Mortons Neuroma

Sandro Giannini, M. Cadossi, D. Luciani, and F. Vannini

Contents Abstract
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3537 Interdigital neuroma is a clinical syndrome
of the forefoot causing pain and disability
Aetiology and Classification . . . . . . . . . . . . . . . . . . . . . . 3538
and it is considered to be one of the most
Anatomy, Pathology and Biomechanics . . . . . . . . . 3539 common causes of forefoot pain. A large
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3539 number of studies have been performed
concerning neuromata over time, neverthe-
Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 3541
less, causes and ideal treatment are still
Pre-Operative Preparation and Planning . . . . . . 3541 under debate.
Nerve Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3542
Conservative treatment is firstly to be
Nerve Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3542 attempted, while the indication for surgery,
Post-Operative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3543 in a patient affected by a Mortons neuroma,
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3543
is essentially clinical and relies on neurolysis
or neurectomy.
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3543
Complications due to surgical treatment are
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3544 few and the literature is consistent with a rate
of clinical success around 80 %. Newer mini-
invasive/infiltrative procedures are still to be
further investigated.

Keywords
Anatomy, Pathology and Biomechanics 
Complications  Conservative treatment 
Diagnosis  Foot  Mortons interdigital
Neuroma  Surgical indications  Techniques-
excision, decompression
S. Giannini (*)
Movement Analysis Laboratory, Istituto Ortopedico
Rizzoli, University of Bologna, Bologna, Italy
General Introduction
Department of Orthopaedic and Trauma Surgery, Istituto
Ortopedico Rizzoli, Bologna, Italy
e-mail: Giannini@ior.it Interdigital neuroma is a clinical syndrome of
the forefoot causing pain and disability and it is
M. Cadossi  D. Luciani  F. Vannini
Department of Orthopaedic and Trauma Surgery, Istituto considered to be one of the most common
Ortopedico Rizzoli, Bologna, Italy causes of forefoot pain [1, 2]. Villadot found

