Morton's Neuroma: Symptoms, Causes & Treatment Guide

What Is Morton's Neuroma?

Morton's neuroma is a thickening of the tissue around one of the nerves leading to your toes, most commonly affecting the nerve between the third and fourth metatarsal bones in the ball of your foot. Despite its name, it is not a true tumor but rather a benign fibrous tissue growth caused by nerve compression and irritation.

Morton's neuroma develops when the interdigital nerve that runs between the metatarsal heads becomes compressed and irritated. This compression causes the nerve to swell and the surrounding tissue to thicken, forming a painful mass. The condition most commonly occurs between the third and fourth toes (in about 70-80% of cases) but can also develop between the second and third toes.

The name "neuroma" is somewhat misleading because this condition is not actually a nerve tumor. It is more accurately described as a perineural fibrosis, meaning there is thickening of the tissue surrounding the nerve rather than a growth of nerve cells themselves. The condition is also known as Morton's metatarsalgia, interdigital neuroma, or intermetatarsal neuroma.

The development of Morton's neuroma is closely related to repetitive stress and compression of the forefoot. When the metatarsal bones are squeezed together, as happens when wearing tight shoes or during high-impact activities, the nerve becomes compressed against the deep transverse metatarsal ligament that runs across the ball of the foot. Over time, this repeated trauma leads to inflammation, nerve damage, and the formation of scar tissue around the nerve.

Anatomy of the Condition

Understanding the anatomy helps explain why Morton's neuroma causes such distinctive symptoms. The interdigital nerves are branches of the medial and lateral plantar nerves that provide sensation to the toes. These nerves run between the metatarsal heads, passing through a relatively narrow tunnel formed by the metatarsal bones above, the plantar fat pad below, and the deep transverse metatarsal ligament at the top.

The third interspace (between the third and fourth toes) is particularly vulnerable because the nerve here receives branches from both the medial and lateral plantar nerves, making it slightly larger than the other interdigital nerves. This larger size, combined with the anatomical constraints of the interspace, predisposes this location to compression and neuroma formation.

What Are the Symptoms of Morton's Neuroma?

The hallmark symptom of Morton's neuroma is a sensation of standing on a pebble, marble, or fold in your sock, accompanied by sharp, burning pain in the ball of your foot that often radiates into the affected toes. Pain typically worsens with tight shoes or prolonged standing and improves when you remove your shoes and massage the area.

Morton's neuroma symptoms can vary significantly from person to person and may develop gradually over weeks to months. Initially, symptoms may be mild and intermittent, occurring only when wearing certain shoes or after prolonged activity. However, if left untreated, symptoms often become more frequent and severe over time.

The most characteristic symptom is the feeling of having something inside the ball of your foot, such as a pebble, marble, or a bunched-up sock. This sensation occurs because the enlarged nerve creates a small mass that you can feel with each step. Many patients describe this as one of the most bothersome aspects of the condition because it creates constant awareness of the foot.

Pain associated with Morton's neuroma is typically described as sharp, burning, or shooting, and it often radiates from the ball of the foot into the affected toes. The pain may be electric-shock-like or feel like a hot poker being pressed into the foot. Some patients experience numbness or tingling in the toes, while others describe a sensation of the toes being "asleep" or lacking normal sensation.

Common Symptoms Include:

• Sharp, burning pain: Located in the ball of the foot, often between the third and fourth toes
• Pebble-in-shoe sensation: Feeling of standing on a small object or sock fold
• Numbness or tingling: Often affecting the third and fourth toes
• Pain radiating to toes: Sharp pain that shoots into the affected toes
• Symptoms worse with activity: Pain increases with walking, standing, or running
• Relief when barefoot: Symptoms often improve when removing shoes
• Symptom patterns: Pain worsens with tight shoes and improves with foot massage

What Makes Symptoms Worse?

Several factors can exacerbate Morton's neuroma symptoms. Wearing tight, narrow, or high-heeled shoes compresses the metatarsal heads together and increases pressure on the nerve. Activities that involve repetitive impact to the forefoot, such as running, jumping, or prolonged standing on hard surfaces, can also worsen symptoms.

