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A Morton's neuroma, also called an interdigital neuroma, intermetatarsal neuroma or a forefoot neuroma, is a benign swelling along a nerve in the foot that carries sensations from the toes.
 
It is important to know that this isn't some cancerous growth and that the reason the nerve starts to swell is unknown. Problem is that, once swelling begins, the nearby bones and ligaments put extra pressure on the nerve, causing more irritation and inflammation which is causing burning pain, numbness, tingling and other abnormal sensations in the toes. This swelling usually develops between the third and fourth toes and other locations are rare. Important thing to know is also that it is rare for a Morton's neuroma to develop in both feet at the same time.

Incidence of the condition

Several researches done in the past have came to the conclusion that the condition is much more common in women than men, probably as a result of wearing high-heeled and narrow-toed shoes.  It is also much more common in obese people because being overweight also increases the risk of a Morton's neuroma. Highest prevalence of Morton's neuroma is found in patients aged 15-50 years, but the condition may occur at any age.

Symptoms of a Morton's Neuroma

When someone has a Morton’s neuroma, he or she will probably have one or more of these symptoms where the nerve damage in occurring:
  • Tingling, burning, or numbness
  • Pain
  • A feeling that something is inside the ball of the foot, or that there's a rise in the shoe or a sock is bunched up.
The progression of a Morton's neuroma often follows this pattern:
  • The symptoms begin gradually and at first- they occur only occasionally, when wearing narrow-toed shoes or performing certain aggravating activities.
  • The symptoms may go away temporarily by massaging the foot or by avoiding aggravating shoes or activities.
  • Over time the symptoms progressively worsen and may persist for several days or weeks.
  • The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.
Typically, the pain is relieved temporarily by taking off shoes, flexing toes and rubbing feet. Symptoms may be aggravated by standing for prolonged periods.

Possible causes of Morton’s neuroma

The fact is that experts don't understand exactly what causes Morton's neuroma. However- there are some theories that tried to explain the cause of the condition and most of them are considering injury to be the direct cause! The condition seems to occur in response to irritation, pressure or injury to one of the digital nerves that lead to toes. The growth of thickened nerve tissue is part of body's response to the irritation or injury. It is proven also that, in some cases, Morton's neuroma may result from abnormal mechanics of the foot. This includes the presence of different bunions, hammertoes, flatfeet or excessive flexibility. Certain activities carry increased risk of excessive toe deformities, such as prolonged walking, running, squatting, and ballet…
 
Factors that appear to contribute to Morton's neuroma include:
  • Wearing high-heeled shoes or shoes that are tight or ill-fitting, including those that box in feet and place pressure on toes
  • High-impact athletic activities, such as jogging, that subject your feet to repetitive trauma
  • Injury to your foot

Diagnosis of Morton’s neuroma

  • Detailed patient’s history
Every doctor should suspect that a patient has a Morton's neuroma based on the nature and location of her or his foot pain. That’s why- doctor should ask questions about shoes — what type of shoes a patient usually wears and whether these shoes have narrow toes or high heels. Differential diagnosis is easy! To rule out other causes of foot pain, doctor should ask questions about medical history, especially any history of arthritis, nerve and muscle problems or previous foot or leg injury.
  • Physical examination
To confirm the diagnosis, every doctor should examine patient’s feet. He should look for areas of tenderness, swelling, calluses, numbness, muscle weakness and limited motion. It is very easy to confirm the diagnosis by squeezing the sides of patient’s foot. Squeezing should compress the neuroma and trigger patient’s typical pain. In some cases, doctor will find numbness in the area between the affected toes. It is also important to know one thing- pain in two or more locations on one foot more likely indicates that the toe joints are inflamed rather than a Morton' neuroma.  
  • X-ray and MRI imaging
Sometimes, a foot X-ray may be ordered to make sure that there isn't a stress fracture, but it will not show the actual neuroma. If the diagnosis is in doubt, doctor should request magnetic resonance imaging (MRI) of the foot.
 

