Morton’s Neuroma

Non-Operative Treatments for Morton’s Neuroma

In nonoperative management, the first line of treatment is using metatarsal dome, which is a kind of an orthotic (an insole) which is put into the footwear to offload that corresponding space and to allow the nerve to get some rest and to reduce the inflammation and swelling.

Steroid Injection for Morton’s Neuroma

If that fails, then the next in the line of treatment is having a steroid injection which can be given either under the ultrasound guidance or blindly in the clinic. Up to two injections can be given which can have up to 80% chance of getting rid of the neuroma symptoms. Steroids are strong anti-inflammatories and they help reduce the inflammation in and around the nerve and as a result the symptoms from the neuroma are resolved.

In one scientific study it showed that the neuroma which is smaller than 5 mm had a better response at six months than those which were greater than 5 mm in size. However at 12 months, the response of injection was no longer significantly different between these two groups.
Another paper recently described a cut off size of the Neuroma at 6.3 mm for CSI ( Cortico-steroid Injection) injection therapy; above which the Morton’s neuroma fail to respond well to the steroid injection. However, the injection is a non-invasive compared to surgery and I would certainly try this before embarking on surgery which is irreversible and also leads to the permanent numbness of the toes, where the nerve is taken out.

Side effects of steroids when used for managing Morton’s Neuroma

Steroids have got their own side effects which include tissue atrophy in the skin or the layers deeper to skin and if the corticosteroid oozes/leaches out, which can lead to hypopigmentation of the skin where the injection was given and the associated localised fat necrosis. The chances of this thing happening is between 1-5%.

Treatment options for Morton’s Neuroma other than Surgery

There are other modalities available other than steroid injection, like injecting the alcohol and hyaluronic acid (artificial joint fluid) or botulinum toxin, but these are not the mainstay or mainstream treatments. Similarly, percutaneous radiofrequency ablation has been used in people who fail, but then these are more of research treatments with limited evidence base and they are not commonly available in the private sector or the NHS Hospital in United Kingdom, where the standard treatments are those of steroid injections and surgery.

Surgery for Morton’s Neuroma

There are two surgical treatments i.e release of the Neuroma / nerve (neurolysis) and excision (removal of the Morton’s neuroma) called as neurectomy.
In the surgical treatment, the most commonly carried procedure is excision of the Morton’s neuroma (i.e. neurectomy) which results in a permanent numbness of the toes as the nerve has been removed and thus this leads to permanent resolution of symptoms. The nerve is stretched before it is cut and its plantar branches (which are going into the skin of the sole of foot) are surgically divided (taken off) to allow the nerve to retract (pull) back into the muscles of the foot. Rarely, this can develop a neuroma and one may need to have further surgery done to resect that neuroma, but the chances of that are very small if nerve / neuroma is stretched before being excised.

Another recently used technique (which is coming into vogue) is neurolysis of the Morton’s Neuroma, i.e. releasing the intermetatarsal ligament which is compressing onto the top of the Morton’s Neuroma or the fibrotic nerve. The beauty of this is that this allows you to have the sensation on the dorsum of your toes as the nerve has not been taken out. However, this is again considered a new treatment and the gold standard is still the excision ( surgical removal) of the Morton’s neuroma.

The Morton’s neuroma surgery either being neurectomy or neurolysis is most commonly performed from the top of the foot, i.e. the dorsum of the foot by making a small surgical incision about 3-5 cm long. However, some surgeons prefer to do the neurectomy, i.e. excision of Morton’s neuroma, from the sole of the foot.

Usually it is done from the top of the foot as any stitches in the sole of the foot are painful and if one develops a painful scar, then one has replaced the problem of having painful (millet or stone sized) feeling in the foot with a tender scar on the sole of the foot.

Risks and Complications of Morton’s Neuroma Surgery

With any surgical procedure, there are associated complications, which range between 5-27%, which include infection, hematoma, hammertoe formation, hypertrophic or keloid (lumpy, mishappen) scar, complex regional pain syndrome, persistent postoperative pain, numbness of the toes and stiffness of the metatarsophalangeal (knuckle joints of the foot) joint. The chances of the surgical success varies between 50-88%.

The chances of recurrence of neuroma as previously stated is low and has been described in literature around 4% of cases. I must stress here that this is even lower if the digital nerve is stretched out before incising (cutting) it, as it gets pulled back and the cut sensory nerve (as Morton’s Neuroma is a being growth / tumour of a sensory nerve) grows into the muscle belly (as nature tries to heal any injured / damaged nerve, unknown to it that a surgeon has cut the nerve) instead of making another bulbous growth like a neuroma again.

My treatment strategy is that one should try nonoperative measures in the form of orthotics (i.e. metatarsal dome or metatarsal bar if more than one neuroma is present) followed by corticosteroid injection (up to two injections maximum for each Morton’s Neuroma)and failing all this, surgery as a last resort. I can offer both Morton’s Neurectomy and Morton neurolysis after discussion with patients. Morton’s Neurolysis has a slight chance of requiring further surgery if symptoms don’t resolve.

Also having only one neuroma being excised in a single sitting if there are two adjacent neuromas, i.e. between the second and the third interspace which can sometime be found. This is to reduce the risk of any vascular damage to the toe, resulting in potential amputation. Doing surgery on one space at a time reduces that risk considerably.

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