Continuing Education Activity

Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot that can cause plantar forefoot pain, paresthesia, reduced walking tolerance, and persistent activity limitation. Effective care requires recognition of typical symptoms, focused examination findings, relevant biomechanical contributors, and appropriate differentiation from stress fracture, plantar plate injury, arthritis, bursitis, peripheral neuropathy, and other causes of metatarsalgia. A practice gap exists when clinicians rely on incomplete assessment or nonspecific treatment without evaluating footwear, nerve compression, metatarsophalangeal joint instability, neuroma size, recurrence risk, and patient expectations. This continuing medical education activity addresses that gap by reviewing current concepts in pathophysiology, diagnosis, conservative treatment, injection therapy, surgical treatment, complications, recurrence, and interprofessional care. Participants are expected to gain actionable strategies to improve diagnostic accuracy, select individualized treatment, reduce preventable complications, and support patient-centered outcomes.

Objectives:

• Identify the clinical symptoms and signs associated with Morton neuroma.
• Implement appropriate diagnostic tests, including ultrasonography or magnetic resonance imaging, to confirm the presence of Morton neuroma and exclude other pathologies.
• Apply evidence-based treatment protocols for Morton neuroma, including conservative management strategies such as orthotics, corticosteroid injections, and physical therapy.
• Collaborate with the healthcare team to provide comprehensive care for patients with Morton neuroma, ensuring effective coordination of follow-up and rehabilitation to monitor progress and adjust treatment plans as necessary.

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Introduction

Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot. This neuropathy primarily results from compression and irritation of the plantar aspect of the nerve branches against the transverse intermetatarsal ligament. Morton neuroma is not a true neuroma because the condition is degenerative rather than neoplastic. Additional terms include Morton metatarsalgia, interdigital neuritis, Morton entrapment, interdigital neuralgia, interdigital neuroma, interdigital nerve compression syndrome, and intermetatarsal neuroma. The most common location for an interdigital neuroma is between the third and fourth metatarsal heads (see Image: Morton Neuroma).[1][2][3]

Etiology

The exact etiology of Morton neuroma is unknown, but 4 major hypotheses have been proposed. The chronic trauma theory, the most widely accepted hypothesis, states that the mechanical effects of walking cause chronic microtrauma to the intermetatarsal plantar digital nerves, which become compressed between 2 metatarsal heads and the metatarsophalangeal joints.[4] The entrapment theory, one of the earliest proposed theories, states that interdigital neuroma results from compression of the interdigital nerve against the anterior end of the deep transverse metatarsal ligament and the plantar soft tissue structures. The intermetatarsal bursa theory states that bursitis in the intermetatarsal region causes compression and inflammation with subsequent fibrosis of the affected common plantar digital nerve. Notably, bursae are close to the neurovascular bundle in the second and third intermetatarsal spaces, where Morton neuromas are most common, whereas Morton neuromas are rare in the fourth intermetatarsal space, where the bursa rarely contacts the neurovascular bundle.[5] The fourth theory is the ischemic theory, which is based on histopathological findings showing that the common plantar digital artery exhibits degenerative changes before the fibrous thickening of the nerve.[6] Common causes include footwear with a narrow toe box, hyperextension of the toes in high-heeled shoes, deviation of the toes, inflammation of the intermetatarsal bursa, thickening of the transverse metatarsal ligament, forefoot trauma, high-impact sporting activities, metatarsophalangeal joint pathology, and lipoma.[7][8]

Epidemiology

Morton neuroma is common in middle-aged women, with an incidence at least 5 times higher than in men.[9] The exact incidence is unknown. Both feet are rarely affected, whereas multiple neuromas on the same foot are common.[10]

Pathophysiology

Morton neuroma is common in the third interspace because it is narrower than the other intermetatarsal spaces. The common digital nerve to the third interspace receives branches from both the medial and lateral plantar nerves, thereby increasing nerve thickness and predisposing it to compression and trauma. Trauma from a crush injury, penetrating injury, thickened transverse metatarsal ligament, enlarged bursa in the interspace, and repetitive trauma from running has been linked to the development of Morton neuroma. Compression and repetitive nerve trauma result in vascular changes, endoneurial edema, and excessive bursal thickening, leading to perineural fibrosis.[11]

Current Understanding

Morton neuroma is not a true neuroma. The condition represents perineural fibrosis of the common plantar digital nerve from chronic repetitive compression between the metatarsal heads. Results from recent studies emphasized the involvement of intermetatarsal bursitis as the primary pain generator, metatarsophalangeal joint instability and deformities, particularly of the second metatarsophalangeal joint, contributing to altered forefoot biomechanics, and footwear-related forefoot compression, especially in narrow or high-heeled shoes.

