Morton’s Neuroma Surgery – All You Need to Know
Morton’s neuroma is a common condition which affects one of the interdigital nerves between the toes. This condition usually affects the nerve between the third and the fourth toes, causing pain in the ball of the foot between these toes. Morton’s neuroma can also develop in other nerves, but less often.
Neuroma actually means benign tumor of the nerve. However, this term is not appropriate for this condition because it is not a tumor. Morton’ neuroma is actually a thickening of the tissue that surrounds the nerve, in medical terminology known as perineural fibrosis.
Even though it is not a tumor, Morton’s neuroma is an unpleasant and painful condition that gets worse over time. As with any other chronic and progressive condition, early diagnosis and treatment will slow down further progression and, in this case, lower the need for surgery. Unfortunately, for some patients, surgical treatment is the only available option.
With the development of simple tests for Morton’s neuroma that even regular people can do, early diagnosis is more often than in the past.
What are the causes of Morton’s neuroma?
The exact cause of this condition is still not known. More recent theories suggest that it is a result of repetitive pressure, irritation, entrapment and injury.
Although the exact cause is still not known, there are several factors that undoubtedly contribute to development of Morton’s neuroma such as:
- High heels, tight and unfitting shoes
This is one of the, if not the most important contributing factor in Morton’s neuroma. High heels and other shoes with narrow toe boxes increase compression on the nerve and other structures between the heads of metatarsal bones.
- Foot deformities
People with foot abnormalities like high arches or flat feet have higher risk for Morton’s neuroma.
- Certain injuries
Fractures and dislocations in this area can narrow the tunnel where the nerve passes and make compression more likely.
- Certain sports and physical activities
Weight-bearing physical activities and sports that involve repetitive action like walking, running, jogging can contribute to the development of Morton’s neuroma.
Sports that feature tight shoes like skiing or rock climbing can also be a contributing factor to this condition.
What are the symptoms for Morton’s neuroma?
The main symptom of Morton’s neuroma is pain. However, the character of the pain widely varies between patients. It is usually a sharp or burning pain in the ball of the foot or at the base of your toes.
The pain can also radiate distally in your toes or proximally in the higher parts of the foot. Some patients also feel like they have a pebble or a stone in their shoes, underneath the ball of the foot/walk on a pebble.
The pain is often aggravated when weight bearing (standing, walking, running etc.) and wearing tight shoes and high heels. Patients usually feel some relief after they take off their shoes and massage the painful area.
Other symptoms like tingling sensation (paresthesia) and numbness can also be present. Paresthesia is usually present in the initial stages of this medical condition, gets worse over time and changes into pain.
In most cases there are no outward signs, like lump, because the nerve is usually not that thick.
How to treat Morton’s neuroma?
Treatment for Morton’s neuroma depends on duration and severity of the condition. Generally, there are two types of treatment for Morton’s neuroma – conservative and surgical.
As with most foot injuries, initial treatment consists of one or more conservative methods. The aim of these methods is to relief pain and pressure of the affected nerve and corresponding area.
Conservative treatment can include one or more of the following methods:
- Rest, massage and ice
These methods should be used as soon as the pain starts. They will reduce further pain and swelling and give time to heal.
- Anti-inflammatory medications
They are used to help with pain and swelling.
- Wide shoes with low heels and soft sole
This type of shoes will reduce pressure on the nerve by spreading the bones, especially during weight bearing activities. Moreover, they will reduce the pain and swelling.
If you’re not sure what type of shoes you should buy, I’ve gathered a list with some of the best shoes for Morton’s neuroma (or best running shoes for Morton's neuroma at here) that are currently available on the market.
- Avoid narrow, tight shoes and high heels
Orthoses like shoe inserts or pads can reduce the pressure on the nerve by lifting and separating the bones. It is recommended to get the custom orthotics that are specifically made for you.
- Injection therapy
If other conservative methods fail, corticosteroid injections with local anesthetic may help, especially with shoe modification.
