A neuroma, most commonly known as Morton’s neuroma, is a painful condition involving the thickening or irritation of nerve tissue in the foot. This enlargement often occurs in the ball of the foot, typically between the third and fourth toes. It is a fibrous change in the nerve, not a tumor, causing symptoms like shooting, burning pain or the sensation of walking on a small stone. Treatment aims to minimize pain, reduce inflammation, and improve foot function.
Initial Non-Invasive Strategies
Initial non-invasive treatments focus on removing the pressure and irritation that aggravate the nerve, which is often the first line of defense against the pain. Changing footwear is a highly effective, immediate step, particularly by avoiding high heels and shoes with narrow or pointed toe boxes. Choosing shoes with a wider front section and a lower heel helps to reduce the compression of the forefoot bones that can pinch the nerve.
Activity modification also plays a significant role in early management by reducing the repetitive microtrauma that irritates the nerve. Individuals are often advised to temporarily avoid or reduce high-impact activities such as running and jumping. Rest and elevation of the foot can help manage the initial inflammation and swelling in the affected area.
Supportive devices placed inside the shoe can help redistribute pressure away from the irritated nerve. Metatarsal pads, which are placed behind the ball of the foot, are designed to separate the metatarsal bones slightly, thereby creating more space for the nerve. Custom orthotics may also be prescribed to provide more specific support and cushioning to the foot. These interventions aim to off-load the painful area and prevent the nerve from being continually squeezed as the foot bears weight.
Over-the-counter anti-inflammatory medications, such as ibuprofen or naproxen, can be used to manage pain and inflammation in the short term. These conservative measures are recommended first, as they carry minimal risk and are effective in early or mild cases. If these simple modifications do not provide sufficient relief, a more targeted approach may be necessary.
Minimally Invasive Nerve Treatments
When conservative measures fail to alleviate symptoms, the next step often involves minimally invasive procedures that directly target the inflamed nerve tissue. Corticosteroid injections, typically a mix of a steroid and a local anesthetic, are a common initial invasive treatment. The corticosteroid is a powerful anti-inflammatory agent injected around the nerve to reduce swelling and irritation, which can provide temporary relief lasting several weeks or months. Studies suggest that approximately 50% of patients experience a significant reduction in pain one year after a corticosteroid injection.
If the inflammation persists, treatments designed to chemically or physically destroy the painful nerve tissue may be pursued. Alcohol sclerosing injections involve injecting a solution, often a percentage of dehydrated alcohol, directly into the neuroma. The alcohol works by chemically damaging the nerve cells and causing dehydration, leading to a process called chemical neurolysis. A series of injections, sometimes four to seven spaced about a week apart, may be required to achieve a lasting effect.
Other minimally invasive techniques use energy to achieve thermal neurolysis, destroying the nerve tissue through temperature extremes. Radiofrequency ablation (RFA) uses heat generated by an electrical current to disrupt the nerve’s ability to transmit pain signals. Cryosurgery, or cryoablation, is the opposite approach, utilizing extreme cold to freeze and destroy the nerve tissue. Both RFA and cryoablation are precise procedures that aim to permanently stop the nerve from causing pain.
These ablation techniques and chemical injections are performed in an office setting, often guided by ultrasound imaging to ensure accurate needle placement. The procedures target the nerve directly, aiming to calm inflammation or permanently disrupt the nerve structure to avoid open surgery.
Surgical Intervention and Post-Procedure Care
Surgical intervention is considered the definitive treatment for a neuroma that remains persistently painful despite non-invasive and minimally invasive efforts. The most common procedure is a neurectomy, which involves surgically removing the damaged segment of the nerve. This is typically performed through a small incision on the top of the foot between the affected metatarsal bones.
An alternative surgical approach is nerve decompression, where the surgeon releases the tight ligament that is pinching the nerve, without removing the nerve tissue. This release of the transverse metatarsal ligament aims to create more space for the nerve to pass through the forefoot. The choice between nerve removal and decompression depends on the size and health of the nerve itself.
Post-operative care begins immediately after the procedure, which is often done on an outpatient basis. The foot is placed in a bulky dressing and a specialized surgical shoe to protect the incision and support the foot. For the first one to two weeks, patients are advised to keep the foot elevated above the heart to manage swelling.
Weight-bearing is often permitted in the surgical shoe soon after the operation, though some surgeons recommend favoring the heel initially. Stitches are typically removed at a follow-up appointment around two weeks post-surgery, allowing the patient to transition to a supportive, roomy shoe. A long-term outcome of a neurectomy is permanent numbness in the area between the toes that the removed nerve supplied.