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Diagnosis and treatment of Morton's neuroma

Article  in  Emergency nurse: the journal of the RCN Accident and Emergency Nursing Association · September 2010
DOI: 10.7748/en2010.09.18.5.16.c7971 · Source: PubMed

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Diagnosis and treatment

of Morton’s neuroma
Anthony Summers describes the causes of,
and management options for, a painful foot condition
that usually occurs in women who wear tight shoes

common age range of people with the condition

Summary
Morton’s neuroma is a benign foot condition that occurs more often in women than
men, and particularly in those who wear narrow, high-heeled shoes. This article
presents a case study of the condition, discusses its symptoms and diagnosis,
and provides information about the range of treatments on offer.
Keywords
Foot pain, Morton’s neuroma, nerve entrapment, toes
Morton’s neuroma is a common cause of
forefoot pain (Basadonna et al 1999), described by
Thomas Morton, from whom the condition received
its name, in 1876 as ‘a peculiar painful affection
of the fourth metatarsophalangeal articulation’
(Rout et al 2009).
The precise pathogenesis of the condition is
uncertain but it probably occurs after repetitive trauma
to the plantar nerve at the edge of the metatarsal
ligament, and to the plantar aspect of the foot, during
the last part of the stance phase of gait, leading to
perineural fibrosis (Wu 1996, Gauthier 1979).
Histologically, the condition cannot be
categorised as a true neuroma because, when
the forefoot is excised and examined, cells from
vascular profileration are present and there is axonal
degeneration (Hughes et al 2007).
The literature suggests that Morton’s neuroma
is caused by the wearing of ill-fitting shoes (Anon
2009). Pointed shoes, for example, can squeeze
the structures of the forefoot causing pain and
inflammation, while high heels can force wearers’
weight forwards and increase pressure on the balls of
their feet (Anon 2009). High-heeled and pointed shoes
are worn by women more often than men, which may
explain why Morton’s neuroma is ten times more
common in women than in men, and why the most
is 30 to 40 (Bencardino et al 2000). Other reported
causes of the condition include repetitive heavy
impact on the feet when running, playing racquet
sports or dancing (Anon 2009).
Morton’s neuroma usually occurs in the
web space between the third and fourth toes
(Basadonna et al 1999), although it has reportedly
occurred between the first and second, and the
fourth and fifth toes too (Vainio 1979).
The most common symptoms are an aching or
burning sensation between the toes (Vainio 1979),
discomfort similar to that caused by a stone in the
shoe (Rout et al 2009) or paraesthesia radiating from
the mid foot to the toes (Hughes et al 2007).
Diagnosis of Morton’s neuroma in the emergency
department is described in the case study below and
the condition is illustrated in Figure 1.
Case study
A 35-year-old woman with increasing pain between
the third and fourth toes of her right foot presented
to an emergency department.
She said that the pain worsened during walking
but eased when she took off her shoes. She did not
recall injuring her foot and had no significant clinical
history. Examination of the patient’s foot revealed
no wounds, injury or deformity.
The practitioner discussed the case with a senior
colleague, who suggested a diagnosis of Morton’s
neuroma. The practitioner gathered information
on the condition so that she could explain the
diagnosis and treatment options to the patient.

16 September 2010 | Volume 18 | Number 5 EMERGENCY NURSE

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Diagnosis This can be clarified during physical Figure 1 Plantar view of foot with Morton’s neuroma
examination by eliciting the Mulder’s sign, in which
the practitioner compresses the medial and lateral Morton’s
sides of the patient’s foot with one hand and neuroma
squeezes between the third and fourth metatarsal
bones, or other web space, with the other. If a clicking
sound is heard (Anon 1999), or if the patient feels
acute pain radiating to the adjacent toes and upwards
along the foot (Vainio 1979), the test is positive.
Diagnosis can be confirmed with an ultrasound
scan, which should show a hypoechoic mass in the
area where Morton’s neuroma is suspected. Such
scans (Quinn et al 2000) have 95 per cent sensitivity
and 98 per cent accuracy for this condition.
Bancroft et al (2008) suggest that about one third
of patients who may have Morton’s neuroma are
asymptomatic and that the mass is usually found
in patients whose feet have been examined for
other problems.

