This document discusses Morton's neuroma, which is a painful condition that affects the ball of the foot. It notes that while traditionally called "Morton's Neuroma," the preferred term is "interdigital neuralgia" as it does not involve inflammation or a true tumor. Risk factors include narrow spacing between the toes and repetitive trauma or pressure to the affected area. Symptoms include sharp or tingling pain in the ball of the foot that may radiate to the toes. Treatment options discussed include pads, corticosteroid injections, alcohol sclerosing therapy, phenol injections, and surgery. Surgical options include dorsal or plantar approaches, and risks include recurrence of symptoms and wound or nerve complications.

1. Dr.Rajiv Shah
‘Foot & Ankle Orthopaedics’
Foot & Ankle Surgeon
President, Indian Foot & Ankle Society

3.  Traditionally referred to as “Morton’s Neuroma”
 Other terms
 Interdigital Neuroma
▪ Though histological analysis shows its not a
true nerve tumor
▪ Intraneural fibrosis, increased elastic fibers
in stroma, degeneration of fibers
 Interdigital Neuritis
▪ “itis” implies inflammation though this is
also a misnomer
 Interdigital Neuralgia
 Preferred term
 Implies pain and lack of inflammation

4.  Metatarsal head spacing
 Intermetatarsal ligament
thickness
 Mobility of surrounding joints
 Trauma
 MPN and LPN share a
communicating branch between
the 3rd and 4th toe in ~ 28% of feet
 Significantly narrower space
between 2nd and 3rd webspace
compared to the 1st and 4th
(Levitsky, FAI 1993)
 Mobility of 1/2/3 MT small secondary
to cuneiform complex
 4/5 are more mobile which could
lead to traction and trauma
 However, incidence of 2nd webspace
neuromas negate this as a primary
cause
 Direct insult
 Overuse with tight shoe
 Aberrant anatomical bands,
fat pad atrophy, and
thickening of MTP joint capsule
 Multifactorial

5.  Women > Men (4-15 times more
common)
 Average age: 40 – 60 years old (avg 55)
 Symptoms: Sharp, stabbing, tingling
with radiation to the toes, feeling of
“waddling up of their sock”
 Mulder’s click
 Compression of the forefoot and the
nerve is pushed plantar by the 3rd and 4th
metatarsal heads
 Neuroma should be diagnosis of
exclusion
 Doubt if not in 3rd webspace
 Very rare in 1st and 4th
 Radiographs – Evaluate for osseous
abnormalities, arthritis, subluxations
 Reliance on MRI or ultrasound would have led
to inaccurate diagnosis in 18 of 19 cases
(Sharp, JBSJ Br 2003)
 33%, 57 MRIs, of asymptomatic feet were
reported to have a neuroma (Bencardino AJR
2000)
 Electrodiagnostic studies are not
recommended
 Diagnostic injections had a 24% failure rate
after resection of nerve and 43% failure after
revision resection (Younger Can J 1998)
 Ultrasound
 Mahadevan et al4 assessed
the diagnostic accuracy of
7 clinical tests for Morton's
neuroma compared with
ultrasonography
Morton’s neuroma
was confirmed on
US at the site of
clinical diagnosis in
98% feet

6.  Metatarsal Pads and a wide toe
box can improve symptoms in
41% of patients
 Corticosteroid injections show 60-
80% relief with injection, but only
30% maintain benefit at 2 years
 Neuroma Alcohol-SclerosingTherapy (NAST) report
overall success of 61% , best with greater than 5
injections (Mozenza et al, J Am Pod ’07)
 Phenol injection:
 An electrode-guided injection of phenol proved to
be effective in 80.3% of cases7
 ~70% of patients eventually elect to have surgical
intervention

7.  Long term outcomes with 85%
satisfaction 5.8 years after
resection (Coughlin JBJS 2001)
 Poor results in 40% and worse
outcomes in 2nd webspace
neuromas (Womack FAI 2008)
 Must be sure to resect offWB
surface of foot
 Long term failure rates range
from 15-50% after surgery
 Dorsal approach usually
advocated secondary to low rate
of wound complications and
ability to immediately
weight bear
 Dorsal:
 Avoids plantar scar
 Further from nerve (nerve always
plantar to vessel)
 Plantar:
 Close to nerve
 Can produce painful scar
 Better for revisions

8.  Plantar transverse incision with
neuroma resection without disruption of
deep transverse ligament
 Five percent complained of scar-related
symptoms
 Plantar neurectomy allows complete
resection of nerve without taking
perineural fat or bursa by mistake

9.  Endoscopic decompression w/o excision
 40 patients
 No hematomas, infections
 3 returned for neurectomy

10.  Mildly compressive dressing
 Elevation of operative extremity for 24
hrs
 WBAT in a hard-soled post-operative
shoe for 4 weeks
 2 weeks of NWB for revision cases
 Suture removal 2 weeks post-op
 4 weeks after surgery may progress as
tolerated in wide toe-box shoes
 Return to sports in 4-6 weeks

24.  Recurrence of symptoms is the most
common complication
 May be due to incorrect diagnosis, incomplete
resection or true recurrence
 Counsel patients pre-operatively
 Wound complications (slow healing,
superficial cellulitis)
 Incisional tenderness after a plantar
approach
 Residual numbness
 2% to 14% of patients
will have persistent
pain after surgery
 60% to 75% of
patients still limited in
choice of shoe wear
and certain activities

25. That’s all…
Thank you all..