Morton’s Neuroma

Morton’s neuroma is a foot condition that develops as a result of thickening of the nerve tissue between the toes due to chronic pressure and causes sharp pain while walking. Early diagnosis is important to prevent the progression of symptoms.

The symptoms of Morton’s neuroma become evident especially as a burning, stabbing, and electric shock-like sensation between the third and fourth toes. The pain that increases during walking intensifies with mechanical stimulation of the compressed nerve and guides clinical examination.

Diagnostic methods for Morton’s neuroma are based on the evaluation of Mulder’s sign during physical examination and demonstrating nerve thickening with ultrasonography. MRI provides additional information in the differential diagnosis of complex cases.

Treatment of Morton’s neuroma aims to control symptoms with offloading insoles, medication, and injection applications. In resistant cases, surgical decompression or neuroma excision are among the effective methods that provide permanent relief.

What Is Morton’s Neuroma?

Morton’s neuroma is a painful nerve entrapment condition in the foot that usually occurs due to thickening of the nerve located between the third and fourth toes. It is characterized by burning, tingling, or an electric shock-like sensation spreading to the toes, which worsens with wearing shoes. Standing for long periods or wearing tight shoes may increase the complaints. Treatment options include orthopedic insoles, injections, and surgical procedures.

Why Does Morton’s Neuroma Occur?

Many patients become worried when they hear the word “neuroma” in the diagnosis and think this is a type of tumor or cancer. However, it is important to know that Morton’s neuroma is not a neoplastic growth, meaning it is not a true tumor. This condition is rather a degenerative process that develops as a result of a mechanical problem. The sensory nerves that go to our toes pass between the metatarsal bones of the forefoot. During this passage, they travel beneath a strong band of connective tissue called the transverse ligament, which holds the bones together.

While walking or standing, this nerve may occasionally become trapped between the metatarsal heads and this firm ligament. When this entrapment becomes continuous or is exposed to repetitive trauma, the body develops a defense mechanism. In order to protect the nerve, it begins to form hardened tissue around the nerve sheath, known as fibrosis. You can compare this to a callus that forms on a hand that is used excessively. The nerve sheath thickens and becomes edematous, which further narrows the canal through which the nerve passes, creating a vicious cycle. As a result, as the pressure on the nerve increases, the pain and discomfort also intensify. In the medical literature, this condition is sometimes referred to as “interdigital neuritis” or “nerve entrapment syndrome,” but it is most commonly known as Morton’s neuroma.

What Are the Symptoms of Morton’s Neuroma?

The complaints that lead patients to consult a doctor are usually very typical and follow a characteristic pattern. Pain is the main symptom of the condition, but its nature may show slight variations from person to person. Generally, the pain is concentrated in the ball of the foot, that is, in the cushion-like area just behind the toes.

The most frequently reported symptoms include:

• Burning sensation
• Electric shock-like pain
• Stabbing pain
• Numbness
• Tingling
• Sensation of a foreign body

These symptoms become more pronounced especially when wearing tight shoes, standing for long periods, or walking on hard surfaces. Many patients state that the pain eases or completely disappears when they take off their shoes and massage their feet. In some cases, the pain radiates toward the tips of the toes, and sometimes it may extend up the leg. The feeling of “a pebble in the shoe” is one of the most distinguishing features of this condition. Patients frequently feel the need to check the inside of their shoes, shake them out, or readjust their socks, but the source of the discomfort lies not outside, but in the nerve tissue inside the foot.

Why Is Morton’s Neuroma Seen Particularly Between Certain Toes?

The anatomical structure is the most important factor determining where this condition occurs. The vast majority of cases are seen in the space between the third and fourth toes, that is, in the 3rd web space. There is a very specific biomechanical reason for this. At this point in the sole of the foot, branches of the two main plantar nerves (medial and lateral plantar nerves) join together and form a thicker nerve trunk.

