Foot Ankle Clin N Am

8 (2003) 49 – 59

Morton’s neuroma
David Kay, MD*, Gordon L. Bennett, MD
Crystal Clinic, 3975 Embassy Parkway, Suite 102, Akron, Ohio 44302, USA

Morton’s neuroma is a commonly encountered source of pain in the forefoot.

The symptoms are described as a burning pain that is often accompanied by an
electric shock pain to the third and fourth toes. The typical patient is a woman in
her 30s to 50s. Physicians are often faced with a patient that insists upon
treatment that is minimally inconvenient and curative. This article gathers a
consensus on the diagnosis and management of this troublesome malady.

Terminology
The lay population, as well as medical professionals, frequently, but incor-
rectly, refer to this problem as a neuroma or nerve tumor. This is incorrect;
histology has defined the pathology to be one of perineural fibrosis. Therefore, an
emphasis must be made to correctly define the terms:
Traumatic neuroma - proliferative mass of Schwann cells and neuritis that may
develop at the proximal end of a severed or injured nerve.
Axontmesis - interruption of the axons of a nerve followed by completed
degeneration of the peripheral segment, without severance of the supporting
structures of the nerve; such a lesion may result from pinching, crushing, or
prolonged pressure.
Neurotmesis - a type of axon loss lesion that results from focal peripheral
nerve injury, in which, at the lesion site, the nerve stroma, axon, and myelin are
damaged to varying degrees, which degenerate from that point distal; with the
most severe Neurotmesis lesions, the gross continuity of the nerve is disrupted.
Neuroplasty - plastic surgery of the nerve. Typically, this surgery is performed
to release the nerve from compressive structures.
Morton’s foot - A foot with a second metatarsal and toe that are longer than the
first toe.

* Corresponding author.
E-mail address: dbkay@earthlink (D. Kay).

1083-7515/03/$ – see front matter D 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S1083-7515(03)00004-4
50 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59

Interdigital neuritis (IDN) - a term coined by Weinfeld and Myerson that

represents the preferred term for this entity (compression neuropathy of the
plantar digital nerves). This phrase signifies an interdigital nerve compression
syndrome and more accurately represents the problem to be discussed.
By the correct application of these terms our diagnosis and treatment will be
more precise and subsequently successful.

History
The affliction of the forefoot was first described by Durlacher in 1845. Later
in the nineteenth century Morton ascribed the pain to pathology of the fourth
metatarsophalangeal joint. The initial treatment was to remove the fourth
metatarsal head to treat the pain. At this time our understanding of the pathology
is well-defined. The Morton’s neuroma is now known to be perineural fibrosis.

Anatomy and pathology

The plantar digital nerves are terminal branches of the medial and lateral
plantar nerves. The nerves run in the deep or fourth space of the foot at the
metatarsal level. The nerves are plantar to the intermetarsal ligament. Just distal to
the ligament, the nerve branches to the adjacent toes to provide sensation to the
plantar web space skin. A particular anatomic finding at the 3/4 metatarsal web
space may be the presence of a branch from the medial and the lateral plantar
nerves. It is believed that this produces a larger nerve that is tethered. These
characteristics are believed to cause a greater likelihood for local trauma that can
result in the greater incidence of symptoms in the 3/4 metatarsal web space. Amis
et al observed that the plantar digital nerve has small branches that attach directly
to the plantar skin. When the nerve is transected distal to these branches, it is
tethered to the plantar skin and will not retract into the surrounding muscle
bellies. This leaves the nerve exposed for further trauma that can result in a
painful neuroma that creates more pain than the original problem. Not cutting
these plantar skin branches is one of the causes of a so-called ‘‘recurrent
neuroma’’, although an adequate procedure was not originally performed. The
digital artery and vein are plantar to the nerve. The neurovascular bundle is
surrounded by fatty tissue that provides protection to the nerve. A small venous
plexus can be seen just distal to the intermetatarsal ligament. Congestion of the
veins may be another source of nerve irritation. It is important that careful
hemostasis be directed to these veins. Indiscriminate cautery or ligation will result
in injury to the digital vessels, whereas persistent bleeding from these veins will
create a significant postoperative hematoma. The lumbrical tendon runs parallel
with the neurovascular bundle. It is a narrow, shiny structure that, on occasion,
will cross the neurovascular bundle. When a limited exposure is used, the tendon
 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59 51

may be mistaken for the nerve. The intermetatarsal bursae may be thick and
inflamed or relatively nonexistent. The dorsal cutaneous nerves are abundant and
must be protected. The dorsal skin may be contracted when associated with claw
toes. The plantar fat pad will be retracted distally with the toes. This will add
further trauma to the metatarsal.
The pathology of removed nerves demonstrates the following histologic
changes:

