Morton’s Neuroma

THE CLINICAL SYNDROME

Morton’s neuroma is one to the most common pain syndromes affecting the forefoot. Morton’s neuroma is characterized by tenderness and burning pain in the plantar surface of the forefoot with associated painful paresthesias into the affected two toes. This pain syndrome is thought to be caused by perineural fibrosis of the interdigital nerves. Although the nerves between the third and fourth toes and, rarely, the fourth and fifth toes can be affected. The patient often feels like he or she is walking with a stone in the shoe. The pain of Morton’s neuroma worsens with prolonged standing or walking for long distances and is exacerbated by improperly fitting or padded shoes. As with bunion, bunionette, and hammertoe deformities, Morton’s neuroma is most often associated with the wearing of tight, narrow-toed shoes.

The pain of Morton's neuroma is frequently made worse with prolonged standing or walking.

SIGNS AND SYMPTOMS

On physical examination, pain can be reproduced by firmly squeezing the two metatarsal heads together with one hand while placing firm pressure on the interdigital space with the other. In contradistinction to metatarsalgia, in which the tender area remains over the metatarsal heads, with Morton’s neuroma, the tender area will be localized to only the plantar surface of the affected interspace with paresthesias radiating into the two affected toes. The patient with Morton’s neuroma will often exhibit an antalgic gait in an effort to reduce weight bearing during walking.

Fractures of the sesamoid bones of the foot are often confused with the pain of Morton’s neuroma. Although the pain of such fractures is also localized to the plantar surface of the foot, they are less neuritic in character than the pain of Morton’s neuroma. Tendinitis and bursitis of the foot as well as stress fractures of the foot can also mimic the pain of Morton’s neuroma.

TREATMENT

Initial treatment of the pain and functional disability associated with Morton’s neuroma should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. Avoidance of repetitive activities that aggravate the patient’s symptomatology, as well as avoidance of narrow-toed or high-heeled shoes, combined with short-term immobilization of the affected foot may also provide relief. For patients who do not respond to these treatment modalities, the following injection technique with local anesthetic and steroid may be a reasonable next step.

Proper needle placement for injection of Morton’s neuroma.

Coexistent bursitis and tendinitis may also contribute to foot pain and may require additional treatment with more localized injection of local anesthetic and methylprednisolone acetate. The described injection technique is extremely effective in the treatment of pain secondary to Morton’s neuroma. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. The use of physical modalities including local heat as well as gentle range of motion exercises should be introduced several days after the patient undergoes this injection technique. Although the described injection technique will provide palliation of the pain of Morton’s neuroma, the patient will often also require shoe orthoses and shoes with a wider toe box to help remove pressure from the affected interdigital nerves.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.