The nerve being thicker at this point makes it more prone to entrapment in the narrow space between the bones. In addition, the third and fourth metatarsal bones may be more mobile than the others, which creates a scissor-like effect over the nerve and increases the trauma. The second most common location is between the second and third toes. Occurrence between the big toe and second toe or between the fourth and fifth toes is quite rare. Therefore, in a patient presenting with forefoot pain, the exact location of the pain gives us very important clues in making the diagnosis.

What Are the Risk Factors for the Development of Morton’s Neuroma?

It is difficult to attribute the emergence of this condition to a single cause; the process usually begins with the combination of several factors. However, statistics reveal a very clear picture: the incidence in women is approximately 8 to 10 times higher than in men. This is closely related to lifestyle and footwear preferences rather than genetic predisposition.

The most prominent risk factors include:

• High-heeled shoes
• Pointed-toe shoes
• Flatfoot
• High-arched foot structure
• Bunion deformity
• Hammer toe
• Excess body weight
• Repetitive trauma

Shoe choice plays a critical role. High-heeled shoes shift body weight from the heel entirely onto the forefoot, that is, the metatarsal heads. When combined with a pointed toe box, the metatarsal bones are squeezed toward each other. The nerve in between becomes crushed under both the load from above and the pressure from the sides. Furthermore, those who participate in sports that repeatedly stress the forefoot—such as running, ballet, or tennis—have an increased risk. Structural foot deformities, such as overpronation (foot rolling inward), increase the mobility of the metatarsal bones and intensify friction over the nerve.

How Is Morton’s Neuroma Diagnosed?

The diagnostic process begins with the patient’s history. Your doctor first asks when the pain started, which types of shoes aggravate it, and about the nature of the pain. Physical examination forms the backbone of the diagnosis. During the examination, specific pressure tests are applied over the forefoot to identify the source of the pain.

One of the most reliable diagnostic methods is the maneuver known as the “Mulder Test” or “Mulder’s Sign.” In this examination, the physician squeezes the metatarsal bones from the sides with one hand while applying pressure from below to the suspected area with the other hand. If a thickened nerve (neuroma) is present in that region, it may slip between the bones, producing a “click” sound or sensation. The appearance of the patient’s typical pain together with this click largely confirms the diagnosis.

Which Conditions Can Be Confused with Morton’s Neuroma?

Unfortunately, Morton’s neuroma is not the only cause of forefoot pain (metatarsalgia). For successful treatment, other conditions that present with similar symptoms must be ruled out. Sometimes a patient may receive a “neuroma” diagnosis, but the underlying problem may actually be entirely bone- or joint-related.

Other conditions considered in the differential diagnosis include:

• Stress fractures
• Metatarsal head avascular necrosis
• Joint osteoarthritis
• Rheumatoid arthritis
• Bursitis
• Tendonitis
• Ganglion cysts
• Plantar plate tears

Stress fractures are particularly common in individuals who engage in intense physical activity and may mimic neuroma pain. Inflammation of fluid-filled sacs called bursae can also compress the nerve and cause similar complaints. Therefore, diagnosis must be based not only on symptoms but on a comprehensive assessment.

Which Imaging Methods Are Used for Morton’s Neuroma?

Although physical examination is often sufficient for diagnosis, imaging methods are used to confirm the diagnosis, determine the size of the neuroma, and exclude other possible conditions. X-rays do not show soft tissues such as nerves, but they are always taken to evaluate the bone structure. X-rays are the first step in ruling out bone-related problems such as stress fractures or osteoarthritis.

The main methods used to evaluate soft tissue are:

• Ultrasonography
• Magnetic Resonance Imaging (MRI)

Ultrasonography is both practical and allows dynamic examination. While examining the region with the ultrasound probe, the physician can simultaneously apply pressure to observe the movement and entrapment of the nerve in real time. MRI, on the other hand, provides more detailed mapping. In cases where surgery is planned or when the diagnosis is uncertain, MRI displays all anatomical structures in the area in great detail. However, it should be remembered that neuroma-like images may also appear on MRI in asymptomatic individuals, so imaging findings must always be correlated with the patient’s complaints.

What Are the Non-Surgical Treatment Options for Morton’s Neuroma?

