Morton neuroma

Anatomy and development: What is Morton's neuroma?

Morton's neuroma is not a "real" tumor, but rather a thickening and fibrosis (scarring) of the common digital nerve (interdigital nerve) between the metatarsal bones. The space between the 3rd and 4th metatarsals is most commonly affected, and more rarely between the 2nd and 3rd.

The trigger is a recurring mechanical irritation in the narrow space under the deep transverse metatarsal ligament. The constant compression leads to inflammation, swelling and painful thickening of the nerve tissue.

• Location: usually 3rd/4th. Space between the toes, rarely 2nd/3rd.
• Mechanism: Nerve compression under the deep transverse metatarsal ligament
• Pathology: irritation, inflammation and scar change (perineural fibrosis)

Typical symptoms

The symptoms often occur depending on the load and improve with rest or after taking off tight shoes.

• Stinging, burning pain in the forefoot, often between two toes
• Tingling, numbness or pins and needles feeling in the affected toes
• Sensation of a “foreign body” or “pebble” in the shoe
• Increased pain in tight, high or hard shoes
• Sometimes an audible or tactile “snap/click” occurs when the forefoot is compressed (clinical sign)

Pain at rest at night is atypical for Morton's neuroma. If pain, severe swelling, redness or fever occur at night, another cause should be ruled out by a doctor.

Causes and risk factors

The interaction between foot shape, footwear and load determines the risk of Morton's neuroma. Repeated pressure and shear forces in the forefoot are the main drivers.

• Tight or pointed shoes, high heels (shift the load to the forefoot)
• Forefoot deformities: Hallux valgus, hammer/claw toes, splayfoot
• Sports with forefoot loading and stop-and-go (running, court sports)
• Occupational stress involving prolonged standing or walking on hard floors
• Previous injury or irritation in the forefoot

Diagnostics in practice

The diagnosis is based primarily on conversation and clinical examination. Imaging helps rule out other causes and plan therapy.

• Anamnesis: Character of pain, stress-related complaints, footwear, sporting/occupational stress
• Clinical tests: pressure pain in the affected space, compression of the forefoot causing typical symptoms
• Ultrasound: Depiction of a neuroma-typical thickening, assessment of accompanying bursa (bursitis)
• MRI: useful for unclear findings or surgical planning; shows soft tissue changes
• X-ray while standing: assessment of the forefoot axis, toe position and accompanying bony findings

Differential diagnoses include mechanical metatarsalgia (overload of the metatarsal heads), intermetatarsal bursitis, stress fracture, MTP joint inflammation, sesamoiditis, or nerve entrapment syndromes.

Warning signs: Pain at rest, fever, pronounced redness/warmth, loss of numbness or trauma require prompt medical evaluation.

Conservative treatment – ​​the first step

The aim of non-surgical therapy is to reduce the pressure on the affected nerves, calm inflammation and favorably change the stress profile. Many patients achieve significant relief from symptoms with this.

• Shoe fitting: sufficient space in the forefoot, soft upper material, moderate heel (<3-4 cm), cushioning sole
• Insoles with forefoot pad (metatarsal pad): relief of the space between the feet and the metatarsal heads
• Activity adjustment: temporarily reduce stressful activities, breaks, alternating loads
• Physiotherapy: mobilization of the forefoot, stretching of the calf and sole fascia, strengthening the foot muscles
• Taping/cushion: temporary relief in everyday life or sport
• Pain and inflammation medication: short-term and as needed according to a doctor's recommendation

Ultrasound-targeted injection therapy may be considered when basic measures are not sufficient. An anesthetic and, if necessary, a low-dose cortisone are given locally to the irritated nerve. This can reduce inflammation and relieve discomfort for weeks to months. The number and spacing of injections are chosen individually and cautiously.

Alcohol sclerotherapy of the neuroma is offered in some centers. The evidence is heterogeneous; it may be considered in selected cases when standard conservative measures fail and surgery should be avoided. Careful information about the benefits and possible risks (e.g. local irritation, neuroma persistence) is important.

Minimally invasive procedures (individually tested)

Radiofrequency ablation or cryoablation aims to destroy the part of the nerve that transmits pain in a controlled manner. They are particularly suitable for well-localized neuromas and after failure of conservative standard therapies. The data is more limited compared to surgery; The benefits and risks are weighed up in a personal conversation.

Surgical options – when protection is not enough

If consistent conservative measures do not help sufficiently over several months and the quality of life is significantly impaired, an operation may make sense. The aim is to relieve pressure and reduce pain. A promise of healing cannot be given.

• Decompression: Splitting the deep transverse metatarsal ligament to relieve pressure on the nerve
• Neurectomy: Removal of the thickened portion of the nerve (leads to numbness in the affected toe area)
• Access routes: mostly dorsal access (from the back of the foot); plantar approach in selected situations

Follow-up treatment: Usually a bandage shoe and relief for 1-2 weeks, wound checks, thread removal after approx. 10-14 days. Everyday stress is gradually increased. Sport is usually possible again after a few weeks - depending on wound healing and resilience.

• Possible complications: wound healing disorders, infection, scar pain
• Persistent symptoms or recurrence (e.g. stump neuroma) are possible
• Permanent changes in sensitivity in the supply area of ​​the removed nerve

Course, prognosis and prevention

With well-fitted footwear, relieving insoles and targeted physiotherapy, Morton's neuromas can often be stabilized or significantly improved. The course is individual and depends on the severity, stress and accompanying factors.

• Early adjustments (shoes/insoles) improve the chances of complaint control
• Regular self-exercises and load control support long-term stability
• Forefoot deformities (e.g. hallux valgus) should be treated to avoid further irritation

Prevention: Make sure there is enough space in the forefoot area, change shoe types, gradually increase physical exertion and strengthen the foot muscles.

What you can do yourself

• Choose shoes with a wide toe box and good cushioning; Avoid high, pointed heels
• Wear the insole with forefoot pad consistently; Have the seat checked regularly
• Vary the load: walking, cycling, swimming alternately
• Stretching: calf muscles and plantar fascia (e.g. 30 seconds 2-3 times a day)
• Strengthen foot muscles: towel claws, toe spreads, foot school courses
• Short cold applications for acute irritation; Pay attention to skin protection

When to see a doctor?

• Forefoot pain persists despite changing shoes and relieving pressure
• Tingling/numbness in toes increases or persists
• Exercise-related pain prevents sports or everyday activities
• Pain at rest, redness/warmth or swelling occur
• Unclear findings after injury

Your orthopedic contact point in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we provide you with individual advice on forefoot problems such as Morton's neuroma. Our focus is on careful diagnostics, understandable information and conservative solutions. If necessary, we plan further interdisciplinary measures.