Many patients notice that symptoms fluctuate throughout the day and between days. Morning symptoms are often milder, with pain increasing as the day progresses and you spend more time on your feet. Symptoms may be particularly noticeable after a long day of walking or standing.

What Causes Morton's Neuroma?

Morton's neuroma is caused by compression and irritation of the interdigital nerve, most commonly due to tight or high-heeled footwear, repetitive forefoot stress from activities like running, and underlying foot deformities such as bunions or hammertoes. The exact cause often involves a combination of these factors.

The development of Morton's neuroma is typically multifactorial, meaning several contributing factors work together to cause the condition. Understanding these causes is essential for both treatment and prevention. The primary mechanism involves repeated compression of the interdigital nerve between the metatarsal heads and the deep transverse metatarsal ligament.

Footwear plays the most significant modifiable role in the development of Morton's neuroma. High-heeled shoes shift body weight onto the forefoot, increasing pressure on the metatarsal heads by up to 75% compared to flat shoes. Narrow toe boxes squeeze the metatarsal bones together, compressing the nerve in the interspace. This explains why the condition is 8-10 times more common in women, who more frequently wear such footwear.

Biomechanical factors also contribute significantly to neuroma development. Foot deformities such as bunions (hallux valgus), hammertoes, flat feet (pes planus), and high arches (pes cavus) alter the distribution of pressure across the forefoot and can increase stress on the interdigital nerves. People with hypermobile joints may also be at higher risk due to increased movement of the metatarsal bones.

Risk Factors for Morton's Neuroma

• High-heeled shoes: Increase forefoot pressure dramatically
• Tight, narrow footwear: Compresses metatarsal heads together
• Female gender: 8-10 times more common in women
• High-impact sports: Running, tennis, basketball, and similar activities
• Foot deformities: Bunions, hammertoes, flat feet, or high arches
• Age 40-60 years: Most commonly affects middle-aged adults
• Occupational factors: Jobs requiring prolonged standing or walking

How Is Morton's Neuroma Diagnosed?

Morton's neuroma is primarily diagnosed through physical examination, including palpation of the forefoot and the Mulder's sign test. Imaging studies such as ultrasound or MRI may be used to confirm the diagnosis and rule out other conditions, but they are not always necessary when clinical findings are clear.

Diagnosis of Morton's neuroma typically begins with a thorough medical history and physical examination. Your healthcare provider will ask about your symptoms, including when they started, what makes them better or worse, and what type of footwear you typically wear. This history often provides important clues to the diagnosis.

During the physical examination, the doctor will examine your foot, feeling for tender areas and checking for any masses in the intermetatarsal spaces. They will also assess your foot structure, looking for deformities such as bunions or hammertoes that might contribute to the condition.

Mulder's Sign

The Mulder's sign test is a classic diagnostic maneuver for Morton's neuroma. During this test, the examiner squeezes the metatarsal heads together while simultaneously applying pressure to the affected interspace from the sole of the foot. In a positive test, this produces a palpable and sometimes audible click, along with reproduction of the patient's symptoms. While not present in all cases, a positive Mulder's sign strongly supports the diagnosis.

Imaging Studies

While Morton's neuroma can often be diagnosed based on clinical findings alone, imaging studies may be helpful in uncertain cases or to rule out other conditions. Ultrasound is frequently used as a first-line imaging modality because it is readily available, relatively inexpensive, and does not involve radiation. An experienced sonographer can visualize the neuroma as a hypoechoic (dark) mass in the intermetatarsal space.

MRI (magnetic resonance imaging) provides the most detailed visualization of soft tissue structures and can identify neuromas as small as 3-5mm. MRI is particularly useful when the diagnosis is uncertain, when multiple interspaces are affected, or when planning surgical intervention. However, it is more expensive and time-consuming than ultrasound.

