Physical Medicine and Rehabilitation for Morton Neuroma Treatment & Management
- Author: Kevin Berry, MD; Chief Editor: Consuelo T Lorenzo, MD more...
Treatment strategies for Morton's neuroma range from conservative to surgical management. The conservative approach to treating Morton's neuroma may benefit from the involvement of a physical therapist. The physical therapist can assist the physician in decisions regarding the modification of footwear, which is the first treatment step. Recommend soft-soled shoes with a wide toe box and low heel (eg, an athletic shoe). High-heeled, narrow, nonpadded shoes should not be worn, because they aggravate the condition.
The next step in conservative management is to alter alignment of the metatarsal heads. One recommended action is to elevate the metatarsal head medial and adjacent to the neuroma, thereby preventing compression and irritation of the digital nerve. A plantar pad is used most often for elevation. Have the patient insert a felt or gel pad into the shoe to achieve the desired elevation of the above metatarsal head.
Other possible physical therapy treatment ideas for patients with Morton's neuroma include cryotherapy, ultrasonography, deep tissue massage, and stretching exercises. Ice is beneficial to decrease the associated inflammation. Phonophoresis also can be used, rather than just ultrasonography, to further decrease pain and inflammation.
When conservative measures for Morton's neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve (as demonstrated in the images below) may be curative. Common adverse outcomes include dysesthesias radiating from a painful nerve stump after surgical excision of the Morton's neuroma. Dysesthesias may be treated as any other dysesthetic pain. (See Medication.)[7, 8, 9, 10]
Surgical options include the following:
Neurectomy with nerve burial [11, 12, 13]
Transverse intermetatarsal ligament release, with or without neurolysis
Endoscopic decompression of the transverse metatarsal ligament
A dorsal surgical approach may decrease recovery time,  although a study by Kundert et al indicated that a longitudinal plantar approach to excision of Morton neuroma is also effective, providing strong pain relief 
If surgical intervention is needed for Morton's neuroma, consultation with an orthopedic surgeon specializing in foot and ankle surgery is recommended.
Another treatment approach involves injection of the Morton's neuroma. Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints. Advance the needle through the midwebspace into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located. Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. The anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad.
Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible.
An Australian investigation using a single, ultrasonographically guided corticosteroid injection for Morton's neuroma found that 9 months after treatment, complete pain relief had occurred in 11 of the 39 neuronal studied.
Studies indicate that a dorsal approach may decrease patient discomfort.
Extracorporeal shockwave therapy
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, whereas 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.
A further nonsurgical option includes thermoneurolysis with percutaneous radiofrequency ablation. This method heats the nerve with radiofrequency to the point of neurolysis and may be as effective as surgical intervention.
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