Histopathology

Grossly, Morton neuroma presents as a fusiform swelling near the bifurcation of the plantar interdigital nerve with thickening of adjacent tenosynovial tissues. Microscopically, the common plantar digital artery shows arterial wall disruption with thrombosis and incomplete recanalization. These findings support the ischemic theory.[12] Additionally, fibrosis surrounds and extends within the nerves, with proliferation of Schwann cells and fibroblasts and damage to myelinated nerve fibers.

History and Physical

The most common symptom is plantar pain between the metatarsal heads, aggravated by walking or by wearing tight-fitting or high-heeled shoes, and relieved by rest or shoe removal. Patients describe the pain as burning, stabbing, or tingling, with electric sensations radiating into the toes. Some patients describe the sensation as walking on a stone or marble. Numbness and paresthesia between the toes are present in less than half of patients. With prolonged walking, the pain can radiate to the hindfoot or leg and cause cramps. 

Evaluation

Diagnosis is usually based on history and clinical examination. Palpation of the affected space may reproduce the symptoms. Compression of the forefoot in the mediolateral direction while palpating the affected space often elicits a significant crunching or clicking sensation, commonly known as the Mulder click or Mulder sign, which is useful but not always present. Furthermore, webspace tenderness is the most sensitive clinical sign. Importantly, palpation and assessment of the metatarsophalangeal joint for instability should be performed because many patients have combined pathology. Some surgeons inject the affected webspace with a diagnostic injection of 1 to 2 mL of lidocaine.

Moreover, plain, weight-bearing radiographs should be obtained to rule out any bony masses, deformities, subluxation, dislocation, or arthritis. Gapping of the distal intermetatarsal space with divergence of adjacent digits may be noted. This finding is known as the Sullivan sign.[13] A radiopaque foreign body can also be visualized on radiographs. Ultrasonography performed by an experienced clinician can be a useful diagnostic aid. Results from some studies cited ultrasonography as more sensitive than MRI for neuromas greater than 5 mm. Ultrasonography can also detect coexisting bursitis and guide corticosteroid injection.

MRI can be obtained for diagnosis confirmation and to rule out other pathologies (see Image. Short-Axis T1-Weighted Magnetic Resonance Imaging of Morton Neuroma).[8][14] MRI demonstrates a dumbbell-shaped soft tissue lesion within the intermetatarsal space. The T1 signal is often low, the T2 signal is frequently low or intermediate, and enhancement is variable (see Image. Coronal T1-Weighted Magnetic Resonance Imaging of  Morton Neuroma). Sonographic evaluation similarly demonstrates a noncompressible, dumbbell-shaped soft tissue lesion with hypoechogenicity within the intermetatarsal space. MRI is the preferred study for patients with multiple neuromas or with metatarsophalangeal joint instability. Modern thin-slice MRI is excellent for assessing plantar plate pathology, an important consideration in the differential diagnosis.

Treatment / Management

Nonoperative Treatment

Wearing a wide, soft-soled, laced shoe with a low heel can effectively relieve pressure on the nerve. Some surgeons recommend a firm-soled shoe instead. Soft metatarsal support with a metatarsal pad, neuroma pad, or metatarsal dome or cookie, placed just proximal to the metatarsal heads, can help spread the metatarsal heads and relieve mechanical pressure on the neuroma. Evidence suggests that early conservative care is effective in reducing symptoms and preventing further pathology.

In the presence of synovitis, instability, or deformity of the digit, a Budin splint, canopy digit strapping, and crest or buttress pad can decrease secondary neuralgia. Oral or topical anti-inflammatory medications, tricyclic antidepressants such as amitriptyline, and antiseizure medications such as gabapentin can be administered to lessen the severity of related nerve symptoms. Aggressive stretching of the calf-Achilles complex is recommended to reduce forefoot pressure from equinus. Vibration therapy, massage therapy, hot wax therapy, laser therapy, acupuncture, and acupressure may also be used.

