Morton's Neuroma

Morton's neuroma is a thickened, irritated nerve between the toe bones, most often between the third and fourth toes. It causes burning or shooting pain in the ball of the foot and a feeling of walking on a pebble. Most people improve with wider shoes, insoles and injections; surgery is for symptoms that persist.

Despite the name, a Morton's neuroma is not a tumour. The common digital nerve, which runs between the metatarsal heads to supply two neighbouring toes, becomes swollen and scarred where it is squeezed in the narrow space between the bones. It is a compressive problem of the nerve, typically seen in women in their 40s or 50s (Gougoulias and colleagues).

What are the symptoms of Morton's neuroma?

• Sharp, radiating or burning pain between the toes, usually the third and fourth
• A sensation of walking on a pebble or a fold in the sock
• Numbness or tingling in the affected toes
• Pain that worsens with tight footwear or prolonged activity, and eases when the shoe comes off

The NHS notes that symptoms often get worse over time. True numbness is not always present.

What causes it?

• High activity levels, such as strenuous walking, running or sport
• High-heeled, pointed or tight footwear that squeezes the forefoot
• Associated foot conditions, such as bunions, hammer toes or flat feet

An instructional review in EFORT Open Reviews (Gougoulias and colleagues) explains that the neuroma is often one part of a wider pattern of forefoot overload. A tight calf, long lesser metatarsals or a bunion can all add pressure to the ball of the foot, and these may need attention alongside the nerve itself.

How is Morton's neuroma diagnosed?

Diagnosis starts with a careful history and examination. Squeezing the forefoot and pressing between the metatarsal heads usually reproduces the pain. Other causes of pain in the ball of the foot, such as plantar plate injury, joint inflammation or a nerve problem higher up the leg, need to be ruled out.

Non-surgical treatment

Most people start with simple measures:

• Wider, lower-heeled footwear to reduce pressure across the forefoot
• Maintaining a healthy weight to reduce the load through the foot
• Over-the-counter pain relief
• Custom orthotics to redistribute weight away from the neuroma

If these are not enough, an ultrasound-guided steroid injection with local anaesthetic can be offered. A Cochrane review (Matthews and colleagues) found moderate-certainty evidence that ultrasound-guided steroid and anaesthetic injections reduce pain and improve function more than injections given without ultrasound guidance. The same review found low-certainty evidence that adding steroid to local anaesthetic may make little or no difference to pain or function. Skin thinning, loss of skin colour and fat pad thinning were the recorded side effects.

The NHS lists alcohol injections as another option for severe symptoms; benefit tends to be short-lived. Shockwave therapy has not been shown to reduce neuroma pain in a randomised trial (Matthews and colleagues, Cochrane review).

When is surgery recommended?

If other treatments fail, the damaged section of nerve can be removed (neurectomy). The operation is performed as a day case under general anaesthetic, through a small incision on the top of the foot. Approaching from the top allows walking soon after surgery and avoids a scar on the sole.

In the review by Gougoulias and colleagues, several studies report good to excellent results in 70–80% of patients after nerve excision. The same review notes that only about half of patients are completely pain-free afterwards, around 30% are better but with some pain, and about one in ten is worse. Recurrent pain from the cut end of the nerve (a stump neuroma) is a recognised risk.

What is recovery like after neuroma surgery?

• 0–2 weeks: rest at home with the foot elevated, keeping the dressing dry
• 2 weeks: return to non-manual work
• 6–12 weeks: return to high-impact activities

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Morton's neuroma. NHS. https://www.nhs.uk/conditions/mortons-neuroma/
2. Gougoulias N, Lampridis V, Sakellariou A. Morton's interdigital neuroma: instructional review. EFORT Open Rev. 2019;4(1):14–24. PMID: 30800476. https://pubmed.ncbi.nlm.nih.gov/30800476/
3. Matthews BG, Thomson CE, Harding MP, McKinley JC, Ware RS. Treatments for Morton's neuroma. Cochrane Database Syst Rev. 2024. PMID: 38334217. https://pubmed.ncbi.nlm.nih.gov/38334217/