Morton’s neuroma is a common condition affecting the forefoot. It causes pain in the ball of the foot. A neuroma is a benign tumour of a nerve. Morton’s neuroma is not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. This thickening of the nerve leads to sensitivity and pain.
Morton’s neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure. It occurs less frequently between the second and third toes, rarely between the fourth and fifth toes and never in the first web space.
The incidence of Morton’s neuroma is eight to ten times greater in women than in men and is most common in middle age.
Normally, there are no outward signs. Burning pain in the ball of the foot that may radiate into the toes is a common symptom. The pain generally intensifies with activity or wearing shoes. Night pain is rare. There may also be numbness in the toes, or an unpleasant feeling in the toes. High heeled shoes, and tight, narrow shoes can aggravate this condition by compressing the toe bones and pinching the nerve.
Initial therapies are non surgical and relatively simple. They can involve one or more of the following treatments:
- Changes in footwear
- Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
- Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
- One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief. This is not appropriate in long standing cases.
If non surgical treatment fails, or is inappropriate for a particular patient, then surgical treatment is indicated.
Surgery is successful in the majority of patients, but it is important you understand that not all patients are cured.
Approximately 90% of patients are significantly improved, with the remainder being unchanged or worse in a small percentage of cases.
Surgery does result in permanent numbness of the affected toes. Many patients still have difficulty with high heeled shoes even after surgery.
I routinely perform this surgery as a day case under a general anaesthetic. Once you are asleep, I put in a local anaesthetic ankle block, which numbs the entire foot. The local anaesthetic ankle block lasts for at least eight hours and also allows for a lighter general anaesthetic (less nausea and drowsiness).
When you wake up your foot will be numb and pain free. There will be a postoperative shoe on your foot, which you should keep on and keep it dry.
You should have a postoperative instruction sheet to go home with.
The surgery is performed through an incision on the top of the foot between the affected toes. The neuroma along with the nerve that supplies the web space between the two toes is removed in such a way as to reduce the risk of recurrence.
You can usually return home within an hour or two of surgery.
Once at home it is important to keep the foot elevated above the level of your heart (tip of your nose should line up with the tip of your toes).
Some bleeding into the dressings is normal and not a concern. Elevation should be continued as much as possible until the wound is healed which is usually two weeks. You will be reviewed at the rooms at this stage.
You will be given both moderate and strong painkillers to take home. If despite these, pain is not well controlled, you can be readmitted to hospital.
You should anticipate permanent numbness between the toes affected by the neuroma. Most patients do not even notice it.
Once the sutures have been removed, two weeks post surgery, you can progress into a capacious shoe or runner. Some minor swelling usually persists for several months.
It is important not to underestimate the time taken to recover from foot surgery.
As the foot is the most dependent part of the body, swelling is always a problem. Swelling causes pain and delays recovery.
It is important to allow two weeks off work as a minimum for clerical duties and up to four weeks for any form of work that requires long periods of standing or walking.
It is necessary to wear a special postoperative shoe day and night for the first two weeks. Most patients take at least four weeks to fit their foot into a regular shoe. In some, swelling can persist up to several months.
Potential complications of Surgery
You should be aware that all surgery has a risk of complications and this surgery is no different.
Medical complications that can occur include:
- heart attack
- drug reaction
- blood clots in the legs or lungs
- and even death in very rare circumstances.
The chance of one of these happening is very small and is reduced by doing the surgery under modern anaesthesia with combined local anaesthetic.
Surgical complications include:
- Infection: antibiotics are given before and after surgery to reduce the chance of infection, but cannot eliminate it.
- Wound healing problems: are rare and tend to happen in diabetics and smokers. If you do smoke you should stop smoking for at least four weeks around the operation.
- Recurrence of neuroma: the neuroma can regrow in a small percentage of patients and this largely accounts for those patients who are made worse by surgery.
- Numbness of toes: all patients will have an area of numbness of the toes adjoining the affected web space. This is because the nerve that supplies the web space is removed along with the neuroma. This is not a complication but an expected result of surgery.
Surgery is effective in the majority of patients with around nine out of ten being happy with the result.
However it is possible, although very unlikely, to be made worse by surgery if a complication develops that cannot be easily fixed.
A more detailed discussion of your individual case will be made at the consultation.