Morton’s neuroma is a thickening of the tissue that surrounds the small nerve leading to the toes. It occurs as the nerve passes under the ligament connecting metatarsal bones in the forefoot (front part of the foot). 

Morton’s neuroma most frequently develops between the third and fourth toes. It often occurs in response to irritation, trauma, or excessive pressure, and is more common in women. 

Causes

The exact cause is unknown. Doctors believe the following may play a role in the development of this condition:

• Wearing tight shoes and high heels
• Abnormal positioning of toes
• Flat feet
• Forefoot problems, including bunions and hammer toes
• High foot arches

Symptoms

Symptoms may include:

• Tingling in the space between the 3rd and 4th toes
• Toe cramping
• Sharp, shooting, or burning pain in the ball of the foot and sometimes toes
• Pain that increases when wearing tight shoes, high heels, or pressing on the area
• Pain that gets worse over time

In rare cases, nerve pain occurs in the space between the 2nd and 3rd toes. This is not a common form of Morton neuroma, but symptoms and treatment are similar.

Exams and Tests

Your health care provider can usually diagnose this problem by examining your foot. Squeezing your forefoot or toes together bring on the symptoms.

A foot x-ray may be done to rule out bone problems. MRI or ultrasound can successfully diagnose the condition.

Nerve testing (electromyography) cannot diagnose Morton neuroma. But it may be used to rule out conditions that cause similar symptoms.

Blood tests may be done to check for inflammation-related conditions, including certain forms of arthritis.

Diagnostic Procedures

• Mulder’s Sign (Pinch Test)²: Lateral squeezing of the forefoot with one hand and the opposite hand pushing up on the nerve

• Rule out fracture
• Reveal soft tissue abnormalities
• Mulder’s Sign²: A positive test is a click or snap at the nerve with severe pain

Treatment

Nonsurgical treatment is tried first. Your provider may recommend any of the following:

• Padding and taping the toe area
• Shoe inserts (orthotics)
• Changes to footwear, such as wearing shoes with wider toe boxes or flat heels
• Anti-inflammatory medicines taken by mouth or injected into the toe area
• Nerve blocking medicines injected into the toe area
• Other painkillers
• Physical therapy

When to use Physical Therapy in Morton’s neuroma?

Morton’s neuroma Physical Therapy should be considered in the following circumstances:

1. In early stage Morton’s neuroma. Physical therapy combined with orthotics and over the counter pain relieving medications are a good first step in the treatment of early stage Morton’s neuroma. We define early stage as Morton’s neuroma pain which only occurs intermittently often aggravated with certain shoes.
2. Post Morton’s neuroma ablation. We perform a number of different ablation procedures to treat your Morton’s neuroma. After we have treated you, you should consider Physical Therapy to help strengthen your muscles and correct any walking (gait) deficiencies that may have arisen due to your previous Morton’s pain. Orthotics also helps with gait abnormalities. If ignored, these gait abnormalities can lead to back pain, arthritis or other problems.

Outlook (Prognosis)

Nonsurgical treatment does not always improve symptoms. Surgery to remove the thickened tissue is successful in most cases.

Possible Complications

Complications may include:

• Difficulty walking
• Trouble with activities that put pressure on the foot, such as pressing the gas pedal while driving
• Difficulty wearing certain types of shoes, such as high-heels

Prevention

Avoid ill-fitting shoes. Wear shoes with a wide toe box or flat heels.

Alternative Names

Morton neuralgia; Morton toe syndrome; Morton entrapment; Metatarsal neuralgia; Plantar neuralgia; Intermetatarsal neuralgia; Interdigital neuroma; Interdigital plantar neuroma; Forefoot neuroma

References

McGee DL. Podiatric procedures. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts & Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 51.

Shi GG. Morton’s neuroma. In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 91.