 Perineural, epineural, and endoneural fibrosis

 Degenerative vascular changes
 Axonal demyelination and branching in organized and disorganized patterns
 Fibrinoid degeneration
 Arrested axonal nerve endings that generate impulses spontaneously
 An increase in sympathetic nerve fibers intermingled with other axons

Clinical presentation
The typical patient is a woman in her fourth to sixth decade; men and young,
active individuals can be affected as well. The primary complaint is intermittent
burning or electric, shock-like pain that occurs in the forefoot. Most patients state
that the pain is worsened by walking in their bare feet and can be alleviated by
wearing dress shoes. Although wearing tight shoes seems to be a paradox,
anesthesia may be created by further nerve compression. Other patients remove
their shoes to alleviate the symptoms. The most common location for the pain is
between the third and fourth toes and the next common location is between the
second and third toes. It is very unusual to have these symptoms at the first/
second and fourth/fifth interspaces. Some individuals will have pain at the sec-
ond/third/fourth interspaces, however. Some patients describe a crepitant sen-
sation when walking. Others will describe a painful numbness to the toes. The
history should be directed to the length of time that the patient has had
symptoms. Individuals with symptoms for more than 1 year will have a
decreased chance for improvement with nonoperative treatment. A notation
should be made if the patient has swelling to the small joints of the hands or feet.
Other peripheral nerve complaints in the opposite foot or the hands should alert
the practitioner to a peripheral neuropathy. Medications, such as antineoplastics,
can be causative agents of neuropathies and should be directly questioned. The
family history should note if rheumatoid or another inflammatory arthritis has
occurred. Diabetics can be prone to having a Morton’s neuroma, in addition to
diabetic neuropathy.
Treatments that have failed must be taken into account, whether these were
tried by the patient or directed by another health care provider. Nonsteroidal
medications alone are of limited benefit. Shoewear modifications need to be
identified. Some individuals will have custom foot orthoses placed into a shoe
that is already of inadequate size. These will only increase the crowding on the
52 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59

toes. The effect to the mobile first and fifth rays is to elevate heads. This creates
an even greater mechanical loading to the central metatarsal heads. Cortico-
steroid injections infrequently will be curative. Many patients will have a series
of three or more corticosteroid injections into the web space. Multiple injections
can create a variety of local problems that will exacerbate the patient’s
symptoms. Atrophic and blanched skin may occur; this is particularly noticeable
in darkly-pigmented skin. Toes that are clawed may dislocate secondary to
rupture of the collateral ligaments or the plantar plate. Systemic steroid effects
can occur, depending upon the concentration of the steroid used. In diabetics,
the blood sugars can elevate significantly. The most damaging local effect is
atrophy of the forefoot fat pad. This problem is particularly pronounced in
perimenopausal women. When the cushioning provided by the forefoot pad is
decreased, this exacerbates the local trauma to the nerves and surrounding
tissues. The only alternative is to provide external cushion with orthotics and
soft-soled shoes.
Work issues must be clearly defined. Some patients state that their symptoms
are caused by long hours of standing on concrete or terrazzo floors and insist that
they should be taken off work for an extended time. It is unlikely that this work
environment is the cause of their complaints. Workers who have to use their feet
repetitively on stiff pedals can injure their forefeet. Professional dancers, whether
classical ballet, ballroom, or flamenco, can traumatize their feet create IDN.
Professional and competitive athletes can damage the forefoot through the
constant use and abuse to the foot in their respective activities.

Physical examination
A general musculoskeletal examination is essential. The key areas to note are
generalized ligamentous laxity and signs of synovitis, particularly to the small
joints. The lower extremity range of motion must be recorded. If a patient has an
equinus contracture it will increase the forefoot loading. The skin is evaluated for
a discrete callosity or intractable plantar keratosis and central metatarsal head
callousing. Epidermoid inclusion cysts and plantar verruca can be a source of
forefoot pain. Atrophic skin and forefoot padding, pulses, capillary refill, and
sensation should be documented.
The posture of the toes, clawed or hammered, will distally displace the
forefoot fat pad and may stretch the neurovascular bundle on the intermetatarsal
ligament. A bunion deformity, when associated with a hypermobile medial
column, will add additional loading to the central metatarsals. When the toes
are splayed, this indicates inflamed and swollen intermetatarsal bursae. The shuck
test, or anteroposterior instability to the metatarsophalangeal joints, is seen with
chronic synovitis. Synovitis and intermetatarsal bursitis can be seen individually
or combined with IDN. The ‘‘click’’, described by Mulder, occurs when
dorsiflexing a metatarsal while plantarflexing the adjacent metatarsal. This is
seen in only 20% of patients with symptomatic IDN. Direct palpation of the
 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59 53