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 3537

DOI 10.1007/978-3-642-34746-7_149, # EFORT 2014
3538
intermetatarsal neuroma to be the cause of
metatarsalgia in 33 % of patients [3].
The literature reveals that the mean age of
presentation is between 45 and 50 and, over-
whelmingly, females are affect by this condition
more than males [4]. Both feet are affected
equally but bilateral presentation is uncommon
as much as is the finding of more than a neuroma
in the same foot [5].
The more frequent localization is in the third
or second metatarsal web spaces [5]. Character-
istic symptoms include burning, numbness, dis-
comfort with shoe wear and the feeling of
a pebble under the metatarsal region.
The first description in the literature of this
pathology goes back to 1835 by Civinini, than
to 1845 by Durlacher and finally to 1876 by
Morton [68].
In 1835, Civinini et al. [6] described the fusi-
form swelling of the third common digital nerve
in a cadaver study. Later, Thomas Morton [8]
explored a series of interdigital neuromata and
described the classic syndrome of acute pain
under the metatarsal heads. Hauser and Williams
[9] also discussed interdigital neuromata in their
1939 text, Diseases of the Foot.
A large number of studies have been
performed concerning neuroma over time, never-
theless, causes and ideal treatment are still under
debate.
Aetiology and Classification
The aetiology of the condition is not clear and
many hypotheses have been proposed.
In 1940, Betts [10] performed isolated nerve
excision of the fourth plantar digital nerve, find-
ing a significant enlargement of the nerve with
a proliferation of soft tissue [13]. Rather than
confirming Mortons concept of compression,
he found the plantar nerve to be stretched under
the pulley of the transverse metatarsal ligament
as the toes dorsiflex and the flexor brevis muscle
contracts.
Also Graham and Graham [11] supported the
same concept. They performed microscopic dis-
sections of symptomatic nerves and found an
S. Giannini et al.
increase in the number of blood vessels sugges-
tive of venous congestion brought about by ten-
sion on the nerve from the intermetatarsal
ligament and no specific inflammatory process
was found.
Netter supported the theory that the nerve
lesion may be a result of an entrapment of the
nerve between the transverse intermetatarsal lig-
ament, and the underlining plantar fascia [12].
Moreover, particularly in the third web space,
the laxity and hyperextension of metatarso-
phalangeal joint is in contrast to the rigidity and
narrowness of the channel in which the nerve
runs, may contribute to create repetitive stresses
on the nerve itself [13]. Netter furthermore spec-
ulated that this condition may be more frequent in
females, probably because of the use of high-
heeled shoes [12].
It was also postulated that the primary rea-
son for the development of a neuroma in the
third interspace was anatomical in nature, in
that a branch of the medial and lateral plantar
nerve joins in this interspace [14]. The anasto-
mosis of the two nerves produces a sling or arch
over the belly of the flexor digitorum brevis,
which anchors the nerve so that dorsiflexion of
the ankle will produce traction upon the nerve
[15]. But in an anatomical study on 71 ft,
Levitsky et al. [16] observed that this commu-
nicating branch is not the cause of interdigital
neuroma, being present only in 27 % of the
specimens.
Again, Levitsky et al. demonstrated that the
the second and the third intermetatarsal spaces
are considerably narrower compared to the first
and fourth [11].
Other authors, like Jones and Klenerman [14],
supported the idea that the neuroma formation is
to be attributed to the fact that the nerve in the
third space is a terminal branch of the medial
plantar nerve and often has a side anastomosis
bto thelateral plantar nerve. This may make the
nerve more susceptible to stress or entrapment in
this space.
Alistair, Brigitte and Sunil [17] supported the
con cept that the neuroma is probably a form of
entrapment neuropathy and may be related to