The treatment approach always follows a “stepwise” strategy. In other words, the least invasive methods are tried first, and if there is no response, more advanced treatments are considered. The vast majority of patients can achieve relief without surgery through lifestyle modifications and conservative treatments. The first step is to eliminate the mechanical factors that cause pain.

The main strategies applied within this scope include:

• Shoe modification
• Custom-made insoles
• Use of metatarsal pads
• Activity modification
• Cold application
• Anti-inflammatory medications

Changing shoes is the most critical step. Shoes with a wide toe box that do not squeeze the toes and with low heel height should be preferred. In this way, the metatarsal bones move away from each other and pressure on the nerve is reduced. Custom-made insoles, particularly those with “metatarsal pad” support, relieve the load on the metatarsal heads by supporting the arch of the foot. This pad is placed just behind the painful area and lifts the metatarsal bones upward, creating more space for the nerve.

Are Injection Treatments Effective for Morton’s Neuroma?

In patients whose pain persists despite shoe and insole modifications, the next step is injection therapy. The goal of these treatments is to relieve the nerve by reducing local edema and inflammation, or to block nerve conduction and thus stop the pain. The most important factor in the success of injections is performing the procedure under ultrasound guidance rather than “blindly.” With ultrasound, the needle can be placed into or next to the nerve sheath.

Injection methods used include:

• Corticosteroid injections
• Local anesthetic combinations
• Alcohol ablation
• Radiofrequency ablation

Corticosteroid injections are known for their strong anti-edema effects. They rapidly reduce swelling around the nerve and provide significant relief. However, this relief may sometimes be temporary, and repeated corticosteroid injections can cause thinning of the fat tissue in the area, so they must be used with caution.

Another option is alcohol neurolysis (ablation), which involves injecting high-concentration alcohol around the nerve to chemically desensitize it. This method can be considered as an alternative to surgery and aims to permanently or long-term interrupt pain transmission. In radiofrequency treatment, thermal energy is applied to the nerve via special needles to interrupt pain signal transmission.

When Is Surgery Necessary for Morton’s Neuroma?

Surgical intervention is not the first-line option; it is considered the last resort when all other methods have been tried and have failed. Generally, if pain persists for 3 to 6 months despite shoe modification, insole use, and injection therapy, and continues to limit daily activities, surgery is recommended. The purpose of surgery is to remove the compressed and thickened nerve tissue (neuroma) and thus eliminate the source of pain. This procedure is medically referred to as “neurectomy.”

Which Techniques Are Used in Morton’s Neuroma Surgery?

There are basically two different approaches for surgery: access from the top of the foot (dorsal) or from the sole (plantar). Each method has its own advantages and disadvantages, but due to certain technical advantages, plantar approach, that is, an incision from the sole of the foot, has become increasingly preferred in modern orthopedic surgery.

The main differences between these surgical approaches are:

• Dorsal approach
• Plantar approach

In the dorsal approach, the incision is made on the top of the foot, and postoperative wound healing may seem more comfortable since no direct weight is placed on the stitches. However, in this method, the transverse ligament may need to be cut to access the nerve, which may later cause spreading and instability in the forefoot. Additionally, reaching the nerve root from this direction is more difficult, increasing the risk of incomplete removal.

In the plantar approach, the incision is hidden in a non–weight-bearing area of the sole. The greatest advantage of this method is that it provides a very clear view of the nerve and neuroma. The surgeon can reach the nerve without cutting the transverse ligament and can cut the nerve from a more proximal (deeper) point. This is the most important factor in minimizing the risk of recurrence.

What Is the Recovery Process Like After Surgery?

The surgery is usually a day-case procedure or may require an overnight stay. It can be performed under regional anesthesia or light sedation. After surgery, a special dressing or postoperative shoe is placed on the patient’s foot. Although recovery varies from person to person, it generally follows a similar course.

