Morton’s Neuroma is a painful foot condition caused by the thickening of tissue around a nerve, most commonly between the third and fourth toes. Patients often describe the sensation as walking on a pebble or a bunched-up sock, accompanied by sharp, burning pain or numbness in the ball of the foot. Treatment follows a progressive approach, starting with the least invasive methods and advancing toward more definitive solutions if earlier steps do not provide sufficient relief.
Conservative Management and Lifestyle Changes
The initial treatment focuses on simple, non-invasive adjustments, starting with footwear modification to reduce nerve compression. Shoes with a wide toe box are recommended to allow the forefoot to spread naturally, alleviating pressure on the nerve between the metatarsal bones. Low-heeled shoes also help, as high heels shift excessive body weight onto the ball of the foot, exacerbating compression.
Over-the-counter metatarsal pads and inserts strategically redistribute pressure. These pads are placed just behind the ball of the foot to slightly lift and separate the metatarsal heads. This action reduces the pinching force on the inflamed nerve, decreasing pain during weight-bearing activities.
Rest and the application of ice help manage acute symptoms of inflammation and localized pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can also temporarily reduce inflammation and discomfort. These conservative measures are designed to calm the irritated nerve and often provide partial relief for many patients, sometimes lasting up to a year.
Minimally Invasive Medical Interventions
If conservative management fails to provide lasting relief, the next step involves minimally invasive procedures administered by a healthcare professional. Corticosteroid injections are often the first specialized intervention, delivering anti-inflammatory medication directly to the neuroma site. The corticosteroid reduces swelling and irritation of the thickened nerve tissue, often leading to significant pain reduction within days.
While effective for short- to medium-term relief, the benefits of corticosteroid injections can diminish over time. Repeated injections are limited due to the risk of side effects, such as fat pad atrophy or tendon weakening. Ultrasound guidance is often utilized during the injection process to ensure accurate placement of the medication.
Another type of injection is chemical neurolysis, often performed using an alcohol sclerosing solution. This procedure involves injecting a concentrated alcohol solution, mixed with a local anesthetic, into the tissue surrounding the neuroma. The alcohol acts as a sclerosant, causing chemical damage that breaks down the nerve tissue, leading to degeneration and atrophy.
This neurolysis procedure is performed in an office setting and usually requires a series of multiple injections, often ranging from three to seven sessions. The goal is to eliminate the nerve’s function, and it has reported success rates of up to 82% in some studies. Custom-molded functional orthotics are prescription devices designed to precisely control the foot’s biomechanics, further stabilizing the metatarsal area to prevent nerve irritation.
Surgical Options for Definitive Relief
For patients whose symptoms persist despite conservative care and minimally invasive interventions, surgical options offer the most definitive solution. The two main surgical approaches are neurectomy and nerve decompression. Neurectomy, or surgical excision, is the most common procedure and involves physically removing the portion of the nerve that has thickened into a neuroma.
This procedure is typically performed through an incision on the top of the foot, which minimizes post-operative scarring on the weight-bearing surface. Neurectomy has a high success rate, often providing long-term relief for most patients. A significant consequence, however, is permanent numbness in the affected web space between the toes, since the sensory nerve is removed.
A less invasive surgical alternative is nerve decompression, or neurolysis, which focuses on relieving pressure on the nerve rather than removing it. This is accomplished by cutting the deep transverse metatarsal ligament, which binds the metatarsal bones and compresses the nerve. Decompression is preferred when nerve thickening is minor, as it aims to free the nerve from its entrapment.
Recovery from either surgery typically involves wearing a protective surgical boot for four to six weeks, with a full return to normal activity taking 8 to 12 weeks. A potential complication following neurectomy is the formation of a stump neuroma, which occurs when the cut nerve end attempts to regenerate and forms a painful mass of scar tissue. Surgeons take care to bury the nerve end in muscle or bone to minimize this risk.