Morton's Neuroma
Morton's neuroma (intermetatarsal neuroma) is a benign thickening and fibrosis of the plantar digital nerve as it passes between the metatarsal heads in the forefoot. It is not a true tumour but a fibrous tissue proliferation caused by chronic nerve irritation. It most commonly occurs between the third and fourth toes and presents with burning, stabbing, electric shock-like pain in the forefoot. Treatment is initially conservative; in refractory cases, surgery or minimally invasive methods are used.
آخرین بهروزرسانی: 2026-06-07
Definition and Pathophysiology
Morton's neuroma is a thickening and perineural fibrosis of the common plantar digital nerve passing between the metatarsal heads, caused by chronic mechanical irritation. Although it is called a 'neuroma', it is not a true tumour but a proliferation of fibrous tissue. It most commonly occurs in the third intermetatarsal space (between the third and fourth toes), which is the narrowest and most mobile passage point. Narrow, high-heeled shoes bring the metatarsal heads together and compress the nerve; repetitive trauma during walking leads to demyelination, oedema and fibrosis. It is markedly more common in women than in men.
Risk Factors
The main risk factor is narrow-toed, high-heeled shoes, which shift body weight onto the forefoot and compress the metatarsal heads. Long-distance walking and running sports, occupations requiring prolonged standing, foot structure and biomechanical abnormalities (flat foot/pes planus, high arch/pes cavus, hammertoe, hallux valgus) and obesity increase the risk. Middle age and female sex are other important factors.
Symptoms
The most typical finding is burning, stabbing, sharp or electric shock-like pain in the forefoot, between the metatarsal heads (usually between the third and fourth toes). The pain increases when wearing narrow/high-heeled shoes and after long walks or standing. A very characteristic finding is relief when the patient removes the shoe and massages the foot. Numbness and tingling may occur on the adjacent surfaces of the affected toes. In advanced cases the pain becomes continuous and limits daily activities.
Diagnosis
Diagnosis is primarily clinical. On examination, tenderness is found between the metatarsal heads, and Mulder's test (a palpable 'click' and reproduction of pain felt when pressure is applied to the space while squeezing the metatarsal heads from the sides) has high diagnostic value. Reduced sensation may be found on the adjacent surfaces of the affected toes. On imaging, ultrasonography is the first choice and shows the neuroma as a hypoechoic, well-defined lesion; MRI is used particularly in uncertain cases and for surgical planning. Marked reduction of pain after a diagnostic local anaesthetic injection confirms the diagnosis and helps predict surgical success. The differential diagnosis includes metatarsalgia, metatarsal stress fracture, intermetatarsal bursitis, Freiberg's infarction and diabetic neuropathy.
Conservative Treatment
Conservative treatment is the first step. Footwear modification is fundamental: wide-toed, flat or very low-heeled, soft-soled shoes are recommended, and narrow, high-heeled shoes are avoided. A metatarsal pad, placed just behind the metatarsal heads, reduces the load on the area and widens the space; a custom orthosis is made when needed. Neuropathic pain agents and short courses of anti-inflammatories provide symptomatic benefit. Physiotherapy (stretching exercises, strengthening of the intrinsic foot muscles) and activity modification are added. Conservative treatment is effective in a substantial proportion of patients, particularly in early and mild cases.
Interventional and Surgical Treatment
In cases that do not respond adequately to conservative treatment, a corticosteroid injection may be used; it often provides short-term relief, with more limited long-term success, and requires caution regarding side effects such as plantar fat pad atrophy. Alcohol sclerosing injection, radiofrequency ablation and cryotherapy are minimally invasive alternatives. In refractory and severe cases, surgery is considered. The gold standard is neuroma excision (neurectomy): the neuroma and the affected nerve segment are removed; because the nerve is divided, permanent numbness on the adjacent surfaces of the affected toes is an expected outcome, and most patients tolerate this in exchange for relief of pain. Alternatively, nerve decompression (neurolysis) may be performed with the nerve preserved. Possible complications include stump neuroma and recurrence.
Prognosis
With early diagnosis and appropriate treatment the prognosis is generally good. Conservative treatment and appropriate footwear control symptoms in a substantial proportion of patients; surgical excision has a high success rate in refractory cases. Long-standing symptoms, large or multiple neuromas and accompanying foot pathology may adversely affect the prognosis. Treatment success is lower in recurrent cases. The treatment plan is individualised for each patient, and no outcome can be guaranteed in advance.
منابع
- Bhatia M, Thomson L. Morton's neuroma - Current concepts review. J Clin Orthop Trauma. 2020;11(3):406-409.
- Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013;6(4):307-317.
- Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma. Cochrane Database Syst Rev. 2004;(3):CD003118.
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