 Injection Therapy

Blind or ultrasonography-guided corticosteroid injections can help, but their effect is not curative.[15][16] Atrophy of the subcutaneous fat and plantar fat pad, discoloration of the skin, and disruption of the joint capsule adjacent to the injected site, causing deformity of the digit, are some of the adverse effects. Radiofrequency ablation, cryotherapy, and alcohol nerve injections have been used effectively as less invasive and more conservative methods for treating neuromas.[1][17][18]

• Corticosteroid injection: Corticosteroid injection provides good short-term relief, and the effect may last 3 to 6 months. Corticosteroid injection is less effective for neuromas greater than 8 mm.
• Dehydrated alcohol sclerosing injections: Evidence is now more mixed, with 2023 to 2024 data showing higher recurrence rates and risk of prolonged neuritis. Dehydrated alcohol sclerosing injections are no longer recommended as strongly in the United Kingdom practice.
• Radiofrequency ablation: Radiofrequency ablation is increasingly used. Results from multiple studies showed 60% to 85% long-term relief.[19] Radiofrequency ablation has a lower complication rate than surgical procedures but a higher cost because of the required commercial machine.

Surgical Treatment

If nonoperative treatment fails, surgical treatment is indicated for recalcitrant cases. The neuroma is excised using a dorsal or plantar approach. The dorsal approach is better tolerated by patients because the plantar scar can be painful.[20] A 3- to 4-cm incision is made just proximal to the involved webspace in the midline to prevent injury to the dorsal cutaneous nerves. The incision is deepened to the transverse metatarsal ligament, which is transected. The common digital nerve is identified in the proximal portion of the wound and traced distally to its bifurcation, and any soft tissue adhesions, if present, are released around the nerve. Nerve decompression or neurolysis is then achieved. Some surgeons finish without any further intervention on the nerve itself. Results from the literature indicate satisfactory outcomes with decompression alone, and this does not preclude future intervention.[21] 

To intervene on the nerve, the common digital nerve is cut proximal to the metatarsal heads and traced distally past the bifurcation, where both branches are transected. Some surgeons suture the cut ends of the nerve to the side of the metatarsal or one of the intrinsic muscles to prevent the formation of a painful stump neuroma. As little plantar fat as possible should be removed. A postoperative shoe is worn until the sutures are removed between 14 and 21 days, and a compressive wrap is recommended for 6 weeks.

The plantar incision, either linear or transverse, is mainly reserved for recurrent neuromas, multiple neuromas, or when the patient has a proximal focal tender trigger point for neuralgia. The plantar approach reduces the rate of missed neuroma and does not require an incision of the transverse metatarsal ligament. The plantar approach permits a more direct exposure of the nerve and allows more proximal nerve resection. The artery and vein can be better visualized and preserved. The main disadvantages are painful plantar scars and plantar keratosis, which occur in about 5% of patients.[22]

Neurectomy: Neurectomy remains the standard treatment when conservative measures fail, with a success rate of 75% to 85%. Risks include recurrence with stump neuroma and numbness in the toes, which is expected and usually well tolerated.

Decompression: Decompression, including intermetatarsal ligament release, is becoming more popular as a first surgical option. The advantage of decompression is nerve preservation with less postoperative numbness.

Postoperative recovery: Return to normal shoes typically occurs in 2 to 4 weeks, and full recovery typically occurs in 8 to 12 weeks. 

Differential Diagnosis

The differential diagnosis of Morton neuroma includes:

• Metatarsal stress fracture
• Hammertoe
• Rheumatoid arthritis or other autoimmune arthritis
• Osteoarthritis
• Malignant neoplasm or tumor
• Ganglion cyst
• Foreign body
• Plantar wart
• Plantar hyperkeratosis
• Fat pad atrophy
• Plantar plate rupture or injury
• Flexor tendinitis
• Metatarsophalangeal joint sprain
• Bursitis
• Distal plantar fasciitis
• Plantar fibroma
• Repetitive stress injury without stress fracture
• Plantarflexed metatarsal
• Exostosis
• Diabetic or other peripheral stocking-glove neuropathy
• Referred neuritis from the spine or sciatic nerve
• Tarsal tunnel syndrome with distal manifestation