Differential diagnosis

There are some condition that should be mixed with this Morton’s neuroma and these may include:
  • Stress fracture of the neck of the metatarsal
  • Rheumatoid arthritis and other systemic arthritis conditions
  • Hammer toe
  • Metatarsalgia  
  • Neoplasm
  • Metatarsal head osteonecrosis
  • Freiburg osteochondrosis
  • Ganglion cysts
  • Intermetatarsal bursal fluid collections
  • True neuromas

Treatment of Morton’s neuroma

Every patient should know that in developing a treatment plan- foot and ankle surgeon will first determine how long does the condition last and evaluate its stage of development.  
For mild to moderate cases of neuroma, treatment options include:

Padding
It is proven that padding techniques provide support for the metatarsal arch, because it involves lessening the pressure on the nerve and decreasing the compression when walking. It could be very beneficial method!

Icing
Placing an icepack on the affected area helps reduce swelling. Ice is also beneficial to decrease the associated inflammation.

Orthotic devices
All patients will confirm- custom orthotic devices provided by foot and ankle surgeon provide the support needed to reduce pressure and compression on the nerve and sometimes –relieve pain completely!

Activity modifications
Activities that put repetitive pressure on the neuroma should be avoided until the condition improves. These include prolonged walking, running, squatting…

Changes in shoewear
It's important to wear shoes with a wide toe box and avoid narrow-toed shoes or shoes with high heels. This will significantly relieve pain and reduce risk for complications!

Medications

Several patients have reported that some nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

Injection therapy
If there is no significant improvement after initial treatment, injection therapy may be tried. Some simple analgesics or nonsteroidal anti-inflammatory medications may be used to relieve pain and inflammation! However, overuse of injected steroids can lead to a number of side effects, including weight gain and high blood pressure, so people usually receive only a limited number of injections.
 

Physical therapy

The physical therapist can help the physician in decisions regarding the modification of footwear, which is the first step to treatment. Every therapist should recommend soft-soled shoes with a wide toe box and low heel. High-heeled narrow non-padded shoes should not be worn; because it is proven that they aggravate the condition. A plantar pad is used most often for elevation. Other possible physical therapy treatment ideas for patients with Morton neuroma include:
  • cryotherapy,
  • ultrasound,
  • deep tissue massage,
  • stretching exercises

Surgical solutions

Most patients are confused because they don’t know when exactly is surgery needed? Well, it is simple- surgery may be considered in patients who have not received adequate relief from other treatments. Generally, there are two surgical approaches to treating a neuroma:
  • removing of the affected nerve
  • releasing of the affected nerve

Recovery period

Every patient should know that the length of the recovery period will vary, depending on the procedure or procedures performed. Regardless the type of treatment, every foot and ankle surgeon should recommend long-term measures to help keep your symptoms from returning.  

Possible surgical Complications

The surgical area contains very small blood vessels, nerves, and muscles and complications can occur.

Haematoma
Once the neuroma is removed, the empty space may fill with blood, resulting in a painful haematoma.

Infection
There is a risk for infection, necessitating careful monitoring by the podiatrist and patient. If the incision site becomes warm or red within a day or two after surgery, or if the patient runs a fever, the surgeon must be contacted immediately.

Recurrence of the pain
Every patient should know that the recurrence is another very common possibility. Problem is that the stump of nerve remaining after resection can begin to grow again. If this occurs, the nerve grows in width and length, creating a burning pain that can be treated by injection or further surgery.
 

Some useful tips for the patients

  • Take anti-inflammatory medications.
  • Try ice massage.  
  • Change your footwear and avoid high heels or tight shoes.  
  • Wear supports or pads  
  • Take a break for a few weeks and reduce activities such as jogging, aerobic exercise or dancing.
About 25% of patients will experience complete resolution of their symptoms by taking these steps.
 

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