overuse of inappropriate footwear.
Mortons Neuroma
Although a chronic traumatic factor is thought
to play an important role, the condition does not
appear to be more common in individuals who
undertake sporting activities that involve high
stresses on the forefoot [18].
Nissen [19] suggested an ischaemic compo-
nent to the neuritis, again through tension on the
transverse metatarsal ligament. A thickening of
the digital arterial wall with gross degeneration of
the vessel was demonstrated in histological
specimens.
Kim et al. [20] investigated the aetiology of
Mortons neuroma in a cadaveric study, conclud-
ing that the aetiology of Morton interdigital neu-
roma is the pinching of the common digital nerve
by the two metatarsal heads and the MTP joint
during walking.
Giannini et al. [21] agreed that the anatomical
characteristics of the neuromas area create
mechanical stresses responsible for neural and ves-
sel degenerative changes. The frequent and very
abundant presence of elastic fibres in the stroma,
particularly evident at the periphery of the lesion,
was similar to that seen in the elastofibroma,
confirming the microtraumatic lesion.
Viladot [22] considered it to be related to
mechanical overload of the forefoot, particularly
frequent in feet affected by some kind of defor-
mity. In up to 80 % of patients, intermetarsal
neuroma may be associated with some other path-
ological findings of the forefoot such as hallux
valgus, hammertoe, or flatfoot.
Finally Bossley and Cairney [23] believed that
an inflammatory mechanism was the basis of
Mortons neuroma, which may also occasionally
represent a local manifestation of a generalized
disease such as rheumatoid arthritis.
Anatomy, Pathology and
Biomechanics
The plantar nerve runs alongside the
intermetatarsal spaces with the artery and liga-
ment. The channel near the metatarsal heads, is
delineated the by transverse intermetatarsal liga-
ment superiorly and by the underlying plantar
fascia inferiorly.
3539
Giannini et al. [21] described in all the 63
cases observed in their series, typical macro-
scopic surgical findings included a thickened
interdigital nerve, particularly at the bifurcation,
and deposition of amorphous material around the
nerve that was loosely adherent to underlying
blood vessels and subcutaneous fat.
Microscopically, the histological alterations
involved nerves, interstitium and vessels.
Typical macroscopic surgical findings include
a thickened interdigital nerve, particularly at the
bifurcation, and deposition of amorphous mate-
rial around the nerve that was loosely adherent to
underlying blood vessels and subcutaneous fat.
Microscopically, the histological alterations
involved nerves, interstitium, and vessels. The
nerves presented thickening and fibrosis of peri-
neurium and epineurium associated with
sclerohyalinosis (Fig. 1). Concentric oedema
and degeneration of the myelinated fibres, in the
form of eosinophilic-roundish, amorphous tissue
deposition, is also evident as well as fibrosis,
oedema, and degenerative sclerohyalinosis of
the interstitium. Lobules of adipose tissue
circumscribed by fibrous septa are described.
Finally an increase of the elastic fibres inter-
spersed in the stroma was seen (Fig. 2). With
regard to the vessels hyperplasia of the muscular
layer is evident. The internal elastic lamina is also
evident, with proliferation of small vessels in the
muscular layer and in the adventitia. A pattern of
arteritis is also present, with fibrinoid necrosis
and presence of reactive giant cells.
Diagnosis
The diagnosis is typically clinical.
Symptoms include a burning pain or ache
between a pair of metatarsal heads with radiation
into the corresponding toes. Generally involved
are the third and the fourth toes, but may affect
also the second and third [24]. Pain is aggravated
by walking or standing, while at rest and removal
of shoes brings temporary relief. Tenderness and
a dorsal bulging lump may be found. In some
cases, the presence of a pseudotumour may
cause deviation of adjacent toes.
3540 S. Giannini et al.

