Morton’s Neuroma

If you sometimes feel that you are “walking on a marble,” and you have persistent pain in the ball of your foot, you may have a condition called Morton’s neuroma. A neuroma is a benign (non-cancerous) tumour (“growth”) of a nerve. Morton’s neuroma is not actually a tumour, but a thickening of the tissue that surrounds the digital nerve leading to the toes.

Morton’s neuroma occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. Morton’s neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure. Morton’s neuroma occurs in women much more commonly than in men (8 to 10 times more).

What are the clinical features?

• Normally, there are no outward signs, such as a lump.
• Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.
• There may also be numbness in the toes, or an unpleasant feeling in the toes.

Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.

Diagnosis

During the examination, your surgeon will feel for a palpable “lump” or a “click” between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot. Usually, an ultrasound scan or Magnetic Resonance Imaging (MRI) scan will confirm the diagnosis.

Treatment options

Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:

• Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
• Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
• Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton’s Neuroma.

Operation

If conservative treatment does not relieve your symptoms, your orthopaedic surgeon may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.

Morton’s neuroma surgery can be done as a day surgery procedure unless you have other medical problems that mean you may need to stay in hospital overnight. The surgery is performed under general anaesthetic (whilst you are asleep). A cut is made over the top of the foot, at the base of the affected toes. The operation involves removing the part of the nerve that is causing the pain and discomfort. The foot and ankle are then bandaged.

What are the potential complications of surgery?

• Swelling
• Recurrence of the neuroma
• Numbness
• Persistent or recurrent pain
• Damage to blood vessels or tendons around the foot
• Infection

What happens after my operation?

2 weeks

You will be seen by the specialist nurses in the outpatient clinic for removal of the dressings and a wound check. Any stitches present still will be removed. You should usually be able to start driving at this stage although the final responsibility rests with the patient. The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact your doctor or the DVLA if you are concerned about this.

6 weeks

You will be seen by the surgeon in outpatient clinic to assess your recovery and to ensure that you have not developed any problems and that you are making a good recovery.