Do you have foot pain on the ball of your foot or between your third and fourth toes? Does it hurt to stand and wear shoes? This may be a symptom of Morton’s Neuroma, a treatable but painful foot condition characterized by debilitating pain from a pinched nerve.
What is Morton’s Neuroma?
A Morton’s neuroma is a pinched nerve in the ball of the foot. It is most commonly found between the 3rd & 4th toes.
Neuromas may cause various symptoms including: burning, tingling, numbness, & sharp stabbing pain. The classic description by the patient is, “it makes me want to sit down, take off my shoes and rub my feet”.
Neuroma vs. Capsulitis
It may be very difficult to tell the difference between a neuroma and capsulitis. Capsulitis is inflammation of a joint in the ball of the foot, which causes pain that can sometimes mimic the symptoms of a Morton’s Neuroma. However, there are tell-tale signs that the pain is caused by a Neuroma and not capsulitis.
For lack of a better description, capsulitis is commonly referred to as a “stone bruise”. The metatarsal joints in the ball of the foot each have a capsule around them, which holds joint fluid helping to nourish and lubricate the cartilage surface. “-itis” literally means inflammation. Therefore, this is inflammation (or swelling) of the capsule, which surrounds the joint. There are various reasons for this including the metatarsal being either – slightly lower and prominent or slightly longer than the other metatarsals. If it is more prominent (for either reason), it receives more pressure and can become inflamed.
Another very common cause of capsulitis is a decrease in the thickness of the layer of fat under the ball of the foot, which provides cushioning for the metatarsals. There is a genetic predisposition for this and it occurs as we are “aging”. Capsulitis is often manifest in people who walk barefoot around the house on hard floors. It is also a common result of wearing dress shoes and running around downtown and through airports. Finally, it is a common overuse injury in athletes.
A systematic treatment plan is needed to manage/resolve capsulitis, and treatment normally includes:
- Barefoot – If the joint in the ball of the foot is inflamed, it is absolutely mandatory that shoes be worn at all time. The more padding the better! This literally includes having a pair of house shoes by the side of the bed and slipping them on in the morning with first weight-bearing.
- Shoes – Changing shoe gear may also provide significant improvement. Often a shoe with a slightly lower heel is important for professional women. Worn-out shoes, or shoes with very thin and flexible soles may also be culprits. The ideal shoe for capsulitis has a thicker rubber sole, which is not flexible. Clogs or mules can be quite effective. An outer sole called a “roller bottom” is perfect for this problem. Better shoe stores will be able to provide this shoe type – some common brands include: Clarks, RockPort, Ecco, RedWing, Danko, Soft Walk, Easy Spirit.
- Aperture pad – An aperture pad is a small “U-shaped” pad which increases pressure on the adjacent metatarsals and decreases the pressure on the inflamed capsule. This is a very simple and inexpensive pad, which is placed on the foot initially, but if it works, new shoes may be dropped off at the office and the pad applied (usually takes 1-2 days) – in the past, we sent patients out to shoes repair shops for this, but it is extremely hard to find a shoe repair that will do this now a days.
- Cortisone injection – As described above, the joint is inflamed. An injection in the area of a very small amount of cortisone may break this inflammatory cycle, and sometimes provide significant improvement. Cortisone injections are normally limited to no more than two.
- Immobilization – If the joint needs to rest, simply changing shoes may not do the trick. In persistent cases, a stiff surgical shoe is used to stop all motion of the forefoot. Anticipate using the shoe for 4-6 weeks.
- Surgery – Surgical treatment is performed as an outpatient surgery. It does require stitches in the foot (must keep the foot dry for 2 weeks) and a surgical shoe for 3 – 4 weeks. Sports and/or dress shoes will be difficult for at least 8-12 weeks after the surgery. Because the metatarsal bone is prominent, the metatarsal must be surgically broken and repositioned; this is not without complication. In fact, surgical treatment has a 20-25% chance of fixing one problem and transferring the pain to the next metatarsal!
