Morton’s Neuroma

Posted on 14/03/2018 by admin — No Comments ↓

What is Morton’s Neuroma?

A Morton’s Neuroma is a benign (non-cancerous) lump or mass that grows out from the nerve tissue. Morton’s neuroma, a common cause of foot pain in adults, is a thickening of tissue on the nerve that runs between the metatarsal bones (the bones of the toes).

The most common place for it to occur is between the third and forth toes. Less often, it happens between the second and third toes. It very infrequently occurs between the first and second toes or the fourth and fifth toes. Morton’s neuroma is much more common in women, who are more likely than men to be wearing shoes that are narrow-toed, high-heeled and/or tight.z

morton's neuroma picture 1

Causes

Morton’s neuroma can be caused by wearing poor fitting footwear. Hard-soled shoes, shoes with a narrow toe that compress the toes together, tight shoes and shoes with high heels are most commonly to blame for this problem.

Morton’s neuroma is more common in people whose foot structure varies from normally anatomy. Abnormally arched feet, with either too low an arch (flat-footedness) or too high an arch, are more likely to grow a neuroma due to the unusual and constant pressure on the ball of the foot.

Trauma is another common cause of Morton’s neuroma, especially from athletic injuries in runners and dancers.

Symptoms

Pain is the predominant symptom of Morton’s neuroma. The pain is felt between the toes or on the ball of the foot, especially while walking. Stopping activity and resting will typically provide relief from the pain. Many find that taking off their shoes and massaging the painful area can be helpful.

Some people report a “tingling” sensation or numbness in the area around the neuroma. Others feel like there is a pebble or other small object stuck in their shoes. Sometimes, a burning sensation is the most bothersome symptom. There can also be an overall or general feeling of discomfort.

Pain, burning, numbness and tingling are not specific to Morton’s neuroma. These symptoms may mimic the symptoms of other conditions like bursitis (swelling of the small sacs that cushion areas around the ones and joints), sprains (full or partial tears of a ligament from the bone), strains (tears in the muscles or tendons) and microfractures (small breaks in the bones), among others.

Diagnosis

Any foot pain, especially pain that persists and/or does not respond to self-treatment, should be examined by a podiatrist (a doctor who specializes in the care and surgery of the foot) or surgical specialist in orthopedics or sports medicine. In addition to the doctor’s examination, imaging studies may be ordered.

X-rays and ultrasound can aid not only in making a diagnosis of Morton’s neuroma, but also in excluding other conditions that might be causing the same symptoms. More sophisticated imaging modalities, such as MRI (magnetic resonance imaging) and CT (computerized tomography) scans, are more costly than X-rays and ultrasound, and less accurate in diagnosing neuromas.

Prevention

As Morton’s neuroma is most commonly caused by mechanical trauma, avoiding practices and conditions that increase the risk of trauma are essential in prevention.

While doing athletic activities that put excessive pressure on the ball of the foot, it is important to wear well fitting, supportive footwear appropriate to the activity.

Limiting the frequency and duration of wearing high heels can help prevent neuromas from developing. Wearing footwear that has a narrow toe or inadequate cushioning on the ball of the foot should be avoided.

Treatment

Whether Morton’s neuroma is treated with or without surgery depends largely on the severity of the symptoms and size of the neuroma. Avoiding surgery is ideal, but if the symptoms do not respond favorably to non-surgical therapeutic measures, surgery may be the best option for relief.

The non-surgical approach to treatment may require up to six months for full recovery. Taking pressure off of the ball of the foot by resting and wearing properly fitted shoes is essential. Sometimes, specialized or custom made shoes or inserts may be recommended.

Footwear in general should be well padded, with low heels and be shock absorbent (shock absorbency is an important feature of a lot of athletic footwear, especially running shoes). Shoes should have a wide toe to prevent additional compression of the toes, which will only exacerbate the severity of and pain from the neuroma.

Pain relieving medications can be used. NSAIDS (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen will help with pain management and reduce inflammation. If NSAIDS do not provide adequate relief, or if NSAIDS cannot be taken, an injection of a combination of cortisone and an anesthetic (most often lidocaine) can be administered. This injection can provide long term relief, for up to three months.

When surgery is necessary, it is most often done on an outpatient basis, in the doctor’s office. The procedure requires the removal of the nerve that is affected by the neuroma. Surgery is permanently successful 80-90% of the time. Recovery takes only a few weeks, but requires the wearing of special shoes with stiff soles for a minimum of two weeks.

At the three to five week point after surgery, physical therapy is started to strengthen the muscles of the foot and increase the range of motion. Return to higher impact athletic activities may take a full six weeks.

Other, less invasive procedures, such as ablation, are under investigation but not yet routinely used in the surgical treatment of Morton’s neuroma.

Shoes for Morton’s Neuroma

The kind of shoes you wear and how you wear them play a part in preventing and treating Morton’s neuroma. If you wear poorly fitting shoes, it can make the forefoot to overload leading to Morton’s neuroma. The overloading of the forefoot occurs when the metatarsal bones over-ride on one another because of a forceful impact, and this can happen when you walk in high-heeled shoes that have narrow toe boxes.

When the overloading occurs and the subsequent overlapping, it can cause entrapment of the intermetatarsal nerve hence leading to formation of neuroma. It’s not possible to alter the anatomical features of the foot, however, research holds that wearing the correct footwear and in the right way can help reduce the formation of Morton’s neuroma.

