eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Morton Neuroma: Treatment & Medication
Updated: May 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
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.
Surgical Intervention
When conservative measures for Morton's neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve may be curative. (See images below and Images 2-5.) 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.)6,7,8
Surgical options include the following:
- Neurectomy with nerve burial9,10
- Transverse intermetatarsal ligament release, with or without neurolysis
- Endoscopic decompression of the transverse metatarsal ligament
Neurectomy: typical incision location.
Neurectomy: superficial exposure.
Neurectomy: deeper dissection.
Neuroma and adherent fibrofatty tissue.
Consultations
If surgical intervention is needed for Morton's neuroma, consultation with an orthopedic surgeon specializing in foot and ankle surgery is recommended.
Other Treatment
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 neuromas studied.11
Medication
Dysesthesias may be treated as any other dysesthetic pain. Tricyclic antidepressants, such as amitriptyline at 10-25 mg PO qhs, may be tried. If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective.
Tricyclic antidepressants
A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active re-uptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain. Low doses, 10-25 mg qhs, may provide pain relief from burning and tingling occurring at rest but function only as an adjunct to definitive treatment.
Adult
10-25 mg PO qhs
Pediatric
Not recommended
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, and renal or hepatic impairment; avoid use in elderly patients
Anticonvulsants
Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants).
Gabapentin (Neurontin)
Neuromembrane stabilizer useful in pain reduction with dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors.
Adult
300-1200 mg PO qhs or divided bid/tid
Titrate up starting at 300 mg qhs changing dose q3d up to therapeutic effect; not to exceed 3600 mg/d
Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, 300 mg tid on day 3)
Pediatric
Not recommended
Antacids may reduce bioavailability of gabapentin significantly (administer at least 2 h following antacids); may increase norethindrone levels significantly
Documented hypersensitivity, renal failure, and patients using other anticonvulsants
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe renal disease
Pregabalin (Lyrica)
Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
Adult
50 mg PO tid initially; if needed, may increase to 100 mg tid within 1 wk
Pediatric
Not established
May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min)
Serotonin-norepinephrine reuptake inhibitors
These agents inhibit neuronal serotonin and norepinephrine reuptake.
Duloxetine (Cymbalta)
Description Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake.
Adult
60 mg PO qd; may initiate with lower dose in patient unable to tolerate 60 mg/d
Pediatric
Not established
Metabolized by CYP1A2 and CYP2D6; coadministration with drugs that inhibit CYP1A2 (eg, fluvoxamine, cimetidine, ciprofloxacin, enoxacin) may increase duloxetine blood levels and toxicity; coadministration with drugs that inhibit CYP2D6 (eg, paroxetine, fluoxetine, quinidine) may increase duloxetine blood levels and toxicity; duloxetine moderately inhibits CYP2D6 and may decrease elimination of CYP2D6 substrates (eg, TCAs, phenothiazines [eg, thioridazine], type 1C antiarrhythmics [eg, propafenone, flecainide]); coadministration with MAOIs may cause serious, sometimes fatal reactions that include hyperthermia, rigidity, myoclonus, autonomic instability, mental status changes including extreme agitation, delirium, and coma
Documented hypersensitivity; uncontrolled narrow-angle glaucoma; within 14 d of stopping MAOI use (do not initiate MAOIs within 5 d of stopping duloxetine)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing, do not abruptly discontinue; caution with hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence and increased sweating
More on Morton Neuroma |
| Overview: Morton Neuroma |
| Differential Diagnoses & Workup: Morton Neuroma |
 Treatment & Medication: Morton Neuroma |
| Follow-up: Morton Neuroma |
| Multimedia: Morton Neuroma |
| References |
| Further Reading |
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References
Morton TG. Peculiar painful affection of fourth metatarsophalangeal articulation. Am J Med Sci. 1876;71:37.
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].
O'Connor FG, Wilder RP, Nirschl R. Foot Injuries in the Runner. In:Textbook of Running Medicine. New York: McGraw-Hill; 2001;258-260.
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].
Zanetti M, Weishaupt D. MR imaging of the forefoot: Morton neuroma and differential diagnoses. Semin Musculoskelet Radiol. Sep 2005;9(3):175-86.
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].
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].
Valente M, Crucil M, Alecci V. Operative treatment of interdigital Morton's neuroma. Chir Organi Mov. May 2008;92(1):39-43. [Medline].
Villas C, Florez B, Alfonso M. Neurectomy versus neurolysis for Morton's neuroma. Foot Ankle Int. Jun 2008;29(6):578-80. [Medline].
Title CI, Schon LC. Morton neuroma: primary and secondary neurectomy. J Am Acad Orthop Surg. Sep 2008;16(9):550-7. [Medline].
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].
Betts LO. Morton's Metatarsalgia. Med J Aust. 1940;1:514.
Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. Dec 1986;7(3):162-76. [Medline].
Cyriax J. Diagnosis of soft tissue lesions.In: Textbook of Orthopaedic Medicine. 8th ed. Philadelphia, Pa:. The Curtis Center;1982.
Guiloff RJ. Carbamazepine in Morton''s neuralgia. Br Med J. Oct 13 1979;2(6195):904. [Medline].
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.
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].
Mizel MS, Miller RA, Scioli MW. Orthopaedic knowledge update. In: Foot and Ankle. Rosemont, Ill:. American Academy of Orthopaedic Surgeons;1998.
Snyder RK. In: Essentials of Musculoskeletal Care. Rosemont, Ill:. American Academy of Orthopedic Surgeons;1997.
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].
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].
Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. Mar 2000;12(2):131-42. [Medline].
Yocum LA. In: Clinics in Sports Medicine. Vol 7. Philadelphia, Pa:. WB Saunders Co;1988.
Further Reading
Related eMedicine topics:
Acute Nerve Injury
Metatarsalgia
Morton Neuroma [Orthopedic Surgery]
Morton Neuroma [Radiology]
Nerve Entrapment Syndromes
Nerve Entrapment Syndromes of the Lower Extremity
Clinical guidelines:
ACR Appropriateness Criteria Chronic Foot Pain
Ankle and Foot Complaints
Clinical studies:
Comparison of Alcohol and Steroid Injection for Treating Morton's Neuroma
Is Ultrasonography Comparable to MRI for the Detection of Morton Neuroma of the Foot?
Keywords
Morton neuroma, Morton's neuroma, neuroma, metatarsal, foot surgery, foot pain, feet pain, metatarsals, neuroma surgery, foot neuroma, neuromas, neuroma treatment, metatarsalgia, plantar nerve, interdigital nerve, Morton's metatarsalgia, interdigital neuroma, plantar neuroma, Morton metatarsalgia
