by Last updated on December 15th, 2023 at 11:47 am
Dr Thomas George Morton is credited with identifying what is now known as Morton’s Neuroma. His son also called Thomas Morton in 1892 confirmed his father’s observation. Morton’s Neuroma is also known as metatarsalgia because it generally presents between the metatarsal (the long bones of the feet). It is also referred to as entrapment syndrome, Morton’s foot or Morton’s disease.
Morton described it as an entrapment neuropathy (nerve damage). It affects what is called the plantar digital nerve(s) found between the metatarsal. The fibrous sheath which surrounds and protects the nerve thickens into a benign tumour and hence a neuroma develops.
Is Morton’s Neuroma a tumour?
Whilst Morton’s Neuroma is a tumour, it is benign. This means it is not cancerous. It is a cluster of cells which do not have the necessary ability to invade other cells. That is, they cannot metastasize unlike malignant tumours that can go anywhere they like. So you can stop worrying about your neuroma being cancerous. It can be serious if it is causing you debilitating pain, as naturally one would try to walk differently thus putting pressue on other areas. This can complicate matters more by causing other foot related injuries.
What is Morton’s Toe?
Many people confuse Morton’s Neuroma with Morton’s Toe. However, Morton’s Toe is a forefoot condition in which the second toe is longer than the big toe. It is not that rare, believe it or not, and it can cause discomfort akin to that of Morton’s Neuroma. In some cases it may even be a contributing factor to the development of Morton’s Neuroma. Nevertheless, a longer second toe is not considered pathological. In fact, the second toe is supposed to be longer. This is based on toe length formula which suggest that the 2nd, 1st, 3rd, 4th and 5th toes should be ranked in that order based on their length.
What are the symptoms of Moton’s Neuroma?
The symptoms of Morton’s Neuroma may include, but are not limited to, tingling sensation in the space between the toes; predominantly between the 3rd and 4th metatarsal. One reason for this is that great force is transmitted to that area of the feet during walking and running. Further, Individuals who have developed Morton’s Neuroma sometimes feel as if they’re standing on a pebble in their shoes. Some have experienced a burning pain in the ball of their feet that may radiate into the toes.
The toes may also become numb or present with a tingling sensation. Moreover, the pain is usually exacerbated by walking or doing exercise that involves moving. Keep in mind that these are some of the more common symptoms and a neuroma may not always present in a similar way. Morton’s Neuroma is very unlikely to present with outward signs and symptoms and it generally gets worse over time (Bhatia and Thompson, 2020).
Who gets Morton’s Neuroma?
Anyone in any age group can develop a neuroma but it is most common in the age group of 40-50 years. This may be due in part to the sedentary life style which inevitably leads to an increased BMI of this population group. Also 3 out of every 4 people diagnosed with Morton’s Neuroma are women. This is mainly caused by the type of shoes women wear and less to do with their anatomical make up.
Remember that it is not just middle age women who gets a neuroma, men and young adults can also develop a neuroma. Athletes, especially runners, also get the condition. This is because of the impact the feet has to undergo when participating in athletic activities.
Can you get Morton’s Neuroma in both feet?
The pathology can develop in both feet, if the predisposing factors are present in both. Nevertheless, its more likely to be unilateral i.e. affecting one side.
What is the cause of Morton’s Neuroma?
The neuroma is caused by irritation of the inter-digital nerve. The inter-digital nerve is found between the metatarsal heads. The nerve mainly gets irritated at the bifurcation (the place where the nerves are joined). The nerve becomes irritated by pressure or force which causes inflamation, leading to swelling especially when more pressure is applied to the area. Stopping or removing the offense to the nerve may resolve the issue but often more clinical intervention is needed.
Morton’s Neuroma diagnosis
It can be diagnosed by any of the symptoms mentioned earlier. Such as, tingling and numbness in the ball of the foot or toes. Threre is also the feeling of standing on a pebble, burning sensation in the ball of the foot and pain when walking or exercising. To rule out fracture of the bones an X-ray is generally taken.
Can you see a neuroma on X-ray?
No, a neuroma will not show up on an X-ray, similar to muscles and other soft tissue which don’t. Keep in mind that pathology such as an inflamed tendon, bursa and arthritis of the metatarsal phalangeal joint can also present as a neuroma. Additionally, nerve compression further up the leg or back may also present itself similar to Morton’s Neuroma. For this reason a very good knowledge of the anatomy of the feet and the different conditions that can affect it is paramount and your clinician needs to be competent to aid in diagnosis.
Morton’s Neuroma Test
Along with the physical examination, the Mulder Click or Squeeze Test is used to help determine if a neuroma is present. It is done by using one hand to squeeze all five toes together while simulataneulsy, using the thumb and fingers to compress the top and bottom of the foot, directly above where the pain is. If a neuroma is present, the patient should experience pain, which would make the test positive. Sometimes the test illicit an audible click, which is the tumour sliding between the heads of the metatarsal.