Differential Diagnosis

Several other conditions can cause similar symptoms to Morton's neuroma and must be considered during diagnosis:

• Metatarsalgia: General forefoot pain from various causes
• Stress fracture: Hairline fracture of a metatarsal bone
• Metatarsophalangeal joint synovitis: Inflammation of the toe joint
• Freiberg's disease: Avascular necrosis of the metatarsal head
• Tarsal tunnel syndrome: Compression of the posterior tibial nerve
• Peripheral neuropathy: Nerve damage from diabetes or other conditions

What Can I Do Myself for Morton's Neuroma?

The most important self-care measures for Morton's neuroma are wearing wide, low-heeled shoes with adequate toe room and using metatarsal pads or orthotics to reduce pressure on the affected nerve. These simple changes resolve symptoms in many patients without the need for further treatment.

Conservative self-care measures are the foundation of Morton's neuroma treatment and are effective for approximately 80% of patients. The goal is to reduce pressure on the interdigital nerve by modifying footwear and providing support to the forefoot. Most patients notice improvement within a few weeks of implementing these changes consistently.

Footwear modification is the single most important intervention. Choose shoes that have a wide toe box allowing your toes to spread naturally, a low heel (ideally less than 2.5cm or 1 inch), and adequate cushioning. Avoid tight, narrow, or pointed-toe shoes, and never wear shoes that compress your forefoot. Many patients find that athletic shoes or walking shoes with good support work well.

Choosing the Right Shoes

When selecting shoes for Morton's neuroma, consider the following guidelines:

• Length: About 1cm (half inch) longer than your longest toe
• Width: Wide enough to move your toes freely inside
• Heel height: Low heel, ideally 2.5cm (1 inch) or less
• Stability: Firm heel counter and supportive midsole
• Closure: Laces or straps for adjustable fit
• Removable insole: Allows insertion of orthotics
• Round toe: Rounded or squared toe box, not pointed

Using Metatarsal Pads

Metatarsal pads (also called metatarsal buttons or forefoot pads) are dome-shaped cushions that are placed just behind the metatarsal heads. When positioned correctly, they lift and separate the metatarsal bones, reducing pressure on the interdigital nerve. They are available over-the-counter in pharmacies and shoe stores, or can be custom-made by a podiatrist.

Correct placement is crucial for metatarsal pads to be effective. The pad should be positioned just proximal to (behind) the metatarsal heads, not directly under the painful area. When you stand, the pad should support the arch of your forefoot without causing discomfort. It may take some trial and error to find the optimal position.

Pain Relief Measures

Over-the-counter pain relievers such as ibuprofen (Advil, Motrin) or naproxen (Aleve) can help reduce pain and inflammation. These should be used as directed on the package and are most effective when combined with footwear modifications. Ice massage to the affected area for 15-20 minutes several times daily can also provide temporary relief.

Resting the affected foot and avoiding activities that aggravate symptoms can help during flare-ups. However, complete immobilization is not necessary and may lead to stiffness. Gentle stretching exercises for the toes and calf muscles may help maintain flexibility and reduce symptoms.

When Should I See a Doctor for Morton's Neuroma?

You should see a doctor if foot pain persists despite 2-3 weeks of self-care measures, if pain is severe enough to limit daily activities, if you experience numbness that spreads or becomes constant, or if you notice any signs of infection such as redness, warmth, or fever.

While Morton's neuroma is not a medical emergency, timely evaluation is important to confirm the diagnosis, rule out other conditions, and access additional treatment options if needed. Early intervention can prevent the condition from worsening and may reduce the likelihood of needing more invasive treatments.

During your appointment, the healthcare provider will perform a thorough examination of your foot, assess your symptoms, and may order imaging studies if needed. They can also provide guidance on footwear, recommend specific orthotics, and discuss treatment options ranging from injections to surgery if conservative measures have failed.

Seek Medical Attention If:

• Foot pain persists despite proper footwear and rest for 2-3 weeks
• Pain is severe enough to interfere with walking or daily activities
• Numbness or tingling in the toes is worsening or spreading
• You have diabetes or peripheral vascular disease
• You notice signs of infection (redness, warmth, swelling, fever)
• You are unsure whether your symptoms are due to Morton's neuroma

How Is Morton's Neuroma Treated?

