Morton’s Neuroma is a painful condition resulting from the fibrous thickening of the plantar interdigital nerve of the foot.

Often described as feeling like there is a pebble in the shoe, this is is a chronic condition not associated with acute trauma. It is gradual in onset but may present as acutely painful.

• AKA Morton’s metatarsalgia, or interdigital neuroma.
• Most commonly presents between the 3rd and 4th metatarsal head region, but can affect any of the toe spaces.
• More common in women (4-15 times) and between the ages of 40-60.
• Increasingly common in runners.
• Cause is uncertain but felt to be related to constriction of (e.g. ill fitting shoes) or pressure (e.g. heels, running, dancing) on the metatarsal head region.

Presentation (may include)

• Pain in forefoot exacerbated by certain footwear and extended weight bearing.
• Relieved by rest and massaging foot.
• Sensation of mass or pebble under forefoot, though unlikely to be palpable.
• Stabbing, burning, and or tingling sensation to forefoot and associated toes, worse on pressure.

Examination

• Pain on applying pressure to the affected area.
• Try to elicit Mulder’s click:
  • Try to grip the neuroma between your forefinger and thumb (with your thumb on the plantar aspect of the foot).
  • With your other hand, simultaneously squeeze the metatarsal heads (1-5) together in the transverse plane.
  • A click can be felt and heard as the enlarged nerve subluxes between the metatarsal heads as they are compressed.
  • Absence of this sign does not rule out neuroma.
• Loss of sensation to the affected toes is a strong indicator, but a sensory deficit may not be apparent.

Treatment

• Advice on use of footwear- Wide toed, flat, cushioned foot wear. No heels, No tight shoes, No thin soles
• Use an over the counter metatarsal pad or insole to relieve pressure to metatarsal head.
• Avoid aggravating activity, such as running. Or reduce as much as is feasible.
• Advise that this can be a long-term problem that may not respond to the above, or be relapsing in nature.
• Sign post to patient advice such as NHS Choices or Patient.co.uk
• If the patient has used the pads and appropriate footwear for 3 months to seek follow up from their GP with a view to specialist referral.

Further Reading 

CKS

PhysioPedia