plantar web space, so that the digital nerve is compressed between the metatarsal
heads, will usually reproduce the pain. A cavovarus foot will load the forefoot
abnormally and may be a contributing factor to the development of forefoot pain.
Foot posture, cavus or planus, although it may be a contributing factor, has not
been implicated as the sole causative factor of IDN.
Observation of previous surgical scars is helpful. Is the scar dorsal or plantar?
If a keyhole dorsal incision was previously used, visualization can be limited with
inadequate nerve resection or release. Metatarsal osteotomies can create unequal
loading or transfer metatarsalgia, as well as adherent scar formation. The dorsal
cutaneous nerves can be the causative agent. If reflex sympathetic dystrophy is
present, then diagnosis of the patient will be challenging. Secondary gain has to
be gauged when dealing with postoperative and work-related problems. These
patients are typically manipulative and can show malingering tendencies.
Standing posture and gait should be examined for abnormalities, particularly
abnormally long periods on the forefoot. However, some will exhibit abnor-
mally short time period at toe off. The foot is typically externally rotated during
stance phase.
The patient’s shoes must be evaluated. Many women have shoe requirements
that are related to their occupation. Numerous women have a social preference to
wear incorrectly fitted shoes. There is excellent documentation that 90% of
women are wearing shoes that are too small for their feet (The American
Orthopaedic Foot and Ankle Society (AOFAS) position statement: women’s
shoes and foot problems. http://www.aofas.org/womensfoot.asp). The sole of the
shoe is typically thin and the shoe’s only mechanism to stay on the foot is by
tightly compressing the toes. A simple method of checking shoe sizing is to trace
the foot while the patient is standing, and place the shoe over the tracing. The
observation is made about how many ‘‘toes’’ are not contained in the toe box.
This should always be pointed out to the patient. Improper shoewear is a
contributing factor in the development and perpetuation of IDN.
An injection is often performed for diagnosis and treatment of IDN. The
injection is performed through the dorsal skin. The injected solution consists of 1
to 1.5 mL of a local anesthetic without epinephrine and is combined with a
soluble corticosteroid. The solution can be mixed or the corticosteroid can be
injected separately. Care must be taken to keep the corticosteroid away from the
skin. The intermetatarsal ligament must be perforated to place the solution
adjacent to the neurovascular bundle. This can be confirmed by observation of
the skin protruding plantarly, or by palpation of the plantar fullness during the
injection. The intermetatarsal bursae and the metatarsophalangeal joint can be
injected through the same puncture. At times, patients can be confused by the
diagnostic component of the injection. Written guidelines are made so that the
following questions are answered:

 Was there resolution of the pain? If so, what percent?

 What was the length of time that the symptoms resolved?
 Were there any adverse events related to the injection?
54 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59

The patient is instructed to call within 3 to 5 days from the injection and the
data are stored in the chart. All attempts should be made to delay surgery, if
possible, to minimize possible soft tissue problems after a corticosteroid injection.
By following the above history and physical examination, most patients with
IDN are diagnosed. Some patients can present a confusing picture, particularly
those who have had failed surgery on the symptomatic or the adjacent interspace.
When a diagnostic dilemma is encountered, it may be appropriate to obtain an
ultrasound or an MRI. The ultrasound, although accurate, is operator-dependent.
The MRI can be overly sensitive and asymptomatic neuromas may be diagnosed
and resected.
Radiographs are not diagnostic of this soft tissue condition. They can provide
valuable secondary information and help to diagnose other conditions that create
forefoot pain. The following features need to be surveyed:

 Erosive changes at the metatarsophalangeal joints

 Elongated central metatarsals compared with the first metatarsals
 Thickened cortices of the central metatarsals. This is indicative of a stress
reaction and is caused by excessive force.
 Stress fractures to the metatarsals
 Freiberg’s infraction or avascular necrosis of the metatarsal head
 Enthosopathic changes or ossification of tendon and ligament insertions

Some patients may have what appear to be abutting metatarsal heads. Surgery
should be performed to allow more space for the nerve through partial
condylectomies. This approach is reminiscent of Morton’s original treatment.
There are no convincing data in the literature that the apparent abutment is any
more than a radiographic variant. Usually MRI and ultrasonography provide little
additional information for classic patients and the cost is rarely justified.