Prognosis

Conservative Approaches 

Conservative approaches have shown varying degrees of effectiveness.[23][24] Footwear changes, activity modification, and pharmacotherapy are often used to minimize pain and lessen symptoms. Results from studies suggest that using multiple strategies can be more effective.[25] For example, findings from a systematic review and meta-analysis of nonsurgical approaches compared both noninvasive methods, including manipulation and mobilization, wider footwear and metatarsal padding, extracorporeal shockwave therapy, and varus or valgus wedges, and invasive methods, including corticosteroid injections, sclerosing injections, radiofrequency ablation, cryoneurolysis, and botulinum toxin injection. The results from the analysis found that corticosteroid injections, manipulation, and mobilization had the strongest evidence for pain reduction.[26]

Surgical Intervention

Results from various papers showed success rates after surgical treatment.[27][28][29][30] Kasparek et al evaluated 81 patients and noted excellent subjective results in 45% and good results in 32%. Approximately 8% of patients experienced a poor outcome.[27] The question of whether to perform neurolysis or neurectomy is debatable; results from one study found that neurolysis yields satisfactory results overall; however, in the presence of a pseudotumor or a markedly thickened nerve, neurectomy may be a more viable option.[31] Furthermore, a systematic review and meta-analysis of 35 articles, including 2998 patients with Morton neuroma, compared injection therapy, both alcohol and nonalcohol, neurolysis, and neurectomy. Results from the analysis found that 43% of patients noted complete pain relief after injection therapy, 68% were pain-free after neurolysis, and 74% were pain-free after neurectomy.[32]

Small neuromas measuring 5 to 6 mm or less have a good prognosis with conservative care, whereas large neuromas greater than 8 mm are more likely to require surgical intervention. Long-term recurrence after surgical treatment occurs in 10% to 20% of patients, depending on the technique. Chronic disease may produce persistent altered sensation, transfer metatarsalgia, or ongoing neuropathic pain, although ongoing neuropathic pain is rare.

Complications

Complications include:

• Chronic pain or complex regional pain syndrome
• Recurrence of the deformity because of inadequate excision or formation of a true neuroma or stump neuroma after excision of the Morton neuroma
• Complications related to surgical treatment, including infection, pain, and bleeding 
• Complications associated with corticosteroid injections include skin or fat pad atrophy and skin discoloration
• Hammertoes or deviated toes are caused by damage to the intrinsic muscles of the forefoot, including the interossei and lumbricals

Deterrence and Patient Education

Patient education should emphasize realistic expectations. Patients should be educated about the variable success rates of physiotherapy, activity modification, appropriate footwear use, and other modalities, such as injections and cryotherapy. When a surgical procedure is being considered, a significant minority of patients report worsening pain after the procedure.[27]

Pearls and Other Issues

If proximal resection is inadequate or the nerve fails to retract, the neural stump can become enlarged and bulbous. The neural stump may also adhere to the adjacent bone and soft tissue, causing traction neuritis. Traction neuritis can cause pain and tenderness in the webspace of previous neuroma excision at or proximal to the metatarsal heads. The clinical examination, investigations, and nonoperative treatment are the same as for a primary neuroma. For surgical treatment, both dorsal and plantar incisions are recommended. The dorsal incision must be extended proximally to visualize the stump; however, exposure can sometimes be difficult. The plantar approach provides better exposure and allows easier identification and resection of the nerve. Importantly, a preexcision local anesthetic block is necessary because general anesthesia alone is rarely adequate for neuroma surgical procedures.

Enhancing Healthcare Team Outcomes

Morton neuroma is first treated nonsurgically with an interprofessional team of healthcare professionals, including a podiatrist, orthopedic surgeon, sports medicine clinician, nurse practitioner, and primary care clinician. Patients may require pain medication, but the key intervention is to change footwear. The patient should wear appropriate, well-padded, nonconstrictive footwear. Patients with obesity may benefit from weight loss, and a dietary consultation is often appropriate. The patient may also benefit from physical therapy, warm compresses, and ice.[33][34] 

Outcomes

Most patients with Morton neuroma have improvement with nonsurgical treatment. Some patients may require a surgical procedure. After a surgical procedure, pain may recur in the area. Key factors in reducing recurrence are proper footwear and weight loss.[35][36]

Review Questions

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References

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Disclosure: Michael Dixon declares no relevant financial relationships with ineligible companies.

Disclosure: Usama Munir declares no relevant financial relationships with ineligible companies.

Disclosure: Dawood Tafti declares no relevant financial relationships with ineligible companies.