Morton’s Neuroma

Morton’s Neuroma is a painful condition resulting from the fibrous thickening of the plantar interdigital nerve of the foot.


Image from Gray's Anatomy of the nerves of the foot

 

Often described as feeling like there is a pebble in the shoe, this is is a chronic condition not associated with acute trauma. It is gradual in onset but may present as acutely painful.

 

  • AKA Morton’s metatarsalgia, or interdigital neuroma.
  • Most commonly presents between the 3rd and 4th metatarsal head region, but can affect any of the toe spaces.
  • More common in women (4-15 times) and between the ages of 40-60.
  • Increasingly common in runners.
  • Cause is uncertain but felt to be related to constriction of (e.g. ill fitting shoes) or pressure (e.g. heels, running, dancing) on the metatarsal head region.

Presentation (may include)

  • Pain in forefoot exacerbated by certain footwear and extended weight bearing.
  • Relieved by rest and massaging foot.
  • Sensation of mass or pebble under forefoot, though unlikely to be palpable.
  • Stabbing, burning, and or tingling sensation to forefoot and associated toes, worse on pressure.

Examination

  • Pain on applying pressure to the affected area.
  • Try to elicit Mulder’s click:
    • Try to grip the neuroma between your forefinger and thumb (with your thumb on the plantar aspect of the foot).
    • With your other hand, simultaneously squeeze the metatarsal heads (1-5) together in the transverse plane.
    • A click can be felt and heard as the enlarged nerve subluxes between the metatarsal heads as they are compressed.
    • Absence of this sign does not rule out neuroma.
  • Loss of sensation to the affected toes is a strong indicator, but a sensory deficit may not be apparent.

Treatment

  • Advice on use of footwear- Wide toed, flat, cushioned foot wear. No heels, No tight shoes, No thin soles
  • Use an over the counter metatarsal pad or insole to relieve pressure to metatarsal head.
  • Avoid aggravating activity, such as running. Or reduce as much as is feasible.
  • Advise that this can be a long-term problem that may not respond to the above, or be relapsing in nature.
  • Sign post to patient advice such as NHS Choices or Patient.co.uk
  • If the patient has used the pads and appropriate footwear for 3 months to seek follow up from their GP with a view to specialist referral.

Further Reading 

CKS

PhysioPedia

 

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