Management

Conservative treatment
The first step is to fit proper shoewear. The ideal shoe has a last that matches
the foot. The shoe should have proper padding with slight rockering and
adjustability to accommodate any volume changes that are frequent during the
course of the day. The above-described shoe can be so unattractive that only the
desperate will consider wearing it. Now the conservative treatment becomes far
more of a challenge. There is a variety of appliances and shoe modifications that
are available that include:
Metatarsal pads. These are ovoid-shaped pads of variable materials, including
firm rubber, viscoelastic gels, and felt. These are attached to the shoe with
adhesive or shoe tacks. They can be applied to a liner that is moveable between
 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59 55

shoes. Poor positioning will worsen the pain. The pad should be located just
proximal to the metatarsal heads.
Neuroma pads. These are a smaller version of the metatarsal pads.
Metatarsal bars. This is a bar of leather or a stiff, synthetic material that is
applied to the sole just proximal to the metatarsal head. This lessens the bending
in the shoe and decreases forefoot loading.
Rocker soles. A rocker sole functions as a metatarsal bar. The height of
an effective rocker may interfere with ambulation and the appearance can
be unsatisfactory.
Drill and fill. The shoe liner and sole are removed. A hole is drilled at the point
of contact of the prominent metatarsal head. The defect is filled with a soft
material, such as plastizote. The liner is reinserted to prevent a trampoline effect
over the hole. A second, thin, half sole can be applied over the existing sole. This
modification has been used very successfully for a variety of forefoot disorders,
including IDN.
Custom shoes. There will be times that only custom shoes will be appropriate.
For most people they are cost-prohibitive.
Basic shoewear changes are the initial treatment and are essential to the
proper management of IDN. When this treatment is ineffective, then a corti-
costeroid injection is recommended. When the symptoms recur, then surgery
is advised.

Surgery
When surgery is recommended, it is critical that the patient is advised about
the expectations. Many individuals are given the false impression that they will
be up and dancing within a few days of surgery. All too often, a guarantee that
they will be ‘‘as good as new’’ is inferred to the patient. Although the recovery
from this surgery can be rapid, it is advisable to impart realistic expectations.
When a rate of 85% good to excellent results occurs, then 15% of patients will be
unhappy. IDN is frequent enough in the general population that a significant
number of patients will be dissatisfied. It is far better preoperatively to discuss:

 The potential of an incorrect diagnosis

 The need to continue wearing correct shoes
 The implications of true neuroma formation
 The swelling and stiffness that is the normal recovery with all foot surgery
 Numbness to the affected webspace
 Further dysfunction to the forefoot

In the preoperative evaluation, a thorough foot evaluation was performed.

When IDN is associated with hallux disorders and lesser toe deformities, it is
generally advised to correct these problems without surgically addressing the
IDN. The philosophy is that by correcting the mechanical abnormalities of the
foot, the symptoms of IDN will resolve; however, they may not. A dilemma will
56 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59

arise when the complaints affect two adjacent web spaces. Nerve resection will
leave an anesthetic central toe. This may be far more troublesome than the
preoperative complaints. When using a typical 3-cm dorsal incision, it is
important that patients understand that a significant amount of dissection will
be needed to resect or release the nerve. This can create postoperative bruising
and hematoma formation. Therefore, limited weight bearing and elevation in the
early postoperative period is essential for proper wound healing.
Anesthesia for surgery can range from a general anesthetic, popliteal block, to
an ankle block. Longer acting anesthetics are preferred for postoperative
analgesia. A tourniquet is typically used to improve visualization. It is imperative
to remove the tourniquet before wound closure so hemostasis is maintained.
Bipolar cautery is advisable to reduce the trauma to the surrounding structures.
Loupe magnification is useful to correctly visualize the anatomic structures,
particularly the dorsal cutaneous nerves. A metatarsal neck retractor will enhance
the visualization of the nerve and blood vessels. Proper visualization is a key
element to all surgical intervention.
The next decision is whether to approach the nerve dorsally or plantar. The
dorsal approach was shown to have a quicker recovery; with the correct
instrumentation, the nerve can be readily visualized. The intermetatarsal ligament
is typically sectioned; however, it is possible to resect the nerve without this step.
There is no conclusive evidence that release of the ligament will create
mechanical instability to the metatarsal heads. The dorsal cutaneous nerves must
be protected. The plantar approach will allow direct visualization of the nerve.
The incision should be just medial or lateral to the metatarsal head. An incision
directly over a bony prominence can be painful. The skin edges must be
accurately opposed with a minimum number of sutures. An inclusion cyst can
form from the punctures created by the needle.

