If you get a sharp, sometimes burning, pain on the ball of your foot between two toes when you walk, you may wonder what the heck is causing that. It may feel like there’s a marble in your shoe.
Such are the classic symptoms of a Morton’s neuroma, an abnormal thickening of tissue that surrounds one of the digital nerves between the long bones (metatarsals) in the foot. Typically, the nerves between the third and fourth toes are affected, though Morton’s neuromas can develop between the second and third toes, too. The pain increases with weight bearing and when wearing high heels or narrow, tight shoes because of the compression they cause in the front part of the foot. In addition to the typical symptoms, there may also be tingling or numbness in the toes.
The condition is named after Dr. Thomas George Morton, a surgeon who described this foot pain in the 19th century. But calling it a neuroma is misnomer since the condition doesn’t involve a neuroma, which is a benign tumor affecting a nerve. Typically, Morton’s neuroma is diagnosed by the symptoms and a physical exam, but imaging tests, such as ultrasound and MRI, may be used for confirmation.
Morton’s neuromas are most common in middle-aged or older women. It’s not exactly clear what causes them, but several factors are thought to be involved, including having bunions, chronically tight calf muscles, and either flat feet or high arches. Wearing high heels or tight shoes is a major contributor and may help explain the gender disparity, since men’s shoes typically have flat heels and a wider toe box compared to women’s shoes. Women are also more likely to have bunions.
In normal foot biomechanics, when you take a step forward, all your weight is transferred from your heel to the ball of the foot (the forefoot). The contributing factors noted above can increase the chance of developing a Morton’s neuroma because they cause greater pressure on the more central forefoot—in particular, on the tissues between the third and fourth toes.
Steps to take
The symptoms of a Morton’s neuroma will often resolve with relatively simple measures. Not surprisingly, ditching the high heels and narrow shoes in favor of shoes with flat heels and a sufficiently wide toe box is the standard first recommendation. Such shoes allow the metatarsal bones to spread out, relieving pressure on the nerve. It’s also worth trying an over-the-counter product, notably a metatarsal pad that sits just behind the base of the toes (or the metatarsal heads, as explained in this video). When appropriately placed, these should reduce pressure on the foot area being stressed. A podiatrist or physical therapist can make custom orthotics; they cost several hundred dollars but may be covered by some insurance plans.
Icing the area can also help reduce symptoms. You should also temporarily ease up on activities like running, hiking long distances, playing tennis, and walking barefoot on hard floors.
For chronic cases, especially if the Morton’s neuroma is large, other treatments may be warranted. Here are some options:
- Corticosteroid injections, sometimes combined with a local anesthetic, to reduce inflammation around the nerve. In most cases, these injections can provide months of relief, especially if they are done within a year of onset of the condition. In one study, however, some 30 percent of patients ended up needing surgery down the road because of persistent pain.
- Ethanol (alcohol) injections. Some studies cite improvements in pain and reduction in the size of the Morton’s neuroma after ethanol injections, but there are also reports of adverse effects, including a burning pain that may last for weeks. Another potential problem is that the injections may cause scarring, which could make surgery (see below) more difficult if that’s needed later.
- Physical therapy. Specific mobilization and manipulation of the metatarsals, as done by a physical therapist, may help reduce the pain, some research has shown. You would need to see a skilled physical therapist who can use these techniques and then show you how to do them at home. These are not mobilizations you can effectively learn by watching YouTube or other videos.
- Other treatments include radiofrequency ablation (where a heated probe is used), cryotherapy (a cold probe is used), laser therapy, shockwave therapy, and Botox injections, but these haven’t been studied enough to recommend them.
If more conservative treatments don’t help enough, surgical resection of the nerve and the tissue around it may be warranted. The method that accesses the nerve from the top of the foot (as opposed to the sole) is preferred because it allows for weight bearing sooner after surgery and is less painful. Most people get years of pain relief after surgery—or even permanent relief—but a small percentage may have continued pain and even a recurrence of Morton’s neuroma. Even after surgery, wider shoes and inserts are still recommended.
BOTTOM LINE: If you’re having foot pain, see a podiatrist or an orthopedic foot specialist as soon as possible for a proper diagnosis—caught early, a Morton’s neuroma might be more easily treated. Certainly, avoiding high heels and shoes with a narrow toe box can be helpful, as might using a properly placed metatarsal pad or orthotic. (Wearing appropriate shoes and shoe inserts may also help prevent development of a Morton’s neuroma in the first place.) A skilled physical therapist may also be worth seeking even though, as with many physical therapy treatments, well-controlled published studies of effectiveness are hard to find. Surgery should be a last resort.