The success rate of conservative treatment is not entirely known, but reasonable estimate is that 20-30% of patients have either total resolution of symptoms or satisfactory improvement with proper footwear modifications and restrictions.
This number is probably higher when injection therapy is included. There are even some reports that more than 80% of patients have improvement when combining injection therapy with other conservative treatments.
However, there are some cases where conservative treatment didn’t help. In these situations, surgical therapy should be considered.
Morton’s neuroma surgery treatment
Surgical treatment of Morton’s neuroma is recommended when none of conservative treatments were successful.
There are two things that surgeon considers before surgery – approach and surgical procedure.
Surgical approach refers to the side of the foot where the incision is going to be made to reach the neuroma. There are 2 surgical approaches – dorsal and plantar. Dorsal approach means that the incision is made on the top of the foot. The stitches are not on the weight-bearing side of the foot and therefore the patient is able to walk soon after the procedure.
Plantar approach means that the incision is made on the sole of the foot. It is much easier to reach and remove neuroma with this approach. The disadvantage of this approach is that the patient should not walk for some time and the scar can make walking uncomfortable.
Morton’s neuroma surgical procedure
The two most common options are decompression procedure and removal procedure.
The aim of decompression is to increase the space around the nerve and decrease the pressure on the nerve. This is done by dividing the intermetatarsal ligament.
The decompression can be done with or without neurolysis. Neurolysis is a procedure in which certain chemicals, heat or freeze are applied to the nerve in order to stop the signal transmission and relief pain.
Doctors who propose this type of surgery believe that there is a less chance for neuroma to reappear when there is no nerve tissue removal. They also believe that if there is less stress on the nerve, there is a higher chance for the return of its function.
Neurectomy is a procedure in which part of the nerve, along with neuroma is removed.
Doctors who propose this type of surgery believe that the nerve is not functional and that decompression of the nerve will only slow down the growth.
The disadvantage of this procedure is that there is a risk for permanent numbness in the affected toes. Moreover, there is a higher chance for neuroma to reoccur.
The surgery is carried out under general anesthesia with an local anesthetic injection in the foot for pain relief after the surgery. Usually there is no need to stay in the hospital after you wake up.
The duration of the recovery depends on the type of surgical procedure. After the surgery, you will wear a protective post-operative shoe until the wound has healed enough to wear a normal footwear.
If the procedure was done using dorsal approach, immediate weight bearing is allowed and the sutures are usually removed after 2 weeks. Patients usually start to wear normal footwear 3 to 4 weeks after surgery.
It is not recommended to do sports 4 to 6 weeks after surgery. Plantar approach delays weight bearing and suture removal for 2 more weeks or until the incision is completely healed.
When you’re not weight bearing, keep your foot elevated. This way you will reduce swelling in the foot. If you notice some bleeding through the bandages, don’t worry. This usually occurs in the first few weeks after the surgery and it is totally normal.
As with all types of surgery, there is a chance for complications. The most often complications come fro wound healing – wound infection and keloid formation. Keloid formation is an overgrowth of the scar tissue on top of the usual scar tissue. Surgical removal is needed if it’s too big.
Patients who had the decompression procedure may continue to have pain. The reason for this is a incomplete decompression and irritation of the nerve.
Patients who had the removal procedure may develop a stump neuroma. Stump neuroma is a result of a detached nerve and can be even more painful than the previously removed neuroma. In this case, re-surgery is needed.
Morton’s neuroma is a painful condition that can limit everyday activities. There are various conservative treatments that can relief this condition.
However, conservative treatments have varying degrees of success. That is why surgical treatment should be considered at some point. Even with possible complications, surgical treatment provides long-lasting and satisfying relief in more patients than the conservative treatment. Given how conservative treatment has varying success rate, some doctors don’t even consider them as the part of the treatment.
I hope that with this text you’ve learned more about the surgical treatment of Morton’s neuroma, so when time for your surgery comes, you will be more prepared and well educated.