Morton's Neuroma
Morton's neuroma is one of the most common causes of forefoot pain in adults, yet it is frequently misdiagnosed or under-treated. Despite its name, it is not a true neuroma. It is perineural fibrosis of the interdigital nerve, resulting from chronic compression and irritation as the nerve passes between the metatarsal heads. The result is a nerve that becomes thickened, scarred, and exquisitely painful with standing and walking. At Maryland Orthopedic Specialists, we provide a full spectrum of care: from simple shoe modifications that relieve symptoms immediately, to ultrasound-guided injections, to definitive surgical neurectomy for patients who have exhausted conservative options.
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What is morton's neuroma?
The interdigital nerves travel between the metatarsal heads to provide sensation to adjacent toes. The third web space (between the 3rd and 4th toes) is most commonly affected, accounting for approximately 70% of cases, likely because the medial and lateral plantar nerve branches both contribute to this web space, making the nerve slightly larger and more prone to compression.
The interdigital nerves travel between the metatarsal heads to provide sensation to adjacent toes. The third web space (between the 3rd and 4th toes) is most commonly affected, accounting for approximately 70% of cases, likely because the medial and lateral plantar nerve branches both contribute to this web space, making the nerve slightly larger and more prone to compression. The second web space is the next most common.
Repetitive compression (from narrow toe boxes, high heels, forefoot loading during sport, or intrinsic metatarsal anatomy) causes perineural and intraneural fibrosis. The nerve enlarges to between 5–10 mm in diameter in most symptomatic cases. The condition affects women far more frequently than men (approximately 8:1 ratio), attributable to footwear patterns.
Bilateral neuromas are uncommon; when present in multiple web spaces simultaneously, secondary causes (systemic neuropathy, inflammatory arthritis) should be excluded.
Symptoms — do you recognize these?
- Burning, electric, or shooting pain in the forefoot, typically radiating to the 3rd and 4th toes (or 2nd and 3rd toes with second space involvement)
- Numbness and tingling in adjacent toes; patients often describe the sensation of "walking on a pebble" or "bunched-up sock"
- Symptoms provoked by narrow shoes, high heels, or prolonged weight-bearing; relieved by removing shoes and rubbing the forefoot
- Mulder's click: With the foot squeezed laterally while applying direct dorsal-plantar pressure in the web space, a palpable and sometimes audible "click" is elicited as the enlarged nerve subluxes. This is the most specific clinical sign for Morton's neuroma and distinguishes it from metatarsalgia and other forefoot pain generators.
Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations. Burning forefoot pain and toe numbness deserve a proper evaluation. Simple changes can deliver fast relief.
How we diagnose it
Clinical examination (including direct web space palpation, Mulder's click provocation, and toe sensation testing) establishes the diagnosis in most patients. Documentation of the specific web space and radiation pattern is essential.
Musculoskeletal ultrasound is the preferred imaging modality: it visualizes the hypoechoic, fusiform nerve enlargement in real time, allows measurement of neuroma size, and guides therapeutic injections. Ultrasound is dynamic, cost-effective, and performed in office.
MRI may be used when the diagnosis is uncertain, symptoms are atypical, or multiple pathologies are suspected (e.g., plantar plate tear, Freiberg's infraction, stress fracture). MRI shows the neuroma as a low-signal ovoid lesion on T1 with variable T2 signal, best seen on coronal sequences.
Weight-bearing X-rays exclude bony pathology such as stress fracture, Freiberg's infraction, or sesamoid disease.
Treatment options
Morton's neuroma responds well to conservative treatment in most patients.
Non-Operative Management
Switching to shoes with a wider toe box is the single most important step and relieves symptoms in many patients on its own. A metatarsal pad placed just behind the affected area takes pressure off the nerve. A corticosteroid injection provides significant pain relief and is effective for most patients who don't respond to footwear changes alone.
Ankle Arthroscopy
Minimally invasive joint scope to treat intra-articular ankle pathology (osteochondral lesions, anterior bony impingement, and synovitis) through small portals with same-day discharge at our ambulatory surgery center.
Click for moreRecovery & rehabilitation
- Conservative: Symptom improvement with footwear/pad changes often within 2–4 weeks; injection benefit within 1–2 weeks.
- Post-neurectomy: Surgical shoe or post-op boot 2–3 weeks; progressive return to normal shoes by 4–6 weeks; full recovery 2–3 months. Return to athletic activity by 6–8 weeks.
Frequently Asked Questions
What is Mulder's click?
Will I lose feeling in my toes after surgery?
Are injections a permanent cure?
Can I have a neuroma in two web spaces?
How long is recovery after Morton's neuroma excision surgery?
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References
- Thomson CE, Beggs I, Martin DJ, et al. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. Journal of Bone and Joint Surgery (American). 2013;95(9):790–798. doi:10.2106/JBJS.J.01748
- Espinosa N, Seybold JD, Jankauskas L, Erschbamer M. Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma. Foot & Ankle International. 2011;32(6):576–580. doi:10.3113/FAI.2011.0576
- Akermark C, Crone H, Skoog A, Weidenhielm L. A prospective randomized controlled trial of plantar versus dorsal incisions for operative treatment of primary Morton's neuroma. Foot & Ankle International. 2013;34(9):1198–1204. doi:10.1177/1071100713484950
- Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic accuracy of clinical tests for Morton's neuroma compared with ultrasonography. Journal of Foot and Ankle Surgery. 2015;54(4):549–553. doi:10.1053/j.jfas.2014.09.010
- OrthoInfo. AAOS. Morton's Neuroma. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/mortons-neuroma