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Physical Medicine and Rehabilitation for Morton Neuroma Clinical Presentation

  • Author: Kevin Berry, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Jan 11, 2016
 

History

Obtaining an accurate history is important to making the diagnosis of Morton's neuroma. Possible reported findings provided by the patient with Morton's neuroma include the following:

  • The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma.
  • Pain is described as sharp and burning, and it may be associated with cramping.
  • Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain.
  • Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks.
  • Some patients describe the sensation as "walking on a marble."
  • Massage of the affected area offers significant relief.
  • Narrow tight high-heeled shoes aggravate the symptoms.
  • Night pain is reported but is rare.
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Physical

Many sources acknowledge that the examination of patients with Morton's neuroma frequently is negative. However, studies have shown that a clinical history and examination may be more sensitive than ultrasonography or MRI.[3] Most often, sensation is wholly intact and maneuvers are unsuccessful in reproducing the characteristic pain. Palpation of the actual neuroma seldom is successful. Most clinicians focus on the history and on the lack of additional findings that might suggest other disorders.

  • Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating neuropathic pain. Pain localized only to the plantar aspect of the webspace also may be consistent with Morton's neuroma.
  • The squeeze test may also result in a "click" (Mulder click) as the neuroma moves between the metatarsals in the dorsal direction.[4]
  • Passive and active toe dorsiflexion may aggravate symptoms.
  • Sensory abnormalities may be observed, although motor deficits are not consistent with an interdigital neuroma because these are sensory nerves exclusively. Weakness would raise concerns for another diagnosis.
  • Careful palpation of the metatarsal heads and shafts may help to differentiate stress fractures or metatarsal head osteonecrosis from Morton's neuroma.
  • Palpation of the tarsometatarsal joint and metatarsophalangeal (MTP) joints may reveal tenderness, indicating midfoot arthritis or metatarsalgia (eg, when the tenderness is primarily on the plantar surface only) or MTP synovitis (eg, when the joint is tender with palpation).
  • Pain from MTP synovitis is aggravated with forced toe flexion. Subtle joint swelling also may coexist with MTP synovitis. Tenderness localized to the second MTP joint, along with swelling and warmth, may be, in rare cases, an early presentation of Freiburg osteochondrosis.
  • Inspection of the foot and evaluation of foot and ankle mechanics should be performed as part of the physical examination, looking for callus formation, hallux valgus, first-ray flexibility, hyperpronation, integrity of the medial arch, and gastrocnemius-soleus flexibility.
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Causes

Various factors have been implicated in the precipitation of Morton's neuroma.

  • Morton's neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion.
  • Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Morton's neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk.
  • A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleus muscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve.
  • Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointe position in ballet.[4]

See the History and Pathophysiology sections.

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Contributor Information and Disclosures
Author

Kevin Berry, MD Physical Medicine and Rehabilitation Physician, Rehabilitation Options of Issaquah

Kevin Berry, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Coauthor(s)

Richard G Bowman, II, MD Rehabilitation and Electrodiagnostic Director, Physical Medicine and Rehabilitation, Pain Management, The Center for Pain Relief

Richard G Bowman, II, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Peter Gonzalez, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, Eastern Virginia Medical School

Peter Gonzalez, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Received honoraria from Allergan for speaking and teaching.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

References
  1. Morton TG. Peculiar painful affection of fourth metatarsophalangeal articulation. Am J Med Sci. 1876. 71:37.

  2. Kim JY, Choi JH, Park J, et al. An anatomical study of Morton's interdigital neuroma: the relationship between the occurring site and the deep transverse metatarsal ligament (DTML). Foot Ankle Int. 2007 Sep. 28(9):1007-10. [Medline].

  3. Pastides P, El-Sallakh S, Charalambides C. Morton's neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg. 2012 Mar. 18(1):22-4. [Medline].

