Mortons neuroma

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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A Morton's neuroma is a benign growth of the sheath surrounding a nerve that runs between the toes. A Morton’s neuroma usually occurs in the third interspace, between the third and fourth toes.

This condition is an abnormal growth, but it is not malignant. It is a painful nuisance. People may experience symptoms of shooting pains or tingling extending into the toe next to the neuroma. Pain is usually most significant with more strenuous activity and when wearing shoes with a narrow toebox.

Problems often develop in this area because part of the lateral plantar nerve combines with part of the medial plantar nerve. When the two nerves combine, they are typically larger in diameter than those going to the other toes. Also, the nerve lies in subcutaneous tissue, just above the fat pad of the foot. Above the nerve is a structure called the deep transverse metatarsal ligament. This ligament is tough and holds the metatarsal bones together. It creates a "ceiling" above the nerve. Therefore, the nerve is subjected to forces from below with walking and pressure above due to the ligament.

The reason a neuroma forms is unknown. The syndrome is more common in women than men, possibly because women wear confining shoes more often. High heels cause more weight to be transferred to the forefoot and tight toe boxes create lateral compression. As a result, there is more force being applied and the nerve is squeezed on all sides. Under such conditions, even a small enlargement in the nerve can elicit pain.

The most common symptom of Morton's neuroma is localized pain in the third interspace between the third and fourth toes. It can be sharp or dull, and is worsened by wearing shoes and by walking. Pain usually is less severe with non weight-bearing. The pain is described as an uncomfortable burning pain. Patients will take their shoes off and rub their food trying to get relief.

Morton's neuroma is the most common cause of localized pain in the third interspace.

The physician squeezes the toes from the side. The physician will then try to elicit Muldor's sign, holding the patient's first, second, and third metatarsal heads with one hand and the fourth and fifth metatarsal heads in the other and pushing half the foot up and half the foot down slightly. In many cases of Morton's neuroma, this causes an audible click.

An x-ray may be taken to ensure that there is not a fracture.

An MRI scan is diagnostic. An MRI also determines the size of the neuroma. If surgery is indicated, the surgeon can determine how much of the nerve must be resected.

In most cases, initial treatment consists of padding and taping. If the patient has flat feet, an arch support is added. The patient is instructed to wear shoes with wide toe boxes and avoid shoes with high heels. An injection of local anesthetic to relieve pain and a corticosteroid to reduce inflammation may be administered. A custom-fitted orthotic may also help. Alcohol injections are given if steroid injection doesn't work.

Conservative treatment does not help some patients and surgery then is necessary.

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