Mortons Neuroma Overview

Overview

Morton neuromas are focal areas of symptomatic perineural fibrosis around a plantar digital nerve of the foot. The abnormality is non-neoplastic and does not represent a true neuroma. It may more correctly be known as Morton?s metatarsalgia. The condition is thought to be due to chronic entrapment of the nerve by the intermetatarsal ligament. It most often occurs in middle-aged individuals and is many times more common in women than men. Approximately 30% of asymptomatic middle-aged persons have the radiological pathologic findings of a Morton?s neuroma.

Causes

Morton’s Neuroma is a foot condition caused from an abnormal function of the foot that leads to bones squeezing a nerve usually between the 3rd and 4th metatarsal heads. Symptoms of Morton’s Neuroma often occur during or after you have been placing significant pressure on the forefoot area, while walking, standing, jumping, or sprinting. This condition can also be caused by footwear selection. Footwear with pointed toes and/or high heels can often lead to a neuroma. Constricting shoes can pinch the nerve between the toes, causing discomfort and extreme pain.

Symptoms

Neuroma pain is classically described as a burning pain in the forefoot. It can also be felt as an aching or shooting pain in the forefoot. Patients with this problem frequently say they feel like they want to take off their shoes and rub their foot. This pain may occur in the middle of a run or at the end of a long run. If your shoes are quite tight or the neuroma is very large, the pain may be present even when walking. Occasionally a sensation of numbness is felt in addition to the pain or even before the pain appears.

Diagnosis

An MRI scan (magnetic resonance imaging) is used to ensure that the compression is not caused by a tumor in the foot. An MRI also determines the size of the neuroma and whether the syndrome should be treated conservatively or aggressively. If surgery is indicated, the podiatrist can determine how much of the nerve must be resected. This is important, because different surgical techniques can be used, depending on the size and the position of the neuroma. Because MRIs are expensive, some insurance companies are reluctant to pay for them. If the podiatrist believes an MRI is necessary, he or she can persuade the insurance company to pay for it by presenting data to support the recommendation.

Non Surgical Treatment

Most non-operative treatment is usually successful, although it can take a while to figure out what combination of non-operative treatment works best for each individual patient. Non-operative treatment may include the use of comfort shoe wear. The use of a metatarsal pad to decrease the load through the involved area of the plantar forefoot. A period of activity modification to decrease or eliminate activities, which maybe exacerbating the patient?s symptoms. For example, avoiding long periods of standing or other activities that result in significant repetitive loading to the forefoot can be very helpful. Wearing high heels should be avoided. Local corticosteroid injections can help decrease inflammation associated with the nerve. However, this does not necessarily address the underlying loading forces that maybe causing the injury to the nerve in the first place. It has been proposed that an alcohol injection in and around the nerve will cause a controlled death to the nerve and subsequently eliminate symptoms from the nerve. In theory, this may be helpful. In practice, adequate prospective studies have not demonstrated the benefit of this procedure above and beyond the other standard non-operative treatments available. In addition there is the concern that the alcohol will cause excessive scarring and death of other important structures in the area.

Surgical Treatment

Operative treatment of Morton?s neuroma should be entertained only after failure of nonoperative management. Standard operative treatment involves identifying the nerve and cutting (resecting) it proximal to the point where it is irritate/injured. This is usually done through an incision on the top (dorsal) aspect of the foot, although in rare instances, an incision on the sole (plantar) aspect of the foot maybe used. An incision on the sole of the foot works very well, unless an excessive scar forms in which case it can be problematic. Some physicians will attempt to treat Morton?s neuroma by releasing the intermetatarsal ligament and freeing the nerve of local scar tissue. This may also be beneficial.

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