Physical Medicine and Rehabilitation for Morton Neuroma Treatment & Management

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

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.

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Surgical Intervention

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 ligamentNeurectomy: typical incision location. Neurectomy: typical incision location. Neurectomy: superficial exposure. Neurectomy: superficial exposure. Neurectomy: deeper dissection. Neurectomy: deeper dissection. Neuroma and adherent fibrofatty tissue. Neuroma and adherent fibrofatty tissue.
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Consultations

If surgical intervention is needed for Morton's neuroma, consultation with an orthopedic surgeon specializing in foot and ankle surgery is recommended.

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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.[14]

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.[15]

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Proceed to Medication
 
 
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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