Morton’s Neuroma
Julie Adkins and Jill C. Cash
Definition
A.A neuroma is a benign tumor of a nerve. Morton’s neuroma is not actually a tumor, but a chronic irritation/inflammation and thickening of the tissue that surrounds the digital nerve leading to the toes. This neuroma occurs as the nerve passes under the ligament of the metatarsals.
Incidence
A.The neuroma usually occurs between the third and fourth toes.
B.It occurs in women 8 to 10 times more frequently than men.
Pathogenesis
A.Morton’s neuroma occurs when pressure is exerted from the bottom of the foot from walking on hard surfaces with poorly padded shoes or barefoot, and/or pressure from the sides of ill-fitting tight shoes. It may also develop from chronic irritation and/or trauma.
Predisposing Factors
A.Poor padded shoes or walking barefoot.
B.Tight shoes or high heels.
C.Trauma.
Common Complaints
A.Burning pain in the ball of the foot radiating to the toes. Pain intensifies with activity or wearing shoes. Night pain is rare.
B.Possible numbness or unpleasant feeling in toes.
C.Sharp pain between toes, dead feeling of toes.
Other Signs and Symptoms
A.Symptoms may be worse with tight shoes or activity.
B.Selective shoes are worn for comfort.
Subjective Data
A.Ask the patient to describe the pain in the foot. Is it a burning, stabbing sensation in the toes?
B.Assess pain intensity. Ask regarding dull or sharp pain between toes.
C.Where does pain occur in the foot?
D.Does the patient have difficulty walking due to pain or numbness?
E.Does the patient take certain measures to improve pain, such as wearing specific shoes, avoiding shoes, or not going barefoot?
Physical Examination
A.Inspect:
1.Inspect foot for redness, swelling, or pain.
2.Inspect for color change, bruising, rash, or other changes in skin.
B.Palpate:
1.Palpate affected foot for palpable mass or a click
between toes.
2.Apply pressure to area to reproduce pain for local tenderness.
3.Assess range of motion (ROM) of toes and foot.
Diagnostic Tests
A.X-ray of the foot to rule out other pathology such as fracture.
Differential Diagnosis
A.Morton’s neuroma.
B.Fracture or stress fracture.
C.Arthritis.
Plan
A.General interventions:
1.Recommend the use of orthoses to help relieve irritation by lifting and separating the bones to eliminate pressure on the nerve.
B.Patient teaching:
1.Make a change in footwear. Avoid high heels or tight shoes. Use of toe spacers may improve symptoms.
2.Ice for soreness: Ice to site for 15 minutes every 4 to 6 hours. Tylenol may be used for pain.
3.Encourage taking extra time in walking because of irritation.
4.Encourage the use of assistive walking devices to decrease pressure on foot.
C.Pharmaceutical therapy:
1.Injection: Local digital nerve block may be trialed.
2.Nonsteroidal anti-inflammatory drugs (NSAIDs) are ineffective because of poor penetration to these tissues.
Follow-Up
A.One month or sooner to evaluate pain relief and/or exacerbating symptoms such as numbness or gait instability.
B.Steroid injection to the point of tenderness if there is no relief from conservative treatments. Steroid injection may be repeated in 6 weeks if pain recurs or persists.
Consultation/Referral
A.Referral to an orthopedist or podiatrist for possible neurectomy if other treatment modalities are unsuccessful or if pain continues after two steroid injections.
Individual Considerations
A.Adults:
1.Injection: Aftercare to include rest for several days and avoidance of all unnecessary weight bearing
2.Surgery may cause secondary problems, such as numbness in adjacent toes.
B.Geriatrics:
1.Encourage patient to wear properly fitting shoes that are comfortable and that do not place weight on the balls of the feet.
2.Avoid or decrease activities of jogging, running, and jumping that place great amounts of impact on the toes or balls of the feet. Encourage geriatric patients to participate in brisk walking for cardiovascular aerobic exercise.
3.Arch support devices and foot pads will help prevent neuropathy from developing further. Short-term steroid treatment may help with inflammation; however, proper footwear is the key to maintaining relief.
4.In severe cases of obesity, depression secondary to pain, increasing discomfort, and ambulation difficulties. Morton’s neuroma excision surgery may be recommended.