A Neuroma (pron. new-row-ma) is the name given to swelling of the nerve between the long bones of the forefoot, just before they enter the toes. As you can imagine there is not a lot of space in your feet. As the nerve swells it is confined by the long bones, causing further compression!
- Feeling a burning sensation under the ball of your foot?
- Is it sharp?
- Does it shoot down the toes?
- Does it just feel like there’s an extra layer underneath?
These are all typical sensations with neuromas.
What are the symptoms?
Depending on the degree of nerve compression, different symptoms can be felt. Commonly a neuroma will occur between the 3rd and 4th toes which is called a Morton’s Neuroma, although they can occur in any space.
These are a few lines that we tend to hear from our clients:
- There is a clicking feeling in the forefoot
- I have sharp shooting pain from under the ball (+/- to the toes)
- I have pins and needles or numbness
- My toes are drifting apart
- A long time standing makes it burn
- A feeling that their sock is bunched up or there is something in the shoe
The progression of an intermetatarsal neuroma often follows this pattern:
- The symptoms begin gradually. At first, they occur occasionally when wearing narrow-toed shoes or performing certain aggravating activities
- The symptoms may go away temporarily by removing the shoe, massaging the area or avoiding aggravating shoes or activities
- Over time, the symptoms progressively worsen and may persist for several days or weeks
- The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent
Morton’s neuroma is most likely to occur between the 3rd and 4th toe, and somewhat less likely to occur between the 2nd and 3rd toe.
What factors contribute to a Neuroma forming?
The exact cause of the neuroma varies between clients, so an accurate diagnosis must be carefully made by a Podiatrist.
They develop as a result of chronic stress and irritation of a plantar digital nerve. This may be due to it being squashed, rubbed, or stretched. Some thickening (fibrosis) and swelling may then develop. This can look like a neuroma and can lead to compression of the nerve.
The anatomy of the bones of the foot is also thought to contribute to the development of Morton’s neuroma. The space between the metatarsals is narrower between the second and third and between the third and fourth toes. This means that the nerves that run between these metatarsals are more likely to be compressed and irritated. Wearing narrow shoes can make this compression worse.
People with certain deformities, such as bunions, hammertoes and flat feet are at higher risk of developing this condition. Other potential causes are activities that involve repetitive irritation to the area, such as running or court sports. An injury or trauma may also be factors.
Your Podiatrist will obtain a thorough history of your symptoms and examine you. They may attempt to reproduce symptoms by manipulating the painful area.
A typical Neuroma assessment will include:
A typical Neuroma assessment will include:
- Hands-on assessment
- Biomechanical and gait analysis
- 3D Force Plate – to analyse how the impact going through your feet with each step is contributing to the neuroma.
- Mobility Range Testing – restricted ankle and foot joints load the painful area further
- Muscle Strength Testing
- Footwear Assessment – potential compression forces that can cause soreness
Some imaging tests are used in the diagnosis
- X-rays – Your Podiatrist is likely to order X-rays, to rule out other causes of your discomfort — such as a stress fracture.
- Ultrasound – This technology uses sound waves to create real-time images of internal structures. Ultrasound is particularly good at revealing soft tissue abnormalities, such as neuromas.
- Magnetic resonance imaging (MRI) – Using radio waves and a strong magnetic field, an MRI also is good at visualizing soft tissues. But it’s an expensive test and often indicates neuromas in people who have no symptoms. These can be ordered by your Podiatrist or doctor.
Treatments for Neuromas
In developing a treatment plan, your Podiatrist will first determine how long you have had the issue and will evaluate its stage of development. Treatments vary according to the severity of the problem.
For mild to moderate cases, treatment options may include:
Conservative Care from your Podiatrist
- Shoes – relief is started by having a good pair of well-fitted shoes to ensure they are not squeezing the nerve. A wide toe box is ideal, as well as avoiding high heels.
- Activity modification – activities that put repetitive stress on the area should be reduced until the condition improves
- Metatarsal Pads – to reduce pressure on the nerve and support your feet
- Custom Flexible Orthotics – if the structure and mechanics are contributing to pain in your feet, an orthotic is effective for relief and reducing compression
- Local Anaesthetic “Hydrodilation” can be very helpful to directly settle discomfort, without having the side effects of cortisone injections. These injections can be done in your Podiatry appointment.
- Dry Needling – usually performed directly at the site as well as into local muscles in the foot and leg
- Surgical Care from a Podiatric or Orthopaedic Surgeon may be sought if symptoms are unchanging after a period of greater than 3 months conservative Podiatry care.
When is surgery needed?
Surgery may be considered for patients who have not responded adequately to non surgical treatments. Your Podiatrist or doctor may refer you to a foot and ankle surgeon, who will determine the approach that is best for your condition. The length of the recovery period will vary depending on the procedure performed.
Surgery normally involves a small incision being made on either the top or the sole, between the affected toes. The surgeon will cut out the affected nerve. Alternatively, the surgeon may create more space around the affected area (known as decompression). If the nerve is resected, there will be some permanent numbness of the skin between the affected toes. This does not usually cause any problems.
The patient will usually have to wear a special shoe for a short time after surgery until the wound has healed and normal shoes can be used again.
Regardless of whether you have undergone surgical or non surgical treatments, your surgeon will recommend long-term measures to help keep your symptoms from returning. These include appropriate shoes, custom orthotics and modification of activities to reduce the repetitive stress.
What is the prognosis for Morton’s neuroma?
About one third of people with Morton’s neuroma get better just with changing their shoes and using metatarsal pads. Of those who choose to have surgery, about three out of four will have good results with relief of their symptoms.
Recurrent or persisting (chronic) symptoms can occur after surgery. Sometimes, decompression of the nerve may have been incomplete or it may just remain ‘irritable’. In those who have had cutting out (neurectomy), a recurrent or ‘stump’ neuroma may develop in any tissue that was left behind. This can itself be very painful. In one in four people who have got better with an operation, the problem returns at a later date. It is important to keep wearing the right shoes to prevent this from happening.
Can Morton’s neuroma be prevented?
Ensuring that shoes are well fitted, low-heeled and with a wide toe area may help to prevent Morton’s neuroma.