Is that Pain in Your Foot Morton's Neuroma?

author : mark881
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If you’ve ever had the feeling of walking around with a rock in your shoe, then you might understand the first symptoms of Morton’s neuroma.

By Mark A Pearl, MD
The Center for Morton's Neuroma

When I went on a ski trip with my family about eight years ago, I ended up in the ski shop because my foot hurt too much to ski.  I thought that my boot was too tight and that was causing the burning pain and tingling in my foot. Luckily, my wife is a Pain Medicine physician and she diagnosed a Morton’s neuroma.   So, for every subsequent ski trip, she gave me a steroid injection into my Morton’s neuroma several days before the trip, which helped.

I jog regularly and at times I felt a sharp pain in my forefoot. I knew that this was probably my Morton’s but I just tried to run through it. Sometimes that would work, sometimes it wouldn’t and I would need a steroid injection.

Eventually, my Morton’s neuroma worsened and I became frustrated with these short-term interim measures. I am a physician (and as you can gather, an avid athlete) and spent many years researching treatment options for my Morton's neuroma. I wanted a more long lasting and permanent solution but I did not want surgery because there is reasonable chance that surgery for Morton’s neuroma can result in nasty complications. (In some studies, as high as 20% of patients have post-surgical complications.) I had tried every simple non-surgical solution I could find including having custom ski boots with custom liners and custom insoles made.

So then I tried more invasive non-surgical procedures. Initially, I had the neuroma frozen (cryoablation therapy), which improved my pain substantially but the Morton’s neuroma still remained. Finally, I just wanted to get rid of it, so I had a sclerosing agent injected into the neuroma under ultrasound guidance. (Ultrasound guidance significantly improves the likelihood of success and lowers the risk of complications). After a few weeks, this procedure was repeated and since then I have had no further foot pain. I now get to ski with my family without any pain.

As a result of the many years of frustration that I suffered with Morton's neuroma and the general difficulty in receiving adequate treatment, I urged and prompted my wife to open the Center for Morton's Neuroma to help other people like me struggling with Morton’s neuroma.

Morton's neuroma symptoms

If you’ve ever had the feeling of walking around with a rock in your shoe, then you might understand the first symptoms of Morton’s neuroma. Often, this condition causes you to feel as if a rock is stuck in your shoe, your sock is bunched up, or something is poking you in the ball of the foot. 

Many people will have different experiences of Morton’s neuroma pain. To some, it will feel like they are walking on a twisted bit of sock, and some express pain when walking over a hardwood floor barefoot. Cramping, numbness, and burning are often reported, and the pain may radiate to other toes than the third and fourth ones.

The pain is generally worse when wearing shoes or with activity, and this is when it creates the feeling of a rock in the shoe. In addition, you may feel numbness and tingling in the toes as the condition affects the sensory facilities of the nerve in the foot.

In addition, the episodes of pain can be intermittent. You may experience flare-ups such as two attacks in a week, but then have no symptoms for over a month. However, the attacks tend to become more frequent as time progresses, and this will probably lead you to seek treatment. Rarely, a foot may contain two separate Morton’s neuromas, but this is not common.

What is it?

Although the word neuroma can conjure up images of cancer, Morton’s neuroma is not a cancerous tumor. It is a thickening of the tissue surrounding a nerve that supplies sensation to the upper half of the foot. It starts when the nerve that runs under the ligament between the metatarsals, or toe bones is squeezed, like when you wear a shoe that is too narrow for long periods of time. The nerve sheath becomes irritated and thickens. Once started, the thickening can progress and enlargen. Usually, it occurs in the ball of the foot between the third and fourth toes, but it can occur between other toes in the ball of the foot as well. In general, Morton’s neuroma does not indicate any serious pathology of the foot. It is common and treatable.

How is it diagnosed?

Care must be taken in diagnosing Morton’s neuroma. In some cases, nerve pathology of the entire foot can be missed because the examiner mistakenly thinks that the problem is Morton’s neuroma. For this reason, it is important to see an experienced practitioner who takes a careful history followed by an in-depth physical examination. Although the doctor may not feel a lump, if it is painful when the doctor presses on the space between the third web, then Morton’s neuroma is a likely diagnosis.

X-rays of the foot will not show Morton’s neuromas, so it is often necessary to turn to other diagnostic measures to help diagnose the condition. Magnetic resonance imaging, or MRI, is a sensitive test for diagnosing Morton’s neuroma. MRI’s can also help determine if the pain is caused by other foot problems, such as a ganglion cyst or cancerous neuroma of the foot. In addition to MRI’s, an ultrasound of the foot can be as effective as an MRI in the diagnosis of Morton’s neuroma.

Another way to determine if the pain is caused by Morton’s neuroma is through a diagnostic injection of a local anesthetic, usually lidocaine. The medication is injected directly into the nerve that serves the affected web space generally between the third and fourth toes. If the pain is eliminated by blocking this nerve, then a diagnosis of Morton’s neuroma is likely. However, if the block fails to relieve the pain, then it is more likely that the pain is caused by a different condition. This diagnostic procedure is helpful when more than one web space is experiencing pain, and it is often as definitive as other tests when the pain is diffuse. 

Treatment of Morton's neuroma

Once diagnosed, Morton’s can be effectively treated. In the early stages, it may be treated conservatively with a combination of rest, physical therapy and wearing correctly fitted shoes with orthotics. If the Morton’s neuroma progresses you have the option of a variety of procedures done under radiological or ultrasound guidance. The use of ultrasound guidance for the procedures increases the likelihood of success and decreases the chances of any complications. Recent studies have shown excellent results for the treatment of Morton's neuroma with ultrasound guided steroid injections, ultrasound guided sclerosing injections, ultrasound guided radiofrequency ablation, and ultrasound guided cyroablation. A physician experienced in treating Morton’s neuroma should work with you to create a treatment plan that is appropriate for you.


Mark A Pearl, MD runs a center that specializes in the non-surgical treatment of Morton's neuroma.  Their website is a great resource on non-surgical treatment options for Morton’s neuroma. (www.mortonsneuroma.com)

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date: April 24, 2014

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