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Morton's Neuroma, is surgery always necessary?

Morton’s neuroma is a common forefoot problem which causes pain and disability. It is caused by a trapped nerve in the ball of the foot. This causes extreme nerve pain, burning, pins and needles and numbness. Generally, this is worse upon walking, in footwear, and is relieved when non weightbearing.

Rather than symptoms settling with time, the frequency and intensity worsens until treatment is sought. It is generally accepted that surgery has been the mainstay of treatment for many years. This involves the removal of the thickened nerve through a small incision. This is not without risk of complication and possible recurrence. If we can manage this condition conservatively might this be preferable?

Firstly, an ultrasound scan can identify the neuroma (the swollen nerve) and confirm the diagnosis. From this measurement of the nerve can be made. Usually the longer the time untreated the larger the thickening, the more thickened the more painful. Conservative treatment works best if treatment is sought early. Proven conservative options include injection with corticosteroid and use of custom foot orthoses. Other less conventional unproven treatments include cryotherapy (freezing) and alcohol injections. My protocol would be to have an ultrasound guided corticosteroid injection, this should not be administered blind, to maximise accuracy. Footwear advise is also important at this stage. If symptoms do not improve within 4 weeks, a custom orthosis is prescribed, and a second guided injection administered. Most patients’ symptoms, treated using this protocol, improve at least enough to resume full activity, and many will be completely pain free. Should symptoms persist, referral for surgery then is the most appropriate course, knowing all reasonable conservative measures have been exhausted.

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