Mortons Neuroma

Morton’s neuroma is a thickening of nerve tissue that occurs in the foot as a nerve passes underneath a ligament between the third and fourth metatarsals (toes). This condition can also be referred to as intermetatarsal neuroma. The thickening occurs as a result of irritation, compression or trauma to the nerve. This then leads to enlargement of the nerve causing irreversible nerve damage. Morton’s neuroma is seen 8-10 times more in women than men

There are no outward signs of morton’s neuroma and symptoms tend to appear gradually at first while doing certain aggravating activities or wearing narrow-toed shoes. These will go away when the external stimulus is removed. Over time the symptoms may progressively worsen and can continue for an extended period even after the aggravator has been removed and the temporary changes to the nerve become permanent.

Some people may feel tingling or numbness in the foot but the most common symptoms is an abnormal feeling that something is ‘stuck’ under the ball of the foot or pain/burning in this area that may radiate from the ball of the foot towards the third and fourth toe. This pain can often be described as sharp, electric or burning.

Morton’s neuroma is caused by irritation, pressure or injury to the nerve between the 3rd and 4th toe. This can be linked to:

• Foot problems such as flat or high foot arches, bunions and hammer toes. This affects the biomechanics of your foot and can increase the pressure in areas that wouldn’t normally have overt pressure on so can often predispose you to issues in the lower limb.
• Wearing tight, pointy or high-heeled shoes. These push your toes into a narrow toe box and can cause increased pressure between the toes, where the nerve responsible for Morton’s neuroma lies
• Doing a lot of activities that puts pressure on the feet such as high impact sports. (running, athletics) or have tight fitting shoes (skiing, rock climbing).
• Direct Injury or trauma to the area.

To diagnose Morton’s neuroma, a thorough case history will be taken of your symptoms and a physical examination of your foot will be carried out. The examiner will attempt to reproduce your symptoms by manipulating the foot and putting pressure between the metatarsals.

Occasionally, some imaging may be necessary to rule out joint inflammation, arthritis or stress fracture. These are often seen on X-Ray.

If these are ruled out, an ultrasound is consequently used to help rule in a neuroma as they are often visible on this type of imaging.

An early diagnosis is the most effective way of lessening the need for more invasive treatments such as surgery when permanent damage has occured to the nerve. If intervention is carried out early, most pain experienced is reversible as the nerve hasn’t been inflamed enough for it to become permanently damaged in such a way that you experience pain once external irritators are removed.

It is recommended to try conservative treatments initially:

• Wear well fitting shoes with adequate space around the toe box with a soft sole and a low heel.
• Try wearing foot pads or insoles that help reduce the pressure on the nerve in the painful area of your foot.
• Activity modification – reduce high impact activities for a few weeks to reduce repetitive stress and compression on the nerve.
• Applying ice for a maximum of 10 minutes to help reduce the inflammation
• NSAIDs (Non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen can help reduce swelling and relieve pain – any questions regarding medication then please speak to your local pharmacist or GP for advice.
• Try to lose weight if you are overweight, this will result in less pressure going through your feet.

Other non-invasive treatments can include:

• Radiofrequency ablation – the use of heat to treat the nerve. A probe is inserted at the base of one of the toes and into the affected nerve. An electrical current is passed through the nerve to destroy the affected portion of the nerve with radiofrequency heat energy.
• Shockwave therapy – extracorporeal shockwave therapy involves the administration of shockwave to reduce the nerve enlargements, this works by causing microtrauma to the tissues and the body responds by sending more blood and releasing chemicals to the local area to repair and heal the tissues.
• Injections – local corticosteroid injections can help reduce swelling and inflammation of the nerve.

If you have severe symptoms or other treatments aren’t working, surgical intervention may be required.

• Decompression surgery- this type of surgery works by reducing the impact of the compression of nearby structures such as the ligament binding the bones around the nerve. This then allows the nerve to heal once the mechanica pressure of the nerve is removed and symptoms should subside.
• Removal of the nerve (Neurectomy) if all other treatments fail, although there is a 20-30% chance of it re-growing (stump neuroma). This doesn’t treat the underlying issue that caused morton’s neuroma to occur in the first place so is only performed once the swelling is too seere

Once the neuroma has formed it won’t go away. The pain that you can experience however, can improve or dissipate completely. The earlier you get a diagnosis and start treatment, the better chance you have of avoiding severe damage and having better outcomes.

In advanced cases the pain can return as you spend more time in aggravating situations such as high impact activity and not wearing appropriate shoes.

Some people can be prone to developing this condition due to characteristics of their feet. It is recommended that if you have flat/high arches, bunions or hammer toes that you have these assessed by a registered podiatrist. This will enable you to receive custom orthotics to reduce the irritation of the nerve between your toes and also to maintain and support the fine structures within the foot.

The main goal with the following exercises is to restore the normal function of your foot by restoring flexibility and promoting overall strength and balance and increasing circulation to the area in order to expedite your own healing capabilities. This all leads to better foot biomechanics which should reduce the strain on the injured area.

Pay attention to your symptoms and stop if they get worse if you develop burning pain throughout.

Toe curl with towel (15-20 reps. 3 times daily)

• Sit on a chair with foot affected by Morton’s Neuroma resting flat on a towel on the edge closest to you
• Slowly bunch up the towel in your direction by curling your toes – attempting to scrunch the front edge of the towel closer to your foot
• Ensure you keep your heel firmly on the ground
• Replace the towel and repeat

Standing calf stretch on wall (3 sets. 2 times daily)

• Put the leg with the affected foot behind the other with the heel on the floor and toes pointing directly forwards. Approx 2 ft away from the wall.
• Place both hands on the wall
• Extend your knee of the behind legs while pushing your hips forward (without bending the knee) until you feel a stretch in your back calf.
• Hold this for 30 seconds

Foot roll

• Using a lacrosse ball or textured massage ball
• Sit in a chair and place the ball under the ball of the affected foot.
• Roll the ball underneath for 10-20 repetitions anticlockwise then repeat clockwise.
• Put as much pressure that you can tolerate without tensing up and increasing the pain.
• Continue this for 1-5 minutes, stop when the foot feels relaxed and the pain has decreased.
• To increase the effectiveness, you can do this with a frozen water bottle or place the balls in the freezer prior for a cooling sensation also.

Big toe strengthening (10-15 reps. 3 sets)

• Wrap a resistance band around your big toe and hold the opposite ends with both hands
• Let the hand pull the big toe up
• Push the big toe back down against the resistance
• Keep the movement slow and controlled in both directions and within your relative comfort range.

Plantar fascia stretch with resistance band (10-15 reps. 3 sets)

• Wrap a resistance band around the bottom of your forefoot and toes and hold the opposite ends with both hands
• Pull with your arms so that you gently pull your forefoot and toes towards your shin
• You should feel a small pull along the bottom of your foot

It is recommended to seek further healthcare advice if:

• Your pain hasn’t improved with self-treatment for 2 weeks.
• You have any severe tingling or numbness in your foot.
• The pain is severe and is stopping you doing your normal activities.
• You have diabetes.
• The pain is worsening/not getting better.