Mortons Neuroma

Mortons Neuroma

Morton's neuroma or Morton' s syndrome is a condition resulting in pain between the third and forth toes cause by compression of a nerve.

Symptoms

Symptoms typically include pain, often with pins and needles on one side of a toe and the adjacent side of the next toe. Pain is made worse by forefoot weight bearing and can also be reproduced by squeezing the forefoot to further compress the nerve. It can be assessed using a very simple test.

The aim is to simulate the nerve being compressed and reproduce the symptoms by pressing in between the third and forth metatarsals. The therapist will squeeze the heads of the metatarsals together which compresses the nerve in between them. They may also squeeze with their finger and thumb on the top and sole of the foot which compresses the nerve top to bottom. If pain is reproduced then Mortons syndrome is a likely diagnosis.

Other things to look at whilst assessing a suspected case of morton's neuroma include:

  • Overpronation at the foot where the foot rolls in or flattens. This can cause the bones of the forefoot to compress the nerve over time.
  • Ankle range of motion should be assessed especially dorsiflexion as this suggests tight calf muscles which may contribute to overpronation of the foot.

Explained

Nerves that transmit messages to the brain from the toes pass between the metatarsal bones of the foot. If the arch in the foot is weak then this can cause the metatarsal bones to pinch the nerve causing it to become inflamed. This is most likely to happen between the 3rd and 4th bones causing a pain or numb sensation on the inside of the two toes that the nerve supplies.

Sometimes it is caused by a neuroma or benign tumour on the plantar digital nerves but it is not a true neuroma but more of a swelling of the nerves from compression. Scar tissue surrounding the nerve can also be a factor.

Morton's neuroma can be caused by ill fitting shoes which press against the nerve as well as activities involving spinning on the ball of the foot such as golfers and tennis players.

Treatment

What can the patient do?

Rest. Continuing with normal training will increase pain and inflammation and prevent the injury from healing. Wear a metatarsal pad under the forefoot which will raise and spread the bones of the forefoot taking the pressure off the nerve. Wearing metatarsal pads in the shoes under the forefoot spreads the metatarsals creating more space for the nerve.

See a sports injury professional who can advise on treatment and rehabilitation. Orthotic inserts may be required to correct any biomechanical dysfunction of the foot.

What can a sports injury specialist do?

A doctor, physiotherapist or podiatrist may prescribe anti inflammatory medication such as ibuprofen. Ibuprofen should not be taken if you have asthma. Reducing the inflammation and any swelling will allow more space for the nerve and reduce pressure and pain.

The may also fit orthotic inserts into the patients shoes which help correct any biomechanical problems with the feet. This will not directly reduce inflammation on its own but may take the pressure of the nerve allowing the foot to heal and preventing the injury returning.

Mortons syndrome taping

Taping the foot to relieve pressure on the nerve can have an instant effect on relieving pain. Exercises to strengthen the arch of the foot can also help prevent the injury returning in the future. For severe or stubborn cases surgery may be indicated.

The aim of this taping is to reduce the pressure on the painful nerve with a roll of 2.5cm or 1 inch non stretch zinc oxide tape and a small piece of padding.

Step 1

Cut a teardrop shape pad from foam padding approximately 2 to 3 cm in size depending on foot size. Some forms of padding for use in sports taping are sticky on one side which enables them to be secured to the foot just under the painful area where the nerve is being pinched.

Step 2

Secure the pad with a strip of 2.5cm non stretch zinc oxide tape to the foot. It is important that the tape is not so tight around the forefoot that is restricts normal foot expansion when walking. It may be a good idea to apply the tape partially around the foot so the two ends do not meet at the top of the foot. Spreading the toes slightly when applying can also help avoid applying the tape too tightly around the foot.

Step 3

Repeat the strips of tape twice more around the forefoot to ensure the teardrop shaped pad is completely covered and has secured the pad in place. Put a sock on over the tape to further secure it then try and walk on the foot. The tape and pad should be felt under the forefoot and have the effect of spreading the metatarsals. If the tape is too tight then the forefoot may be compressed and pain would be increased rather than relieved.

Surgery

Surgery for mortons neuroma consists of either a decompression, where more space is created for the nerve or a resection, where this part of the nerve is removed completely. This will result in some permanent minor numbness. Success rates for surgical procedures to treat mortons neuroma have a high success rate.

Rehabilitation program

Treatment for Morton's Syndrome may be based around reducing pain and inflammation, stretching the muscles of the foot, strengthening and returning to full fitness.

Morton's syndrome causes pain, numbness and tingling between the third and forth toes in the foot from compression of a nerve which passes between the metatarsal bones. The aim of treatment is to reduce pain and inflammation and prevent compression on the nerve in future.

Reducing pain and inflammation

Apply ice of cold therapy to the foot for 10 to 15 minutes every hour initially if possible reducing frequency as required as pain and inflammation is relieved. Do not apply ice directly to the skin as it may cause ice burns. Wrap in a wet tea towel or use a commercially available cold pack.

Rest from painful activities. This may initially mean staying off your feet altogether. Continuing to exercise on the foot will not allow the inflammation to reduce and the injury to heal. It is important to maintain fitness through non weight bearing exercises such as swimming or cycling or use the opportunity to work on upper body strength.

A metatarsal lift or pad is a small padded insert which is worn in shoes under the forefoot. It raises the central part of the forefoot spreading the metatarsals, increasing the space between them taking the pressure off the nerve.

The initial pain and inflammation should go away within a few days if looked after properly. However more chronic cases that do not respond to rest and ice and padding may require a corticosteroid injection as well as padding. If overpronation is obvious then the use of orthotics is essential to prevent recurrence. If there is still no improvement then surgery may be required.

Stretching and strengthening exercises

As soon as pain allows stretching and strengthening exercises can begin. Stretching for the lower leg, calf and achilles muscles can be done along with exercises to stretch the plantar fascia along the bottom of the foot.

It is important to start very gradually with the strengthening exercises to ensure the nerve is not inflamed again. Strengthening exercises are aimed at maintaining and improving the transverse arch of the foot.

Return to full fitness

When the athlete can walk without pain and have good mobility and flexibility they can begin to return to running. f biomechanical problems such as over pronation are not corrected with orthotics then it is more likely the injury will recur at this stage. An example of a gradual return to running is given below:

  • Day 1 - walk 4 minutes, jog 2 minutes, repeat 4 times
  • Day 2 - rest
  • Day 3 - walk 4 minutes, jog 3 minutes, repeat 3 times
  • Day 4 - rest
  • Day 5 - walk 3 minutes, jog 4 minutes, repeat 4 times
  • Day 6 - rest
  • Day 7 - walk 2 minutes, jog 6 minutes, repeat 4 times

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