SOME MEDICAL FACTS
Description: Mortons Neuroma
Morton’s Neuroma, is a painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes. Morton’s neuroma may feel as if you are standing on a pebble in your shoe or on a fold in your sock. Morton’s neuroma involves a thickening of the tissue around one of the nerves leading to your toes. This can cause a sharp, burning pain in the ball of your foot. Your toes also may sting, burn or feel numb. The female-to-male ratio for Morton’s neuroma is 5:1. The highest prevalence of Morton’s neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient.
Morton’s Neuroma, seems to occur in response to irritation, pressure or injury to one of the nerves that lead to your toes. It appears that tight fitting shoes in the area of the Metatarsal arch (where your toes meet your feet) is the main contributing factor. Women’s high heel shoes are considered the most common cause of this condition.
Risk Factors; that appear to contribute to Morton’s neuroma include:
- High heels. Wearing high-heeled shoes or shoes that are tight or ill fitting can place extra pressure on your toes and the ball of your foot.
- Certain sports. Participating in high-impact athletic activities such as jogging or running may subject your feet to repetitive trauma. Sports that feature tight shoes, such as snow skiing or rock climbing, can put pressure on your toes.
- Foot deformities. People who have bunions, hammertoes, high arches or flatfeet are at higher risk of developing Morton’s neuroma.
Typically, there’s no outward sign of this condition, such as a lump as the injury is buried deep between the toes of the foot. Instead, you may experience the following symptoms:
- A pebble or marble in your shoe is the most common description
- A burning pain in the ball of your foot that may radiate into your toes
- A tingling or numbness in your toes
Mortons neuromas are more common in women, with a female-to-male ratio of 4:1. They tend to occur in the fifth decade of life and frequently are exacerbated by constrictive footwear. Symptoms are typically unilateral, with the third interspace most often involved followed by the second and the fourth interspaces. Simultaneous neuromas occurring in the same foot are uncommon.
Possible reported findings provided by the patient with Morton’s neuroma include the following:
The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma.
Pain is described as sharp and burning, and it may be associated with cramping.
Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain.
Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks.
Some patients describe the sensation as “walking on a marble.”
Massage of the affected area offers significant relief.
Narrow tight high-heeled shoes aggravate the symptoms.
Night pain is reported but is rare.
Episodes of pain are intermittent. Patients may experience 2 attacks in a week and then none for a year. Recurrences are variable and tend to become more frequent. Between attacks, no symptoms or physical signs occur. Two neuromas coexist on the same foot about 2-3% of the time. Other diagnoses should be considered when 2 or more areas of tenderness are present.
Many sources acknowledge that the examination of patients with Morton’s neuroma frequently is negative. However, studies have shown that a clinical history and examination may be more sensitive than ultrasonography or magnetic resonance imaging (MRI). Most often, sensation is wholly intact and maneuvers are unsuccessful in reproducing the characteristic pain. Palpation of the actual neuroma seldom is successful. Most clinicians focus on the history and on the lack of additional findings that might suggest other disorders.
Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating neuropathic pain. Pain localized only to the plantar aspect of the webspace also may be consistent with Morton’s neuroma.
The squeeze test may also result in a “click” (Mulder click) as the neuroma moves between the metatarsals in the dorsal direction.
Passive and active toe dorsiflexion may aggravate symptoms.
Sensory abnormalities may be observed, although motor deficits are not consistent with an interdigital neuroma because these are sensory nerves exclusively. Weakness would raise concerns for another diagnosis.
Palpation of the tarsometatarsal joint and metatarsophalangeal (MTP) joints may reveal tenderness, indicating midfoot arthritis or metatarsalgia (eg, when the tenderness is primarily on the plantar surface only) or MTP synovitis (eg, when the joint is tender with palpation).
Pain from MTP synovitis is aggravated with forced toe flexion. Subtle joint swelling also may coexist with MTP synovitis. Tenderness localized to the second MTP joint, along with swelling and warmth, may be, in rare cases, an early presentation of Freiburg osteochondrosis.
Inspection of the foot and evaluation of foot and ankle mechanics should be performed as part of the physical examination, looking for callus formation, hallux valgus, first-ray flexibility, hyperpronation, integrity of the medial arch, and gastrocnemius-soleus flexibility.
Imaging tests, some imaging tests are more useful than others in the diagnosis of Morton’s neuroma:
- X-rays. Your doctor is likely to order X-rays of your foot, to rule out other causes of your pain — such as a stress fracture.
- Ultrasound. This technology uses sound waves to create real-time images of internal structures. Ultrasound is particularly good at revealing soft tissue abnormalities, such as neuromas.
- Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, an MRI also is good at visualizing soft tissues. But it’s an expensive test and often indicates neuromas in people who have no symptoms.
The term neuroma, as applied to this condition, may be a misnomer. Morton neuroma may be best described as a clinical syndrome stemming from a constellation of factors related to the local anatomy and the forces applied on the forefoot with ambulation and shoe wear. Interestingly, it is not uncommon for the histopathology to be interpreted as relatively normal, even in light of classic preoperative findings and dramatic postoperative results. Clearly, the histopathology is not that of a typical neuroma. Some or all of the following may be observed:
- Sclerosis of the endoneurium
- Hyalinization of the walls of endoneurial vessels
- Thickened perineurium
- Demyelinization of nerve fibers
Anatomic studies have revealed a wealth of information and helped to resolve some misconceptions regarding the etiology of this disease. The intermetatarsal space is narrower in the second and third interspaces than in the first and fourth interspaces, and this difference correlates with the clinical presentation pattern. The composition of the tarsometatarsal articulation allows relative hypermobility between the second and third metatarsals, which contributes to mechanical irritation of the nerve.
Narrow toe-box footwear can exacerbate the compression between the metatarsal heads, and hyperextension of the toes in high-heeled shoes tethers the nerve beneath the ligament and may expose it to more biomechanical stresses with gait. Less commonly, metatarsophalangeal (MTP) joint pathology, inflamed bursa, or lipomas can create compression at the level of the common digital nerve.
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Another treatment approach involves injection of the Morton’s neuroma. Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints. Advance the needle through the midwebspace into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located. Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. The anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad.
Invasive Surgery: “Not Recommended”
If conservative treatments haven’t helped, your doctor might suggest:
Surgical options include the following:
Neurectomy with nerve burial
Transverse intermetatarsal ligament release, with or without neurolysis
Endoscopic decompression of the transverse metatarsal ligament
A dorsal surgical approach may decrease recovery time, although a study by Kundert et al indicated that a longitudinal plantar approach to excision of Morton neuroma is also effective, providing strong pain relief; a study by Habashy et al found comparable outcomes and patient satisfaction with either a plantar (17 patients) or dorsal (20 patients) approach to neurectomy for Morton neuroma.
- Decompression surgery. In some cases, surgeons can relieve the pressure on the nerve by cutting nearby structures, such as the ligament that binds together some of the bones in the front of the foot.
- Removal of the nerve. Surgical removal of the growth may be necessary if other treatments fail to provide pain relief. Although surgery is usually successful, the procedure can result in permanent numbness in the affected toes.