The nerve that provides feeling to the bottom of the foot and toes comes down the back of the leg, around the inside of the ankle, and into the bottom of the foot. It then branches and sends one branch in between each toe; just before reaching the toes it again branches providing sensation to the bottom of each toe. As the nerve travels between the metatarsals it may be pinched. A normal nerve in this area is about the size of the tip of the pencil. Microscopically, the nerve looks like a telephone cable. There are hundreds of tiny nerve fibers which are encased in a sheath.
If the nerve is pinched between the metatarsals, there is swelling in that nerve sheath pushing on the fibers. This swelling is replaced with scar tissue and the nerve enlarges. Over a period of time, the nerve becomes so enlarged that any pressure stimulates it and causes symptoms. When symptomatic, the nerve may literally be the size of the little finger.
An experienced podiatrist can discern between the symptoms to make the correct diagnosis and treatment plan.
Morton’s Neuroma Diagnosis & Treatment
The diagnosis of a neuroma is done clinically and includes a thorough history of the pain, range of motion, and palpation of the foot. Symptoms are normally reproduced with pressure between the toes and a resultant click (or pop) called a Mulder’s sign.
- A systematic treatment plan is needed to take care of a neuroma, and includes:
- Shoes – Changing shoe gear may provide significant improvement. Avoiding shoes with a narrow toe box is critical. Often a shoe with a slightly lower heel is important for professional women. Worn-out shoes, or shoes with very thin and flexible soles may also be culprits.
- Metatarsal pad – a metatarsal pad is a small pad which lifts the metatarsals and decreases the pressure on the nerve. This is a very simple and inexpensive treatment, which we will put in the shoes initially, but if it works, these may be purchased through the office and placed in new shoes by the patient.
- Cortisone injection – As described above, the nerve is inflamed. An injection in the area of a very small amount of cortisone may break this inflammatory cycle, and sometimes provide significant improvement. Cortisone injections are normally limited to no more than two.
- Surgery – Surgical excision of a neuroma is 95% successful. This is performed as an outpatient surgery. It does require stitches in the foot (must keep the foot dry for 2 weeks) and a surgical shoe for 3 – 4 weeks. Sports and/or dress shoes would be difficult for at least 6 weeks after the surgery.
- Remember there is at least a 5% chance of no improvement of symptoms with foot surgery; as well as the potential for different/worse symptoms requiring future surgical treatment. There is never a good time to have surgery, but one of the keys to an excellent surgical outcome is your expectations. Here is what you can expect:
What You Need to Know Before Having Surgery for Neuroma
The surgery will be done on an outpatient basis. You will not be put to sleep. We will use sedation and a local anesthetic in your foot.
Your foot should stay asleep for 12-24 hours, so there really should not be much pain when you get home.
Your job is to keep your foot elevated with an ice pack around the ankle.
For the first 3-4 days, get up to use the restroom and for meals, otherwise spend time on the sofa or in bed.
You will be seen to change the bandage about 4 days after the surgery.
You will have to keep your foot dry for 10-14 days.
With your right foot, you won’t be able to drive for 3 weeks.
You will have to wear a surgical shoe for 3-4 weeks.
You will be able to use an exercise bike or left weights (upper body) after 5-7 days.
After 3-4 weeks, you will be able to wear either a sandal or a large tennis shoe. At 6 weeks you will be able to wear some soft flats that may be a half size larger that you are use to. You will not be able to wear a 1inch or higher heel, all day, for 4-6 months.
At 6 weeks, you will be able to begin exercise walking.
You should not plan any prolonged trips for 4-6 weeks.
Your foot will swell and hurt more than it does today for 4-6 months.
Somewhere around 4-6 months you will be glad you had the surgery.
Your foot will improve for an entire year.
Schedule a Visit to Our Houston Podiatry Office
Are you experiencing pain in your foot and think it could be a neuroma or other foot problem? Call our podiatry office now to schedule an appointment with foot doctor Dr. Dennis, who has over 40 years of experience.