A neuroma is a thickening of nerve tissue that may develop in various parts of the body. The most common neuroma in the foot is Morton’s neuroma, which occurs between the third and fourth toes. It is sometimes referred to as an ‘international’ neuroma. The Intermetatarsal describes its location in the ball of the foot between the metatarsal bones. Neuromas may also occur in other locations in the foot. The thickening of the nerve that defines a neuroma is the result of compression and irritation of the nerve. This compression creates enlargement of the nerve, causing the symptoms of Morton’s neuroma and eventually leading to permanent nerve damage.
Additionally, the condition has a couple of other names that are less commonly used, which are known as Morton’s metatarsalgia, Morton’s disease, Morton’s neuralgia, Morton’s nerve entrapment, plantar neuroma, and intermetatarsal neuroma.
Usually, there are no lumps or any other outward signs. The problems start gradually, with burning pain. First, there is only occasional pain, for example when you wear narrow shoes. The pain stops when you remove the triggering factor. However, as the neuroma grows, pain can become intense and lasts for days or weeks at a time.
Once it has formed, Morton’s neuroma will not go away naturally. However, the pain may improve, or even disappear for periods of time. The earlier you receive treatment, the better your chance of having the pain resolved.
With more advanced neuromas, the pain may return in episodes as you spend a lot of time on your feet, or if you continue to wear tight shoes. This may require treatments repeatedly. A neuroma can be removed entirely, through surgery. However, there is a 20-30% chance of it re-growing (also known as stump neuroma).
Causes & Symptoms
Generally, anything that causes compression or irritation of the nerve can lead to the development of a neuroma. One of the most common offenders is wearing shoes that have a tapered toe box or high-heeled shoes that can cause the toes to be forced into the toe box. Patients who are living with certain foot deformities, bunions, hammertoes, flat feet, or flexible feet are all at a higher risk for developing Morton’s neuroma. Other potential causes are activities that involve repetitive irritation to the ball of the foot, such as running or court sports. An injury or other type of trauma to the area may also lead to a neuroma.
If you have Morton’s neuroma, you may have one or more of these symptoms where the nerve damage is occurring, such as the following:
- Tingling, burning, or numbness.
- A sudden feeling of pain.
- A feeling that something is inside the ball of the foot.
- A feeling that there is something in the shoe.
Additionally, the progression of Morton’s neuroma follows this type of pattern:
- The symptoms start gradually. Firstly, they occur occasionally when wearing narrow-toed shoes or performing certain aggravating activities.
- Secondly, the symptoms may go away temporarily by removing the shoe, massaging the foot, or avoiding aggravating shoes or activities.
- Over time, the symptoms progressively worsen and may persist for several days or weeks.
- Lastly, the symptoms become much more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.
Who Gets Morton's Neuroma?
Anyone can develop Morton’s neuroma, however, the specific cause of this condition remains unknown – the condition begins as nerves in the forefoot are compressed by the long bones called the metatarsals. This occurs when these bones are more abnormal or when there is a traumatic injury to the area.
Risk factors for Morton’s neuroma include:
- Flat-feet or high arches.
- Foot deformities.
- Ill-fitting or high-heeled shoes.
- Repetitive trauma caused by running or other sports.
- Injury resulting from previous surgery.
How Does It Affect You? How Serious Is It?
Morton’s neuroma can make walking difficult and can restrict weight-bearing physical activities such as running, playing golf, tennis, skiing, soccer, and football. Patients with this foot condition may also have trouble with any activities that put pressure on the foot, even pressing the gas pedal while driving. Generally, untreated Morton’s neuroma can worsen and can progress to restrict all weight-bearing activities eventually leading to a patient sitting or lying all day because weight-bearing becomes more painful.
Patients often try to walk in a way that avoids putting weight on the ball of their Morton’s foot. After a while, some individuals with Morton’s neuroma develop an abnormal walking pattern (which is known as “abnormal gait”) due to continuous pain and pressure. This can lead to other problems such as arthritis and back pain.
Recommended Treatment & Rehabilitation
During a diagnosis, the foot and ankle surgeon will first obtain a thorough history of your symptoms and examine your foot. During the physical examination, the doctor attempts to reproduce your symptoms by manipulating your foot. Other tests or imaging studies may also be performed.
The best time to see your foot and ankle surgeon is early in the development of symptoms. Early diagnosis of Morton’s neuroma greatly lessens the need for more invasive treatments and can help you avoid any further surgical procedures. If surgery is required, surgery may be considered in patients who have not responded adequately to nonsurgical treatments. Your foot and ankle surgeon will determine the approach that is best for your condition. The length of the recovery period will vary depending on the procedure performed. Regardless of whether you have undergone surgical or nonsurgical treatment, your surgeon will recommend long-term measures to help keep your symptoms from returning. These include appropriate footwear and modification of activities to reduce the repetitive pressure on the foot.