Fig. 1 Surgical specimen

(stained with haematoxylin
and eosin and Weighert
stains X150) demonstrating
concentric oedema of the
nerve

Fig. 2 Surgical specimen

(stained with haematoxylin
and eosin and Weighert
stains X150) containing the
interstitium, demonstrating
an increase of the elastic
fibres interspersed in the
stroma

Examination reveals pain and paresthesiae on
plantar pressure at the affected areas. Swelling
and erythema are rare findings [24]. The pain may
be reproduced by application of upward pressure
on the plantar surface of the foot with one hand
(which puts the nerve between the metatarsal
heads), followed by compression on the forefoot
with the other hand [25, 26].
A palpable click during this manoeuvre is
a positive Mulder sign which can be painful to
the patient (Fig. 3). Symptoms of Mortons
neuroma may also be replicated through the
Gauthier test, in which the forefoot is squeezed
and medial to lateral pressure is applied [27].
Bratkowski [28] described a test that involves
hyperextending the toes and rolling the thumb
of the examiner in the area of symptoms. This
manoeuvre may reveal a tender, thickened, lon-
gitudinal mass. Patients with Mortons neuroma
also may demonstrate Tinels sign and Valleix
phenomenon. Differential diagnosis is performed
by examinining the metatarsal heads for
Mortons Neuroma
Fig. 3 The patient may demonstrate a Mulders sign,
elicited by squeezing the forefoot and applying plantar and
dorsal pressure. A positive test consists of a click or pop that
can be felt or heard; this can be painful to the patient
impingement or metatarsalgia and the metatarso-
phalangeal joint for instability, which are the
more frequent causes of mis-diagnosis.
Other differential diagnosis are:
Stress fracture
Neoplasm
Bursitis
Metabolic neuropathy
Fibromyalgia and other chronic pain
syndromes.
A standard X- Ray is important to exclude
other bony conditions, otherwise the appearances
are normal.
Both ultrasound and MRI may be used to doc-
ument the presence of the neuroma. T1-weighted
images with fat suppression, are reported to reveal
the presence of the neuroma. Nevertheless the
detection rate of MRI for Mortons neuroma is
reported to be 79 % [29]. On the contrary in
a study on asymptomatic volunteers Studler et al.
[30] found an high percentage rate of alterations in
the plantar fat pad which may mimic the presence
of a neuroma. Dominik et al. [31] demonstrated
that Mortons neurona appears significantly differ-
ent during MRI in prone, supine or weight-bearing
positions and supported the idea that visibility of
Morton neuroma is best in MRI images obtained
in the prone position.
However, some have not found MRI to be
reliable [15, 25] especially for smaller lesions.
The use of the MRI is, therefore, to be consid-
ered a complementary diagnostic tool necessary
only for those cases where it is difficult to be sure
of the site of the lesion or where the history is
3541
atypical. The cost and a rate of false positive
detection should limit the method to the more
equivocal clinical findings.
US, although false negatives are reported, and
validity only with neuoromatalarger than 4 mm.,
may be a viable complementary tool and a
more economical alternative, even if extremely
operator-dependent [31].
Indications for Surgery
The indications for surgery, in a patient affected
by a Mortons neuroma ar essentially based on
the clinical signs.
Surgery is not the only choice. Some Authors,
like Viladot et al. [22], considered that conserva-
tive treatment such as the use of insoles is effec-
tive in 70 % of cases.
Conservative treatments included well-fitting,
metatarsal pads, non-steroidal anti-inflammatory
medications and injections of a mixture of corti-
costeroid and local anaesthetic into the involved
webspace. These are widely used with a variable
reported success rate [3235].
Usually, conservative treatment is firstly
attempted by the majority of authors, neverthe-
less there are those who support an immediate
surgical alternative, due to the poor results of
conservative treatment and complications
following steroid injection [3638].
Pre-Operative Preparation and
Planning
Different operative techniques are described,
such as: neurolysis or neurectomy through a dor-
sal approach and neurectomy through a plantar
approach.
Mann and Reynolds [15] preferred the dorsal
approach as this not only avoids painful sole scars
associated with the plantar approach but also pro-
vides adequate visualisation and prevents painful
scars [15]. However, a retrospective study found
that there are several advantages in using the
plantar transverse incision such as improved
exposure and access to the neuroma [39].
3542 S. Giannini et al.

