Physical Medicine and Rehabilitation for Morton Neuroma 

  • Author: Kevin Berry, MD; Chief Editor: Consuelo T Lorenzo, MD   more...
 
Updated: Mar 30, 2010
 

Background

Morton neuroma (interdigital neuroma), first described in 1876, is a perineural fibrosis and nerve degeneration of the common digital nerve.[1]Morton neuroma, or Morton's neuroma, is not a true neuroma, although it results in neuropathic pain in the distribution of the interdigital nerve secondary to repetitive irritation of the nerve. The most frequent location is between the third and fourth metatarsals (third webspace). Other, less common locations are between the second and third metatarsals (second webspace) and, rarely, between the first and second (first webspace) or fourth and fifth (fourth webspace) metatarsals.

Plantar view showing the relationships between thePlantar view showing the relationships between the metatarsal heads, the intermetatarsal ligament, and the neuroma. Neuroma and adherent fibrofatty tissue. Neuroma and adherent fibrofatty tissue.

Episodes of pain are intermittent. Patients may experience 2 attacks in a week and then none for a year. Recurrences are variable and tend to become more frequent. Between attacks, no symptoms or physical signs occur. Two neuromas coexist on the same foot about 2-3% of the time. Other diagnoses should be considered when 2 or more areas of tenderness are present.

Recent studies

Fridman et al investigated the efficacy of extracorporeal shockwave therapy in the treatment of Morton's neuroma. The study included 23 patients who, after more than 8 months of conservative therapy, had a visual analog scale (VAS) pain score of at least 4. In the study, 13 patients were treated with shockwave therapy, with the rest receiving a sham treatment. By 12-week posttreatment follow-up, members of the shockwave treatment group showed a significant reduction in their VAS pain score, while patients in the sham treatment group did not. The authors concluded that extracorporeal shockwave therapy may be an effective alternative to surgical excision in the treatment of Morton's neuroma.[2]

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Pathophysiology

Interdigital nerves are composed of communicating branches from the lateral and medial plantar nerves. At the level of the metatarsal heads, the interdigital nerve traverses inferior to the intermetatarsal ligament. At this site, the nerve may be compressed or stretched from repetitive toe flexion and extension. Other studies have shown perineural fibrosis and demyelination at the level of the metatarsal heads, indicating that the damage in Morton's neuroma may be more distal than the intermetatarsal ligament.[3]

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Epidemiology

Frequency

United States

Morton's neuroma is a common disease entity of the foot.

International

The incidence of Morton's neuroma is presumed to be the same internationally as in United States.

Sex

The female-to-male ratio for Morton's neuroma is 5:1.

Age

The highest prevalence of Morton's neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient.

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Contributor Information and Disclosures
Author

Kevin Berry, MD  Resident Physician, Physical Medicine and Rehabilitation Department, University of Colorado Hospital

Kevin Berry, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Medical Student Association/Foundation, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Peter Gonzalez, MD  Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine

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, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Robert J Kaplan, MD  James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine

Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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, and Association of Academic Physiatrists

Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD  Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health, Immanuel Rehabilitation Center

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. 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. May-Jun 2009;99(3):191-3. [Medline].

  3. 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. Sep 2007;28(9):1007-10. [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. 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. Mar-Apr 2007;8(2):148-55. [Medline].

  6. Zanetti M, Weishaupt D. MR imaging of the forefoot: Morton neuroma and differential diagnoses. Semin Musculoskelet Radiol. Sep 2005;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. May-Jun 2008;159(3):165-7. [Medline].

  9. Valente M, Crucil M, Alecci V. Operative treatment of interdigital Morton's neuroma. Chir Organi Mov. May 2008;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. Sep 2009;14(5):574-8. [Medline].

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

  12. Title CI, Schon LC. Morton neuroma: primary and secondary neurectomy. J Am Acad Orthop Surg. Sep 2008;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. Apr 2010;34(4):511-5. [Medline].

  14. 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].

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

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

  17. Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. Dec 1986;7(3):162-76. [Medline].

  18. Cyriax J. Diagnosis of soft tissue lesions.In: Textbook of Orthopaedic Medicine. 8th ed. Philadelphia, Pa:. The Curtis Center;1982.

  19. Guiloff RJ. Carbamazepine in Morton's neuralgia. Br Med J. Oct 13 1979;2(6195):904. [Medline].

  20. Jahss MH, Kummer F. Non-inflammatory synovitis of the second metatarsophalangeal joint and its surgical management. Paper read at: 16th Annual Meeting of American Orthopaedic Foot Ankle Society, New Orleans, La. February 1986.

  21. Logan PM, Janzen DL, O'Connell JX, et al. Magnetic resonance imaging and histopathologic appearances of benign soft-tissue masses of the foot. Can Assoc Radiol J. Feb 1996;47(1):36-43. [Medline].

  22. Mizel MS, Miller RA, Scioli MW. Orthopaedic knowledge update. In: Foot and Ankle. Rosemont, Ill:. American Academy of Orthopaedic Surgeons;1998.

  23. Snyder RK. In: Essentials of Musculoskeletal Care. Rosemont, Ill:. American Academy of Orthopedic Surgeons;1997.

  24. Terk MR, Kwong PK, Suthar M, et al. Morton neuroma: evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology. Oct 1993;189(1):239-41. [Medline].

  25. Vazquez-Abad D, Tian L, Monteon V, et al. CRI-EM is a human idiotype highly specific for scleroderma. Ann N Y Acad Sci. Apr 5 1997;815:512-5. [Medline].

  26. Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. Mar 2000;12(2):131-42. [Medline].

  27. Yocum LA. In: Clinics in Sports Medicine. Vol 7. Philadelphia, Pa:. WB Saunders Co;1988.

 
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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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