Treatment for Morton's neuroma follows a stepped approach, starting with conservative measures (footwear modifications, orthotics, and padding), progressing to corticosteroid or alcohol injections if needed, and considering surgery only when conservative treatments fail after 3-6 months. About 80% of patients improve with non-surgical treatment.

The treatment of Morton's neuroma is guided by the severity of symptoms and their response to initial interventions. Healthcare providers typically recommend a progressive approach, starting with the least invasive options and advancing to more aggressive treatments only if necessary. This strategy is based on the excellent success rates of conservative treatment and the potential complications of surgical intervention.

The first line of treatment includes all the self-care measures discussed previously: footwear modifications, metatarsal pads, over-the-counter orthotics, and activity modifications. A podiatrist or orthopedist may recommend custom-made orthotics, which are molded to your feet and can provide more precise support than over-the-counter options.

Corticosteroid Injections

If conservative measures do not provide adequate relief after several weeks, corticosteroid injections may be recommended. These injections deliver a powerful anti-inflammatory medication directly to the area around the nerve, reducing swelling and providing pain relief. Multiple studies have shown that corticosteroid injections provide significant short-term relief in 50-70% of patients.

The injection is typically performed in the office setting and involves minimal discomfort. While many patients experience substantial relief, the effects are often temporary, lasting weeks to months. Repeated injections may be offered, although there are limits to how many can be given safely due to potential side effects such as fat pad atrophy and skin changes.

Alcohol Sclerosing Injections

Alcohol sclerosing therapy involves a series of injections of diluted alcohol into and around the neuroma. The alcohol causes controlled destruction of the nerve tissue, reducing the size of the neuroma and alleviating symptoms. Studies suggest success rates of 60-90% with this treatment, and it may be offered as an alternative to corticosteroids or when corticosteroids have provided only temporary relief.

Surgical Treatment

Surgery for Morton's neuroma is typically reserved for patients who have failed 3-6 months of conservative treatment including injections. The most common surgical procedure is neurectomy, which involves removing the affected portion of the nerve. This procedure has a success rate of approximately 80-85% for significant pain relief.

Neurectomy can be performed through either a dorsal (top of foot) or plantar (sole of foot) approach. The dorsal approach is more commonly used because it allows for faster recovery and less post-operative pain. After surgery, patients typically can bear weight in a surgical shoe within a few days and return to normal footwear within 3-6 weeks.

Potential Complications of Surgery

While surgery is generally safe and effective, patients should be aware of potential complications. The most common issue is permanent numbness in the toes adjacent to the removed nerve, which occurs in approximately 20-30% of patients. Most patients find this numbness acceptable given the relief from pain, but it should be discussed before surgery.

Other potential complications include wound infection, painful scar tissue formation (stump neuroma), recurrence of symptoms, and complex regional pain syndrome (CRPS). The overall complication rate is relatively low when surgery is performed by an experienced foot surgeon.

What Is the Outlook for Morton's Neuroma?

The prognosis for Morton's neuroma is generally excellent. With appropriate treatment, the vast majority of patients achieve significant symptom relief. About 80% improve with conservative measures alone, and surgical treatment is successful in 80-85% of the remaining cases.

Morton's neuroma is a highly treatable condition, and most patients can expect substantial improvement in their symptoms with appropriate management. The key to a good outcome is addressing the underlying causes, particularly footwear, and being consistent with treatment recommendations.

For patients who respond to conservative treatment, the outlook is particularly favorable. By maintaining proper footwear habits and using orthotics as needed, many patients can keep symptoms well-controlled long-term without further intervention. Some patients find that after a period of strict footwear modification, they can gradually return to wearing a wider variety of shoes without symptom recurrence.

For those who require surgery, the success rate is also high, with 80-85% of patients reporting significant improvement in pain. Recovery from surgery typically takes 3-6 months for full return to normal activities, though many patients are walking comfortably in regular shoes within 3-6 weeks. The permanent toe numbness that occurs in some patients is usually well-tolerated and preferable to the pre-operative pain.

Frequently Asked Questions