Peter Lamb
Treatment This is usually conservative although the
neuroma can be excised surgically if conservative
measures have failed. risk of recurrence. The ethanol produces a chemical
Patients should be encouraged to wear shoes with neurolysis and subsequent destruction of the
wide toe boxes and low heels to alleviate pressure neuroma by dehydration necrosis and precipitation
on the forefeet (Anon 2009). Custom shoe orthotics of protoplasm (Hughes et al 2007).
or neuroma pads, which are adhesive pads placed
under the areas where neuromas are suspected, Conclusion
can also reduce pressure and spread the metatarsal Morton’s neuroma is a painful condition that occurs
bones (Hughes et al 2007). more often in women than men, particularly in those
Injection of steroids into the affected area who wear narrow, high-heeled shoes.
has a success rate of about 80 per cent and can It is a benign condition that often resolves or
provide rapid relief of the symptoms. Possible side improves with conservative management but, should
effects of such injections, however, are atrophy of such management fail, a surgical option is available. Online archive
subcutaneous fat, altered cutaneous pigmentation The symptoms of Morton’s neuroma tend to be For related information, visit
and telangiectasia (Basadonna et al 1999). specific so its assessment and diagnosis by nurse our online archive of more than
6,000 articles and search using
Other pain-relieving measures include use of practitioners is usually straightforward. Being usually the keywords
non-steroidal anti-inflammatory agents, either in conservative, management is also within nurse
tablet or topical form, and massage with ice of the practitioners’ scope of practice. This article has been subject
to double-blind review
area around the neuroma for 20 minutes, once or Nurse practitioners can expand their roles and has been checked
twice a day (Anon 2009). by undertaking injections of local anaesthetic or using antiplagiarism software
Hughes et al (2007) report that a series of steroid solution around the neuroma, although
Anthony Summers is a
four injections of ethanol around the neuroma can these activities should be discussed first with senior clinical nurse at Caboolture
completely alleviate the symptoms and reduce the colleagues to ensure safe practice. Hospital, Queensland, Australia

References
Anon (2009) Recognizing and treating Morton’s
neuroma. Harvard Women’s Health Watch.
16, 6, 5-6.
Bancroft LW, Peterson JJ, Kransdorf MJ (2008)
Imaging of soft tissue lesions of the foot and
ankle. Radiologic Clinics of North America.
46, 6, 1093-1103.
Basadonna PT, Rucco V, Gasparini D et al
(1999) Plantar fat pad atrophy after
corticosteroid injection for an interdigital
neuroma: a case report. American Journal
of Physical Medicine and Rehabilitation.
78, 3, 283-285.
Bencardino J, Rosenberg Z S, Beltran J et al
(2000) Morton’s neuroma: is it always
symptomatic? American Journal of
Roentgenology. 175, 3, 649-653.
Gauthier G (1979) Thomas Morton’s disease:
a nerve entrapment syndrome. A new surgical
technique. Clinical Orthopaedics and Related
Research. August, 142, 90-92.
Hughes RJ, Ali K, Jones H et al (2007) ultrasound by primary care physicians. Quality
Treatment of Morton’s neuroma with alcohol in Primary Care. 17, 4, 277-282.
injection under sonographic guidance:
Vainio K (1979) Morton’s metatarsalgia in
follow up of 101 cases. American Journal of
rheumatoid arthritis. Clinical Orthopaedics
Roentgenology. 188, 6, 1535-1539.
and Related Research. 142, 85-89.
Quinn TJ, Jacobson JA, Craig JG et al (2000)
Wu KK (1996) Morton’s interdigital neuroma:
Sonography of Morton’s neuromas. American
a clinical review of its etiology, treatment and
Journal of Roentgenology. 174, 6, 1723-1728.
results. Journal of Foot and Ankle Surgery.
Rout R, Tedd H, Lloyd R et al (2009) Morton’s 35, 2, 112-119.
neuroma: diagnostic accuracy, effect on
treatment time and costs of direct referral to

EMERGENCY NURSE September 2010 | Volume 18 | Number 5 17

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