Shoes Associated With Increased Risk

There certain things in your footwear that will make you prone to having Morton’s neuroma. According to a publication in Foot & Ankle International, it suggests that if you wear shoes with the following characteristics, you may likely develop neuroma.⁶

Shoes with narrow-toe box
Shoes that are ill-fitting or do not fit properly
Using high heels frequently
Having inadequate padding or worn out sole on your shoe’s base

Recommended Shoes

Wearing correct shoes may help manage the discomfort and pain you experience if you have Morton’s neuroma. Again, removing the entrapment source for instance, the narrow toe-box shoes may help to restore the natural anatomy of the foot. Wearing correct footwear in itself isn’t a cure, and it should work along with conservative treatment and other forms of treatment.

If you are seeking for shoes for Morton’s neuroma, you want to ensure that:⁷

You get the ones that are working with you and not against you. Try shopping for the shoes in the evening because it is the time when the feet are bigger. Get shoes that allow a toe room of about a half-inch. When trying them, make sure you feel how they fit the foot – walk and lightly jog in the shoes.
You have shoes that have proper arch support. This helps to offset the pressure or strain that is created when you are in the shoes, especially for people with active lifestyle. The arch support acts as shock-absorbers.
Have the right-size of shoes. You may not know it, but many people have different sizes of the right and left foot. For instance, 80 percent of individuals have a slightly smaller right foot than the left foot. It may not be necessary that you have different sizes of the shoes, however, you should make sure they fit properly. Sometimes, you may need custom-made shoes to prevent straining of the connective tissue of the foot.
Have shoes with wide toe box. To help prevent having direct impact created by force or pressure on the forefoot, you want to get shoes that have wider toe box. Your feet should fit the toe box at end of the day because this is the time when the feet tend to swell.
Have shoes that are very low or with zero drop. These are flat shoes that will not put pressure on the metatarsal bones and the nerves.
Get shoes that have adjustable fitting. You may want to have shoes with straps and laces that you can adjust to fit your feet. However, remember that too roomy or too narrow shoes can equally be bad.
Get custom-orthotics. These help to correct problems of gait and stance while also providing cushioning and padding to offset pressure on the inflamed connective tissue.
Do away with old, worn-out shoes. The pair of shoes you buy won’t last forever, so if you think that the tread and heels are worn out, you can get another pair to avoid worsening the problem or causing more pain.

Morton’s Neuroma Surgery

If conservative treatment methods have failed, surgery may be preferred. The surgical procedure involves removal of the nerve that has been affected within the foot’s ball. The surgeon will remove the nerve extending back so that it will not continue becoming impinged. Similarly, a surgeon may prefer performing another type of surgery that is intended to release the tight ligament encasing the nerve. At times though, this type of surgery may not be very effective. The best surgery for Morton’s neuroma is neurectomy.⁵

Recovery time for Morton’s surgery

After having neurectomy, it only takes a few weeks before a patient can walk on the operated foot. Typically, it will take up to 4 weeks for an individual to recover and be able to walk, but again this depends on how fast the operated area heals. The patient may be able to wear shoes after about 2 to 6 weeks following the surgery. The time it takes to heal may be affected by things like poor nutrition, age, smoking, or some medical problems.⁵

Morton’s Neuroma Pads

A patient may use Morton’s neuroma pads or inserts to help in supporting the arch and provide space between their toes. The pads also help relieve pressure that may be put on the pinched nerve. Metatarsal pads help to place the forefoot in its natural resting position and keeping the heads of the metatarsal bones supported. If you wear high heels much more, you may find these pads helpful because they reduce the pain and burning experienced within the ball of the foot.⁸

When applying the metatarsal pad, make sure that you take the insole out to ensure proper placement. You may think that the pad is placed on the actual ball where pain is experienced, however, this is not the case. To place the pad, press on the foot’s ball (the padded area found below the toes on the underside of the foot). See how you feel – make sure that you feel like there is a wide, flatter area right on both of the toe bones- it’s the metatarsal head.

Next, with the finger resting on the foot’s bottom and on the metatarsal head, you take the other hand and use it to bend the toes. When doing this, you will feel an area where there are two bones meeting – and these are the joints. Your pad should go underneath those joints you are feeling.

Practically, your met pad is in the middle area of the foot. The goal of positioning the pad there is to make sure that the whole arch within the metatarsal area is lifted and the toes drop downward. This way, it will help release the pressure.⁸

morton's neuroma pads pictures

References

2017 ICD-10-CM Diagnosis Code G57.60. (n.d.). Retrieved March 22, 2017, from http://www.icd10data.com/ICD10CM/Codes/G00-G99/G50-G59/G57-/G57.60
Espinosa, N. Peripheral Nerve Entrapment Around the Foot and Ankle. In: Miller MD, Thompson SR, eds. DeLee and Drez’s Orthopaedic Sports Medicine. 4th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 113.
Fields, K. B. (2016, November 1). Evaluation and diagnosis of common causes of foot pain in adults. March 22, 2017, from https://www.uptodate.com/
Neuromas | Foot Health | Learn About Feet | APMA. (2017). Retrieved March 22, 2017, from http://www.apma.org/Learn/FootHealth.cfm?ItemNumber=987
Foot Neuroma Surgery (Morton’s Neuroma). http://bunionsurgeryny.com/procedures/foot-neuroma-surgery-mortons-neuroma/
Efficacy of corticosteroid injection versus size of plantar interdigital neuroma. https://www.ncbi.nlm.nih.gov/pubmed/22995258
What shoes should I wear for Morton’s neuroma? https://www.mortonsneuroma.com/what-shoes-should-i-wear-for-mortons-neuroma/
The #1 Mistake with Metatarsal Pad Placement. https://www.theinsolestore.com/blog/1-mistake-with-metatarsal-pad-placement/