In developing a treatment plan, your foot and ankle surgeon will first determine how long you have had the neuroma and will then evaluate its stage of development. Treatment approaches vary according to the severity of the problem. For mild to moderate neuromas, treatment options may include:
- Padding – Padding techniques provide support for the metatarsal arch, thereby lessening the pressure on the nerve and decreasing the compression when walking.
- Ice application – Placing an ice pack on the affected area helps reduce swelling.
- Orthotic devices – Custom orthotic devices provided by your foot and ankle surgeon provide the support needed to reduce pressure and compression on the nerve.
- Activity modifications – Activities that put repetitive pressure on the neuroma should be avoided until the condition improves.
- Shoe modifications – Wear shoes with a wide-toe box and avoid narrow-toed shoes or shoes with high heels.
- Medications – Oral non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
- Injection therapy – Treatment may include injections of cortisone, local anesthetics, or other agents.
Some common interventions in the treatment of Morton’s neuroma include:
- Manual therapeutic technique (MTT) – Hands-on care including soft tissue massage, deep friction massage, manual stretching, and joint mobilization by a physiotherapist to regain mobility and range of motion of the foot and nerves.
- Therapeutic exercises (TE) – including stretching and strengthening exercises to help regain range of motion and strengthen the foot and affected muscle.
- Modalities – these can include the use of ultrasound, electrical stimulation, ice, cold laser, and others to decrease pain and inflammation at the foot and nerves.
- Neuromuscular Reeducation – to restore stability, retrain the lower extremity, and improve movement technique and mechanics in daily use of the involved lower extremity. This may also involve the use of pads, taping, and modification of footwear.
- Home programmes – including strengthening, stretching, stabilization exercises, and instructions to help the patient perform daily tasks and advance to the next functional level.
The primary goal for foot pain exercises is to restore normal function and get you back to your regular life. This is accomplished by reducing pain, boosting healing potential, restoring flexibility, and promoting better overall foot strength and balance. Use the combination of stretching and strengthening exercises below for the best possible results:
Toe scrunch with a towel
Place a small towel flat on the floor and place your foot in the center of it. With your feet comfortably flat on the floor, begin to scrunch the towel by grabbing it with your toes. Lift the toes and then curl them toward the ball of your foot as you attempt to scrunch the front edge of the towel closer to your foot. Keep your heels resting on the ground. Focus on one foot at a time. Repeat this exercise 15-20 repetitions for up to 3 sets per day.
Self-massage of the foot with a ball can be a great daily exercise for foot pain management. Grab a textured massage or tennis ball to get started. Sit in a comfortable chair and place your massage tool under the ball of your foot. How much pressure to place depends on what you can tolerate without tensing up and increasing pain. Roll the ball under the clockwise for 10-20 repetitions before switching directions.
Standing calf stretch
Firstly, stand near a wall or the back of a chair for balance. Then, step into a staggered lunge position with the foot / calf you want to stretch in the back. Keep your back knee straight, both of your feet firmly planted on the ground and toes pointing forward as you shift your weight into your front foot. Bend the front knee as you shift your weight forward until you feel a strong stretch in the back of the calf. Finally, hold for 30 seconds for 2-3 sets on each leg.
Big toe strengthening
Grab a light resistance band, then place the band around the big toe and hold the ends in both hands at a comfortable resistance level. Allow the toe to lift up towards the ceiling before pushing against the resistance back down toward the floor. Keep the movement at a slow pace and controlled in both directions. Repeat for 10-15 for 2-3 repetitions on each foot.
Alternative & Homeopathic Treatment
If you have aggravating pain at the bottom of your feet between your middle toes, possibly indicating Morton’s neuroma, you can first try home remedies before seeing a doctor. Some of the most effective home treatments include the following:
- Rest – Taking some time off from donning heels and from your regular high-impact exercises can help provide relief from the pain. You may also massage the affected area of your foot to facilitate circulation.
- Ice pack – In addition to rest, you may also apply ice therapy on the painful area to help alleviate pain and reduce swelling. You can use an ice pack to roll over the affected area; be sure to take breaks so you do not develop frostbite on your skin.
- Over-the-counter medication – Your first-aid medication for pain is non-steroidal anti-inflammatory drugs (NSAIDs). These over-the-counter medicines can provide immediate relief to your foot pain and reduce swelling.