According to Villas, the following guideline

should be followed when choosing the appropri-
ate surgical treatment: when the nerve shows
macroscopic thickening or the typical
pseudoneuroma, it has to be resected trough
a dorsal approach; when the nerve has no macro-
scopic changes, the intermetatarsal ligament and
any other potentially compressive structure is to
be released [40].

Nerve Decompression
Fig. 4 Dorsal surgical access to the third intermetatarsal
Open or endoscopic decompression of the nerve space; the neuroma is identified
are alternative procedures to excision. Zelent
et al. [41] described the results obtained in 14
patients with the help of an instrument designed
to release the transverse carpal ligament for car-
pal tunnel syndrome. The rationale of
decompressive procedures is based on the fact
that when the nerve is resected, a true neuroma
is then produced [4244] Gauthier [27] believed
that the decompression procedure was effective
in reduction of the neuroma symptoms by remov-
ing the mechanical irritation of the
intermetatarsal nerve that occurred through
pressureagainst the anterior edge of the
intermetatarsal ligament during gait [27].
Furthermore, in order to decrease post- Fig. 5 With a pair of scissors, the nerve is resected as
proximally as possible
operative complications, such as haematoma,
infection, and delayed wound healing, although
very scarcely reported, endoscopic techniques
were developed to accomplish the nerve release. A 23 cm. longitudinal dorsal skin incision is
A difficult learning curve and the multiple made and centred between the two metatarsal
approaches required significatively limited the heads of the affected space, extending distally to
use of these methods [45, 46]. the base of the digital web space to reach the two
distal digital nerve branches. The common digital
nerve is identified and its pathology macroscop-
Nerve Excision ically evaluated (Fig. 4). The nerve including the
neuroma is freed and resected by scissors 3 cm.
In the variety of techniques reported, the authors proximal to the transverse metatarsal ligament, to
support a surgical excision of the neuroma, prevent its proximal end from lying in the weight-
independentely from the dimensions of the neu- bearing area (Fig. 5) [47, 48].
roma, from a dorsal approach. The two distal branches are freed and resected
Patients can be treated on an outpatient basis: the 3 mm. distal to the neuroma. The neuroma is then
operations are performed under ankle nerve block removed (Fig. 6). A standard suture is finally
anesthesia and under tourniquet control. inserted (Fig. 7).
Mortons Neuroma
Fig. 6 Macroscopical appearance of the neuroma
Fig. 7 Final wound closure
Post-Operative Care
Post-operatively, patients are placed in dressing for
the forefoot and a post- operative talus shoe.
Weight-bearing activities are limited and the patient
is advised to hold the foot elevated as much
as possible. Sutures are removed 1015 days
after surgery, and patients are allowed to resume
activities as tolerate.
Complications
Complications from surgical treatment are few.
The infection rate is low, and the major compli-
cation reported is the recurrence of the syndrome.
3543
Pain due to hypertrophic scars is reported in
some procedures performed from a plantar access
[40].
Ronconi et al. reported rare cases of infection,
of hypertrophic scars and in 20 % of cases the
persistence of the symptomatology (10 %
required neurectomy) [49].
Mann and Reynolds [15] found that 65 % of
their patients experienced persistent plantar tender-
ness after neurectomy with maximal recovery from
pain occurring by 3 months post-operatively.
Johnson and associates [50] studied 39 patho-
logical specimens resected from recurrent neuro-
mas. 46 % percent had a portion of primary
interdigital neuromatous tissue, clearly demon-
strating an inadequate primary resection in
a great percentage of cases. An additional 21 %
had a stump neuroma at the previous removal
site. Interestingly, 12 % showed no neuromatous
tissue, demonstrating that persistent pain after
neurectomy may be due to other factors.
Mann and Reynolds [15] advocate repeating
the dorsal approach to investigate the presence of
a recurrent neuromata. They found 9 of 11 (82 %)
of patients to be satisfied with this secondary
procedure.
On the contrary, Johnson et al. [50] advocate
a longitudinal plantar approach to trace the nerve
well proximal to the metatarsal heads. They
found that 67 % of their patients experienced-
complete pain relief after revision surgery, with
24 % of their patients having no improvement or
worsening pain.
Summary
Mortons neuroma is a common cause of
metatarsalgia, frequently requiring surgery. Var-
iable rates of success are reported with conserva-
tive treatment, and even after surgery. The
literature is consistent, with a rate of clinical
success around 80 %.
We believe that the anatomical characteristics
of the area studied primarily create mechanical
stresses responsible for neural and vessel degen-
erative changes.
3544
The frequent and very abundant presence of
elastic fibres in the stroma, particularly evident
at the periphery of the lesion, is similar to
that seen in elastofibromata, confirming the
microtraumatic origin of the lesion [50]. The
elastofibroma, in fact, has been considered
a non-neoplastic reactive process in response
to repeated minor trauma and is characterized
by an abundant reactive hyperplasia of elastic
fibres.
Because of the above mentioned histological
points and because of the absence of specific
aetiopathogenetic markers, we think that
repeated trauma to the connective tissue ele-
ments, including nerves and arteries in the
interdigital clefts, is the cause of a reactive over-
growth producing a Mortons neuroma.
Once conservative treatment fails, the ideal
surgical treatment is still debatable.
Excision is still the most common surgical
management. Anyway, due to pathophysiology
of Morton neuroma, lysis can be considered
when symptoms are present without a neuroma.
Nonetheless, there is a lack of comparative
randomized prospective studies supporting the
advantages obtained with neurolysis compared
with neurectomy.
Furthermore, also the ideal surgical access has
been under debate ever since the introduction of
the different surgical approaches.
Betts reported a longitudinal plantar approach
and Kaplan suggested a transverse, plantar inci-
sion; whereas McElvenny advocated a dorsal
websplitting incision and McKeever another dor-
sal incision [10, 5153].
In a retrospective study comparing plantar
versus dorsal incision, Akermark et al. reported
that the clinical outcome regarding post-
operative pain at follow-up and the overall satis-
faction rating was similar in both groups, whereas
significant differences, in favour of plantar inci-
sions were present with regard to residual sensory
loss and number of complications. The most seri-
ous complication with the dorsal approach is to
miss the neuroma [54].
We support an excision of the nerve through
a dorsal incision as the less traumatic. It permits
S. Giannini et al.
an excision of the Mortons neuroma, providing
adequate exposure and avoiding the risk of pain-
ful plantar scars [15].
Further investigations and prospective com-
parative studies should assess the validity of
newer intriguing mini-invasive methods such as
alcholization with phenol infiltrative treatment,
with the support of a needle-electrode able to
localize the nerve for selective infiltration [55].
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