Nerve resection
The most common method for surgical treatment of IDN is nerve resection.
When the decision has been made, it should be made clear to the patient that a
true neuroma will be created. The nerve should be resected proximal to the
intermetatarsal ligament. If the nerve is resected distal to the ligament then it
will not retract into the foot. The true neuroma will then be prone to trauma.
Metatarsal neck retractor is essential for visualization. The cut end of the nerve
may be ligated or cauterized to reduce the neuroma formation. Neither of these
maneuvers has been shown to enhance the results, however. The cut end of the
nerve should be protected by the intrinsic foot musculature, usually the
transverse or oblique head of the adductor hallucis. If a tourniquet is used
it should be released so that proper hemostasis can be obtained. The nerve
should be sent to pathology to determine if the nerve was resected and that it
demonstrated perineural fibrosis. On occasion the anatomy is unclear; in this
case a frozen section should be sent for pathologic confirmation. Wound
closure is generally the skin only and a bulky compressive dressing is applied.
Weight bearing can be immediate; however, it should be limited for 7 to
 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59 57

14 days. When the plantar incision is used, weight bearing should be delayed
for 10 to 14 days

Nerve decompression
The approach to nerve decompression is dorsal. The intermetatarsal ligament
and the fascia to the adductor hallucis are released. When the nerve is scarred,
an epineurolysis can be performed. Routine epineurolysis is not recommended
because of excessive scar formation about the nerve. The surrounding fat
should not be removed; thickened and inflamed intermetatarsal bursae may be
resected, however. The nerve will often demonstrate an indentation or ‘‘hour-
glass’’ appearance that emphasizes that this is a compression neuropathy.
Sometimes the nerve is heavily scarred and adherent to the surrounding tissues.
When this occurs, the decision may be made to excise the nerve. This must be
discussed with the patient preoperatively. The postoperative course is the same
as for resection

Surgical failure
All surgical procedures can have unanticipated outcomes. It is imperative that
patients be given reasonable expectations and that all failures are scrutinized
carefully. Management of a patient with a failed procedure will need to be
handled with skill. Honest questioning of the patient will be needed. We must
clearly identify the source of the dissatisfaction.

 Did we have the correct diagnosis?

 Was the surgery performed correctly?
 Did this patient have realistic or unrealistic expectations?
 Did the patient follow the postoperative regimen? What type of shoewear is
currently being used?

The diagnosis must be clearly defined. For revision surgery the testing will
need to change. MRI, ultrasonography, serologic evaluation for inflammatory
arthritis, and electrodiagnostic testing may now be pertinent. If the surgery was
done elsewhere, an attempt should be made to obtain a pathology report. It is
imperative to determine that nerve was removed, as well as the length of the
specimen. If only a short segment of nerve was excised then a neuroma
entrapment is the usual cause of the failure. When the decision to operate has
been made, the tactics are clear. Resect the nerve to a more proximal level and
bury the stump neuroma in the intrinsic musculature. This may leave a broader
zone of anesthesia with trophic changes to the skin and subcutaneous fat. In
revision surgery, the incision can again be either dorsal or plantar, but most
surgeons choose the latter. The plantar approach gives direct access to the nerve
and its branches. The plantar branch must be protected longer than the dorsal
approach, however. Sometimes the previous dorsal scar is retracted and creates
58 D. Kay, G.L. Bennett / Foot Ankle Clin N Am 8 (2003) 49–59

toe deformities. In this case, the authors approach the nerve from the dorsal side
and address the toe deformity simultaneously.

Summary
Morton’s neuroma is a common problem. Progress has been made in the
understanding of this frequent problem since Morton’s original description and
treatment. Today, we accept a failure rate of 15% to 20%, even in the best of
series. We must ask ourselves if this is good enough. What can we do to achieve
an acceptable failure of 5% or less? How can we improve? Only through an
honest analysis and discussion can we improve the care that we deliver.

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