  4. O'Connor FG, Wilder RP, Nirschl R. Foot Injuries in the Runner. In:Textbook of Running Medicine. New York: McGraw-Hill; 2001. 258-260.

  5. Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015 Aug. 25 (8):2254-62. [Medline].

  6. Zanetti M, Weishaupt D. MR imaging of the forefoot: Morton neuroma and differential diagnoses. Semin Musculoskelet Radiol. 2005 Sep. 9(3):175-86.

  7. Akermark C, Saartok T, Zuber Z. A prospective 2-year follow-up study of plantar incisions in the treatment of primary intermetatarsal neuromas (Morton's neuroma). Foot Ankle Surg. 2008. 14(2):67-73. [Medline].

  8. Monacelli G, Cascioli I, Prezzemolo G, Spagnoli A, Irace S. [Surgical treatment of Morton's neuroma: our experience and literature review]. Clin Ter. 2008 May-Jun. 159(3):165-7. [Medline].

  9. Valente M, Crucil M, Alecci V. Operative treatment of interdigital Morton's neuroma. Chir Organi Mov. 2008 May. 92(1):39-43. [Medline].

  10. Lee KT, Lee YK, Young KW, et al. Results of operative treatment of double Morton's neuroma in the same foot. J Orthop Sci. 2009 Sep. 14(5):574-8. [Medline].

  11. Villas C, Florez B, Alfonso M. Neurectomy versus neurolysis for Morton's neuroma. Foot Ankle Int. 2008 Jun. 29(6):578-80. [Medline].

  12. Title CI, Schon LC. Morton neuroma: primary and secondary neurectomy. J Am Acad Orthop Surg. 2008 Sep. 16(9):550-7. [Medline].

  13. Pace A, Scammell B, Dhar S. The outcome of Morton's neurectomy in the treatment of metatarsalgia. Int Orthop. 2010 Apr. 34(4):511-5. [Medline].

  14. Faraj AA, Hosur A. The outcome after using two different approaches for excision of Morton's neuroma. Chin Med J (Engl). 2010 Aug. 123(16):2195-8. [Medline].

  15. Kundert HP, Plaass C, Stukenborg-Colsman C, Waizy H. Excision of Morton's Neuroma Using a Longitudinal Plantar Approach: A Midterm Follow-up Study. Foot Ankle Spec. 2015 Aug 7. [Medline].

  16. Rout R, Tedd H, Lloyd R, et al. Morton's neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians. Qual Prim Care. 2009. 17(4):277-82. [Medline].

  17. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int. 2008 May. 29(5):483-7. [Medline].

  18. Yap LP, McNally E. Patient's assessment of discomfort during ultrasound-guided injection of Morton's neuroma: selecting the optimal approach. J Clin Ultrasound. 2012 May 15. [Medline].

  19. Fridman R, Cain JD, Weil L Jr. Extracorporeal shockwave therapy for interdigital neuroma: a randomized, placebo-controlled, double-blind trial. J Am Podiatr Med Assoc. 2009 May-Jun. 99(3):191-3. [Medline].

  20. Moore JL, Rosen R, Cohen J, Rosen B. Radiofrequency thermoneurolysis for the treatment of Morton's neuroma. J Foot Ankle Surg. 2012 Jan-Feb. 51(1):20-2. [Medline].

  21. Betts LO. Morton's Metatarsalgia. Med J Aust. 1940. 1:514.

  22. Lee MJ, Kim S, Huh YM, Song HT, Lee SA, Lee JW, et al. Morton neuroma: evaluated with ultrasonography and MR imaging. Korean J Radiol. 2007 Mar-Apr. 8(2):148-55. [Medline].

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Plantar view showing the relationships between the metatarsal heads, the intermetatarsal ligament, and the neuroma.
Neurectomy: typical incision location.
Neurectomy: superficial exposure.
Neurectomy: deeper dissection.
Neuroma and adherent fibrofatty tissue.
 
 
 
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