Important points during the recovery process include:

• Rest
• Elevation of the foot
• Wound care
• Gradual weight-bearing
• Use of wide shoes

Keeping the foot elevated above heart level for the first few days is very important to reduce swelling (edema). Stitches are usually removed within 2–3 weeks, or absorbable sutures may be used. Patients are often allowed to walk by bearing weight on the heel, but full weight-bearing and transition to regular shoes may take 3–4 weeks.

Are There Risks Associated with Morton’s Neuroma Surgery?

As with any surgical procedure, neuroma surgery has certain risks and consequences. The most notable of these is permanent numbness. Because part of the nerve is removed, permanent numbness develops between the toes that receive sensation from that nerve (usually the facing sides of the third and fourth toes. However, the vast majority of patients do not consider this numbness a problem, as they are relieved of severe pain, and many are barely aware of it.

Other possible complications include:

• Wound infection
• Hematoma
• Scar sensitivity
• Stump neuroma

One of the most troublesome postoperative complications is the formation of a “stump neuroma.” This occurs when the cut end of the nerve grows back in an uncontrolled manner and forms another painful lump. It usually happens when the nerve is not cut far enough proximally during the first surgery, leaving the cut end again in a weight-bearing and pressure-prone area. One of the reasons the plantar approach is preferred is that it allows the nerve to be cut from a more proximal point, thus reducing this risk.

Does Morton’s Neuroma Recur?

The recurrence rate after successful surgery is quite low. However, if a stump neuroma develops as described above, or if a different nerve branch in the same area is affected, symptoms may return. In addition, if patients continue their risk factors after surgery (for example, persistently wearing tight, high-heeled shoes), new neuromas may form in other web spaces even if there is no recurrence at the original site.

Treating recurrent cases is more complex and usually requires revision surgery. In revision procedures, if the first surgery was performed dorsally, a plantar approach is typically chosen to reach the nerve root. Therefore, performing the first surgery with the correct technique and with adequate resection is the most critical factor for long-term success.

Frequently Asked Questions

In which foot and between which toes is Morton’s neuroma most commonly seen?

Morton’s neuroma most commonly occurs due to thickening of the nerve between the third and fourth toes. Since this is where the nerve is most frequently compressed, most cases are observed in this web space.

Why is Morton’s neuroma more common in women?

High-heeled and pointed-toe shoes place excessive pressure on the forefoot. This pressure irritates the nerve and increases the risk of Morton’s neuroma in women.

What kind of pain does Morton’s neuroma cause in the foot?

Patients describe burning, stabbing, electric shock-like pain in the forefoot that may radiate to the toes. Prolonged standing and tight shoes worsen these complaints.

How is Morton’s neuroma recognized on physical examination?

When the metatarsal bones are squeezed during examination, a “click” sound or sensation and an increase in pain are noted. This is called Mulder’s sign and is highly characteristic of Morton’s neuroma.

Which other foot conditions can be confused with Morton’s neuroma?

Stress fractures, metatarsalgia, synovitis, plantar fasciitis, and ganglion cysts can cause similar pain and may be confused with Morton’s neuroma. A careful differential diagnosis is essential.

Can Morton’s neuroma be completely resolved with non-surgical treatment?

In mild to moderate cases, significant relief can be achieved with appropriate footwear, orthopedic insoles, and injection therapies. However, surgery may be necessary in resistant cases.

Which injection treatments are used for Morton’s neuroma?

Injections of local anesthetics and corticosteroids can reduce pain. More advanced options include alcohol ablation and radiofrequency applications.

When does surgery for Morton’s neuroma become unavoidable?

If pain persists despite at least 3–6 months of conservative treatment, quality of life is impaired, and there is a risk of permanent nerve damage, surgical intervention is required.

What is the recovery process like after Morton’s neuroma surgery?

Most patients return to normal walking within a few weeks after surgery. However, swelling and mild tenderness may continue for several months. Wide and soft shoes help facilitate this process.

Can Morton’s neuroma recur?

Since the nerve is completely removed in surgery, the likelihood of recurrence is low. However, rarely, a new “stump neuroma” can develop at the cut nerve end, causing pain again and requiring further intervention.