Morton’s Neuroma: Causes, Symptoms, and the Expert Treatment Ladder for Foot Pain

What Is Morton’s Neuroma and Why Does It Cause Pain?

Morton’s neuroma is a common, painful condition affecting the ball of the foot, most frequently occurring in the space between the third and fourth toes. Less often, it can appear between the second and third toes. Despite its name, a neuroma is not a tumor; rather, it is a benign thickening of the tissue surrounding one of the nerves leading to the toes, specifically the interdigital nerve.

This thickening occurs due to irritation, compression, and chronic trauma to the nerve as it passes between the metatarsal heads (the long bones leading to the toes). The resulting inflammation and scarring cause the nerve to swell, leading to significant discomfort.

Who Is Most At Risk?

While anyone can develop a neuroma, it is significantly more common in women, largely due to footwear choices. Shoes that compress the toes—such as high heels or those with a narrow toe box—put excessive pressure on the metatarsal bones, squeezing the nerves and triggering the condition. Active individuals, like the 68-year-old walker who covers 2 to 5 miles daily, are also susceptible due to repetitive stress on the forefoot.

Recognizing the Symptoms and Confirming Diagnosis

Identifying Morton’s neuroma is relatively straightforward based on the specific type of pain it causes. The primary symptoms are localized in the forefoot and often worsen when wearing tight shoes or engaging in weight-bearing activities.

Key symptoms include:

• Sharp, burning pain in the ball of the foot that may radiate into the toes.
• A sensation of standing on a pebble, marble, or bunched-up sock inside the shoe.
• Numbness or tingling (paresthesia) in the affected toes.
• Pain relief when removing the shoe and rubbing the foot.

Diagnosis typically involves a physical examination where a doctor can often feel the thickened nerve tissue or reproduce the pain by squeezing the metatarsal bones together. Imaging tests, such as ultrasound or MRI, may be used to confirm the diagnosis, rule out other conditions (like stress fractures or bursitis), and determine the exact size and location of the neuroma, especially if multiple neuromas are present, as in the case of the active patient with two in her left foot.

The Treatment Ladder: Prioritizing Non-Surgical Solutions

Treatment for Morton’s neuroma follows a conservative-to-aggressive ladder. The goal is always to reduce pressure on the nerve and decrease inflammation. For active individuals, the initial focus is on simple lifestyle and footwear modifications.

Step 1: Conservative Management (The Foundation)

This is the most crucial step and often provides significant relief, particularly for those whose activity level contributes to the irritation.

1. Footwear Modification: This is non-negotiable. Patients must switch to shoes with a wide toe box that allows the toes to spread naturally. Heels should be low (less than two inches) or flat to shift weight off the forefoot.
2. Orthotics and Pads: Over-the-counter or custom-made orthotics can help. Specifically, a metatarsal pad placed just behind the ball of the foot can lift and separate the metatarsal heads, relieving pressure on the nerve.
3. Activity Adjustment: While stopping exercise is rarely necessary, temporarily reducing high-impact activities or switching to lower-impact options (like cycling or swimming) can help during flare-ups.
4. Anti-Inflammatory Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help manage pain and reduce nerve inflammation.

Step 2: Medical Interventions

If conservative measures fail after several weeks or months, the next step involves targeted medical treatments administered by a podiatrist or orthopedic specialist.

• Corticosteroid Injections: A mixture of a steroid and a local anesthetic is injected directly into the area around the neuroma. This is highly effective at reducing inflammation and swelling, often providing long-term relief. Multiple injections may be required, though they are typically spaced out over several months.
• Alcohol Sclerosing Injections: In some cases, injections of concentrated alcohol may be used to chemically destroy the nerve tissue, shrinking the neuroma over time. This is generally considered less invasive than surgery.

When Surgery Becomes Necessary

Surgery is reserved as a last resort when the neuroma is large, or when all non-surgical treatments have failed to provide adequate pain relief, significantly impacting the patient’s quality of life and mobility.

The most common surgical procedure is a neurectomy, which involves surgically removing the affected portion of the nerve and the surrounding thickened tissue. This procedure is typically performed on an outpatient basis.

“For active patients, the key is consistency with conservative care. If you can eliminate the compression and irritation caused by footwear, many neuromas will quiet down significantly without needing invasive procedures.”

Post-Surgical Considerations

While neurectomy is generally successful, it does carry the risk of permanent numbness in the affected toes, as the nerve supplying sensation is removed. In rare cases, a stump neuroma (a recurrence of nerve thickening at the site of the severed nerve) can develop, requiring further treatment.

Key Takeaways for Managing Morton’s Neuroma

If you suspect you have Morton’s neuroma, especially if you maintain an active lifestyle involving walking or running, remember these critical points:

• Immediate Action: Prioritize switching to shoes with a wide, square toe box and avoiding high heels immediately.
• Diagnosis: Seek confirmation from a podiatrist or orthopedic specialist to rule out other causes of forefoot pain.
• Treatment Path: Follow the established treatment ladder: conservative care first, followed by injections, and only then considering surgery.
• Active Management: Metatarsal pads and custom orthotics are essential tools for managing symptoms while maintaining activity levels.

Disclaimer: This information is for educational purposes only and should not replace consultation with a qualified medical professional. Always discuss treatment options with your doctor.