition in the Mulders Test. This involved squeezing the toes together with one hand while moving each individual toe up and down with the other hand. A reproduction of pain or a clicking sensation as the swollen nerve is squashed between the bones is considered a positive test.
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| The Mulders Test |
However, the main way the condition is diagnosed is via an MRI or ultrasound scan which can image a neuroma and measure its size.
3) What are the Treatment Options ?
Well if you’ve been following so far you will no doubt have worked out that a change in footwear is going to be the single most important thing that you need to do. Avoid any footwear which pushes the toes together. Anything with a heel is also likely to be a problem. Of course most people with the condition will have quickly worked out which shoes hurt them and which shoes don’t. Generally a shoe with open toes or with a wide toe box is likely to be your best option. Some people will go up a shoe size to find something comfortable. Walking barefoot around the house is also likely to be helpful.
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| Suitable Footwear |
The next self help treatment are the orthotics. Various types are available but ones which support the transverse arch of the forefoot are likely to be the most helpful. Mortons neuroma pads or insoles with a metatarsal dome can also be helpful for some people especially if you have a very flat foot.
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| Metatarsal Pads Insole with a Metatarsal Dome |
However, the best option is to see a podiatrist who can provide a bespoke orthotic tailored to your individual foot posture.
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| Custom fit Insoles from a Podiatrist |
Anti-inflammatories can also be helpful, especially during the early stages when the nerve might feel inflamed or if you’re getting any resting pain. The gel or creams are unlikely to penetrate to a depth where they can be helpful and so the tablets, such as ibuprofen are a better option. Taken for a few weeks at maximum dose can be helpful in some cases. Not everyone can take anti-inflammatories so please check with a pharmacist or a prescriber before taking them.
The idea of all the things we’ve discussed so far is to stop irritating the nerve and ultimately reduce any swelling or fibrosis around the nerve.
If the pain continues despite trying these self-help treatments then you have a choice to make. You can continue to follow the footwear and / or orthotic advice for the long term. If your symptoms are mild and manageable then this might be a perfectly good option for you. But, if your symptoms are more severe and intrusive then you might want to seek a specialist opinion to discuss the additional treatments that an expert foot & ankle clinician can provide.
Specialist Treatments
The first additional treatment that might be offered is a cortisone injection. For a persistent Mortons neuroma this is usually the next thing to try. Cortisone is a steroid which is injected between the toes and aims reduce swelling and inflammation around the nerve. It can often be very helpful, but if the neuroma is large and fibrotic rather than inflamed, then the result might be short-lived.
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| Cortisone Injection |
Other specialist treatments are alcohol injections, radiofrequency ablation and minimally invasive cryosurgery. These treatments all aim to shrink the neuroma by using non-surgical means.
Surgery is the last remaining treatment option. Depending on the size of the neuroma, a surgeon can either remove fibrous tissue from around the thickened nerve (neurolysis) or just remove the whole nerve (neurectomy), which will hopefully resolve the pain but will leave a permanent area of numbness around the affected toes.