Explaining Morton's Neuroma or Metatarsalgia

Pain in the forefoot, the front part of the foot not including the toes themselves, is known as metatarsalgia as the pain occurs around the metatarsals. It is a symptom of an underlying problem rather than a condition in itself. The pain can be caused by various conditions including inflammatory arthritis and a nerve growth on one of the nerves between the toes, a condition known as Morton's neuroma or Morton's metatarsalgia. Metatarsalgia can occur in anyone but is more common in middle aged and older people and those who participate in high-impact activities in sport.

The forefoot region is the focus of where the stresses are targeted during walking and running, with the first two heads of the metatarsals suffering the greatest forces. During running the metatarsals can endure up to 275 percent of the bodily weight, with estimations made of the foot taking over 100 tons of force over a mile run. The forefoot takes the majority of the burden in activities like running and walking. Inflammatory changes may occur in the little digital nerves supplying the toes, a digital nerve neuritis, caused perhaps by mechanical foot stresses and resulting in foot pain, numbness and pins and needles in the forefoot.

Morton's neuroma is more common in women at the ratio of four women to one man, occurring mostly in a person's forties and worsened by tight shoes. One side is usually affected with the space between the third and fourth metatarsal heads being the most common site. A neuroma, an abnormal growth of part of a nerve, will often not be present on microscopic examination of the nerve and the nerve may be relatively normal or show some pathological changes. The space present between the metatarsals is less between the second and third metatarsals and this may contribute to the problem.

Wearing shoes with very narrow fronts may elevate the stresses of compression across the metatarsal heads and if high heels are worn this extends the toes and puts the structure under the heads and alongside them under increased tension. Typically patients present with pain with pins and needles over one space between the metatarsals with some referred pain to the toe. Variability of the symptoms over months and years can be considerable with exacerbations on wearing tight footwear and improvement on taking them off. Conservative management concentrates on foot care and on reducing the stresses on the digital nerves.

The shoes normally worn by the patient may be contributing but recommendations to change can be difficult if they want to keep wearing fashionable ones. Assessment and provision of a metatarsal pad or a more complicated orthotic can be performed by a podiatrist or a physiotherapist. Conservative treatment may alleviate the foot symptoms sufficiently for the patient to find the result functionally acceptable. The painful area can be injected with corticosteroid or anaesthetic which is not very effective alone. Morton's neuroma can be managed by foot surgery and an initial approach cuts the metatarsal ligament to allow sufficient room for the nerve.

A second surgical approach is to remove the nerve from the locally affected area, cutting out the nerve tissue which might be abnormal but a nerve regrowth might occur and form a troublesome neuroma. The difference in success between the two types of operation has not been scientifically shown with both showing about eighty percent reasonable results. After operation the patient will need to limit their weight bearing as they need to, with a steady approach to wearing footwear again. Patients will notice a loss of feeling in the area between the metatarsals if the nerve has been removed but this is rarely a concern.

The foot pain can persist beyond the operation or an improvement may occur which is then followed by the symptoms recurring. If the decompression operation has been performed the nerve may remain in an irritated state or may grow into a neuroma if the nerve has been cut out. A neuroma can give more troublesome symptoms than the original condition. The neuroma can be again removed and this may improve the situation. Morton's neuroma is the term given to this condition because no medical agreed term has been established.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Sheffield. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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