What can be done for Morton’s Neuroma?
The first thing to do if you think you have a neuroma, is to rest. This may be very difficult to do, especially if you have to be on your feet for work. Nevertheless, the involved foot should be rested as much as possible as it is an effective treatment of Morton’s neuroma. Try to avoid narrow footwear and those with high heels. Your footwear should be wide and deep enough and it should have a fastener to prevent the toes from clawing for grip when walking.
Footwear with a rocker bottom or just a toe rocker may help to off load the forefoot. Anti-inflammatory medication such as Ibuprofen, either the tablets or the gel may help in the short term. Keep in mind too that prolonged use of the tablet can irritate the stomach. As with any medication, make sure you consult a qualified health professional before use.
Using an orthotic
An orthotic device to off load the neuroma and correct any biomechanical abnormality may help. If you are overweight, it’s of utmost importance in the medium to long term to get to an appropriate weight. Weight gain put pressure on the feet and hence pressure to the neuroma particularly during gait.
Also, if your daily routine involves carrying loads such heavy hand bags or loads related to work, it would be helpful to modify such activities greatly or desist completely from doing them. A metatarsal pad or dome is sometimes issued by practitioners, as it helps to splay the metatarsal heads taking pressure off the neuroma.
Assessment and rehabilitation
A Podiatrist (foot specialist) or an appropriately qualified medical practitioner may carry out a musculosketal assessment to see if there are any compromises. Reduced range of motion at the ankle (ankle equinus), whether osseous or fibrous can lead to forefoot pathology.
The two main culprit here are tight calf muscles and/or tibialis posterior muscle weakness. In both cases during gait, excess pressure or force will be place on the forefoot due to the compensation that’s needed to ambulate. Calf stretching and tibialis posterior strengthening exercises can be very helpful and can be prescribed by your medical practitioner.
Non-conservative treatment options
All the treatment options mentioned thus far can be deemed as conservative treatments and they are the starting point generally for most foot related pain. Having said that, injection therapy and surgery may be an option if all else fails. Steroid is anti-inflammatory and many practitioners inject it in the vicinity of the neuroma to reduce inflammation and thus pain. The injected fluid can move around and for this reason some practitioners place the feet in a removable total contact cast to improve clinical outcome.
Corticosteroids injection
Further, steroids can damage soft tissue and for this reason many practitioners limit the number of injection to only three appropriately spread out. Another type of injection that practitioners use is alcohol sclerosing injection. This reduces the size of the neuroma. About 4–7 injections appropriately spread out are generally given.
Radiofrequency ablation
Radiofrequency ablation is sometimes used to treat Morton’s Neuroma. This involves doing an ankle block and injection into the neuroma with anaesthetic. An ultrasound guided probe is inserted to the neuroma and radiofrequency pulses are then applied to the neuroma. This causes thermal ablation of the affected part of the nerve, reducing inflammation and pain over a few weeks. It’s a new treatment for Morton’s Neuroma that’s worth speaking to your care provider about.
Surgery
Surgery mainly involves excising or removing the offending part of the nerve. Generally, the results from surgery can be good and satisfactory for patients. However, surgery is not without risks and patients with multiple neuroma have worse outcomes. Surgery can lead to deficit in the sensory nerves and some foot and ankle disorders are common. Nevertheless, this does not affect patient’s satisfaction.
Can acupuncture help with Morton’s Neuroma?
There is not enough evidence either from random control trials or systematic reviews in the major journals for the treatment of Morton’s Neuroma. This is not to say acupuncturists and other clinicians may not have had success with acupuncture for Morton’s neuroma.
Furthermore, studies have shown that for some chronic pain, acupuncture is better than placebo. The Bafeng Acupunture Points have been used for peripheral neuropathy and may be beneficial to Morton’s Neuroma. If you are interested in this mode of treatment make sure you see a qualified registered clinician.
How long does Morton’s Neuroma treatment last?
If you have had Morton’s Neuroma surgery, it can take an average of about 6 weeks to heal. It’s important too, to keep in mind that healing times varies from individual to individual and in some cases it could take longer depending on how compliant patients are to the advice given by their practitioner.
Rehabilitation takes time and should be done until full healing is achieved the foot pain. Finally, sitting and waiting for the neuroma to go away may not be the best option. It is always a good idea to seek help if you are worried about something medical.
References
- Bhatia, M and Thomson, L. (2020). Maneesh Bhatia∗ and Lauren Thomson. NIH. 11(3), pp.406-409. [Online]. Available at: 10.1016/j.jcot.2020.03.024 [Accessed 15 December 2023].
