Morton’s neuroma is a common foot condition involving the thickening of tissue surrounding a digital nerve in the forefoot, usually between the third and fourth toes. This enlargement is not a true tumor but results from chronic irritation and compression of the nerve. The condition causes burning pain, sharp sensations, and the feeling of “walking on a marble” in the ball of the foot. Initial treatment focuses on conservative measures like changes to footwear, custom orthotics, and targeted corticosteroid injections to reduce inflammation. Surgery is considered only after these non-surgical treatments have failed to provide lasting relief from chronic, debilitating pain.
Deciding When Surgery Is Necessary
The decision to proceed with surgery is made after a persistent pattern of pain and functional limitation has been established. Candidates typically have chronic forefoot pain that is unresponsive to conservative management over several months. Non-surgical options, including shoe modifications, padding, and injections, must be exhausted before an operation is considered.
Imaging studies like ultrasound or magnetic resonance imaging (MRI) help confirm the diagnosis and assess the size of the neuroma. A larger neuroma, sometimes exceeding 0.8 centimeters, often correlates with a lower likelihood of success from non-surgical treatments. The presence of severe, ongoing pain that significantly restricts daily activities and quality of life is the primary indicator that surgery is the appropriate next step.
Surgical Techniques for Nerve Relief
The surgical management of Morton’s neuroma involves two distinct procedures: neurectomy, the removal of the affected nerve, and neurolysis, which aims to decompress the nerve without excision. The choice depends largely on the neuroma’s size and the amount of nerve damage sustained. Both procedures are typically performed on an outpatient basis, allowing the patient to return home the same day.
Neurectomy, or surgical excision, is the most common technique and involves cutting out the thickened, painful portion of the nerve. This procedure permanently eliminates the source of pain by removing the damaged nerve tissue. The operation is frequently performed through a dorsal incision—a small cut made on the top of the foot between the toes. This approach is generally well-tolerated and avoids scarring the weight-bearing surface of the foot.
A plantar incision is an alternative approach used on the sole of the foot, often for revision surgeries requiring a more direct view of the nerve. Following neurectomy, the patient experiences permanent numbness in the toe web space supplied by the removed nerve. A potential complication specific to this procedure is the formation of a stump neuroma, where the cut end of the nerve attempts to regrow and forms another painful nodule.
Neurolysis, or nerve decompression, is a less invasive option used for smaller neuromas that lack significant nerve thickening, often referred to as a pseudoneuroma. This procedure does not remove the nerve. Instead, it involves cutting the deep transverse metatarsal ligament, the tight band of tissue that compresses the nerve. Releasing this ligament relieves pressure, allowing the nerve to recover.
The advantage of neurolysis is avoiding the permanent numbness and the risk of a stump neuroma associated with nerve excision. Studies suggest neurolysis is an effective option when the nerve shows no macroscopic thickening and the primary issue is mechanical compression. The ultimate success of either technique hinges on the surgeon’s ability to accurately identify and address the source of the nerve irritation.
Navigating Post-Operative Healing
Following surgery, the immediate recovery phase focuses on reducing swelling and managing discomfort. Patients are typically sent home in a bulky dressing and a specialized surgical shoe to protect the incision site and the forefoot. Keeping the foot elevated above the heart for the first few days is recommended to minimize swelling and aid in wound healing.
Weight-bearing instructions vary, but many surgeons permit immediate full or restricted weight-bearing in the surgical shoe, primarily through the heel, for the first two to four weeks. Stitches are usually removed during a follow-up appointment ten to fourteen days after the operation. At this stage, patients may begin transitioning into comfortable, wide-fitting athletic shoes.
The timeline for returning to normal activities is gradual, with most patients requiring six to eight weeks before resuming daily routines without significant restriction. Low-impact activities, such as walking, can often be started after the incision has fully healed, approximately four to six weeks later. A full return to high-impact sports or demanding physical labor may take up to three months, and forefoot swelling can intermittently persist for six months or longer.
While surgery offers a high rate of pain relief, patients should understand possible outcomes during the healing process. Permanent numbness in the toes adjacent to the surgical site is expected after neurectomy, and patients should be counseled on this possibility pre-operatively. There is a small chance of persistent pain or recurrence, often due to the formation of a stump neuroma or residual scar tissue, which may require further intervention.