What is a Morton’s neuroma?
A Morton’s neuroma is a benign swelling of the interdigital nerves most commonly affecting the nerve between the 3rd and 4th toes. It occurs more commonly in women and has a mean age of onset of 50 yrs.
What causes Morton’s neuroma?
We are unsure of the exact cause but it is thought to be related to increased compression across the front of the foot, possibly related to wearing narrow shoes. Other abnormalities of the joints and soft tissues in the 2nd and 3rd webspaces can also cause compression of the digital nerves leading to a Morton’s neuroma. It can occasionally develop following trauma to the forefoot. There is also cross over with inter-metatarsal bursitis which is often treated as part of the same entity as Morton’s neuroma.
What are the symptoms?
The most common symptom is plantar pain related to the 2nd or 3rd webspace. Patients often describe it as feeling like they have a pebble in their shoe. 60% of people describe nerve symptoms with shooting, burning and stabbing pain often radiating into the toes and occasionally radiating towards the back of the foot. The pain is exacerbated by weight-bearing and wearing tight shoes.
How is it diagnosed?
The diagnosis is mainly based on the history of the pain and the clinical examination findings. X-rays are useful to rule out other causes of pain in the same region. An ultrasound scan and MRI can be helpful but has limited accuracy and the diagnosis is mainly based on clinical assessment.
What treatments are available?
Initial treatment involves wearing wide soft shoes with minimal heels to allow the foot to spread out reducing the pressure on the nerve. Modification of activities and anti-inflammatory medication can improve symptoms. Orthotics with a metatarsal dome support can be useful. Steroid injections can also be useful in the short term but are only effective in 30–50% longer-term. Radiofrequency ablation has been shown to provide total or partial symptomatic relief in 70% of patients.
What is the surgical treatment?
If all other management fails then the surgery involves an incision over the webspace and excision of the nerve. This is over 80% effective at relieving symptoms. The surgery involves a small incision over the top of the webspace and then excision of the bursa and the nerve in this area. This often leaves patients with an area of numbness on the toes on either side of the webspace.
What is post-operative recovery?
The surgery is carried out as a day case procedure. You will be allowed to fully weight-bear in an orthopaedic shoe but are advised to elevate the foot as much as possible in the first two weeks to reduce swelling and allow the wound to heal.
You can transition into a wide comfortable shoe as pain and swelling allow between 2–4 weeks after the surgery.
What are the risks of the surgery?
General—General anaesthetic problems, scar irritation, infection or wound healing problems, ongoing symptoms, deep venous thrombosis (DVT) and pulmonary embolism (PE).
Specific—10–15% risk on some ongoing symptoms, neuroma recurrence, numbness over the webspace and toes in 50% or more of patients.
When can I return to work?
This is always dependent on the type of work you do and the recovery period can be extremely varied for individuals.
2 weeks
- Desk work
4–6 weeks
- Standing work
8 weeks or more
- Heavy lifting work
When can I drive?
Some postoperative pain medicines can affect your concentration, mood, coordination and reactions thereby reducing your ability to drive safely. You mustn’t return to driving whilst still taking any of these medications. Please check this link for further information https://www.vicroads.vic.gov.au/safety-and-road-rules/driver-safety/drugs-and-alcohol/medicines-and-road-safety
You can not return to driving when any foot involved in driving the car is restricted by an orthotic (post-op shoe, walking boot or plaster cast).
Car type
Operated foot
Automatic
Right—2–4 weeks. When you are fully weight-bearing in normal shoes
Left—Restrictions related to post anaesthetic and pain medications
Manual
Right/Left—2–4 weeks. When you are fully weight-bearing in normal shoes
When can I run?
This is extremely variable but in general, would not be before 10–12 weeks. It is important to build up gradually from walking to light jogging. Returning to activities may increase swelling and pain but this should settle with rest in between.