Management

Conservative

• success of treatment reduces with the duration of the symptoms present (1)
  • attention to footwear, orthoses (including the metatarsal pad) and calf-stretching exercises can all help to reduce pressure on the area
    • use of wider shoes with lower heels and a round toe box
    • use of a metatarsal pad (just proximal to the metatarsal head) to reduce the pressure on the forefoot
    • total contact orthoses – this will relocate the pressure into the longitudinal and transverse metatarsal arch (1)
  • approximately one third of patients are helped by this conservative approach with a further third benefiting from a cortisone injection
  • injection therapy
    • blind or ultrasound-guided steroid injections may help, but their effect is rarely long-lasting (2)
    • a series of sclerosant injections (alcohol and local anaesthetic) can be used to ablate the nerves (3)
      • less commonly used in the UK
  • radiofrequency ablation
  • cryotherapy (2)
  • there is no role of anti inflammatory medication in the treatment of Morton’s neuroma (1)

Surgical

• excision of the neuroma
  • dorsal approach
    • reduces the need for non-weight-bearing and the risk of symptomatic callus formation over a plantar scar
    • also there is a risk of stump neuroma formation which would require a plantar incision and thus the initial dorsal approach leaves healthier tissue for the second surgery should it be required
  • plantar approach
    • currently reserved for the management of recurrent neuromas (1)
    • main disadvantages are painful plantar scars and plantar keratosis in about 5% cases
• transverse metatarsal ligament release with or without neurolysis.
  • can be used instead of neuroectomy
  • release of the offending structure (intermetatarsal ligament) will reduce compression of the nerve

Failure of conservative therapy, fixed toe deformities or people who do not respond to steroid injections should be referred to an orthopaedic consultant (4).

Reference:

• (1) Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005;71(6):646-55
• (2) Munir U, Morgan S. Morton Neuroma. [Updated 2017 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan .
• (3) NHS Scotland (2005) Musculoskeletal - foot and ankle