Overview
Morton neuroma is a painful condition affecting the ball of the foot, most commonly between the third and fourth toes. It involves thickening of tissue around one of the nerves leading to the toes, causing sharp, burning pain or a sensation of standing on a marble. It is strongly associated with narrow or high-heeled footwear.
How common is it?
Morton neuroma is common, particularly in women aged 40 to 60. The female to male ratio is approximately 8:1, reflecting the role of narrow, high-heeled footwear. It accounts for about 30% of forefoot pain referrals in podiatry.
Causes and risk factors
Repetitive pressure or irritation causes the nerve to thicken (perineural fibrosis). The nerve is most vulnerable as it runs between the metatarsal heads.
Common risk factors
- Wearing high-heeled or pointed-toe shoes (compress metatarsals and nerve)
- Flat feet or high arches
- Tight, narrow footwear
- High-impact activities (running, ballet, sports with toe-off motion)
- Metatarsal stress fracture or bursitis
Symptoms
- Sharp, burning, or stabbing pain in the ball of the foot between toes
- Sensation of standing on a pebble or marble
- Numbness or tingling in the affected toes
- Pain worsened by tight footwear or walking and relieved by removing shoes and rubbing the foot
- Clicking sensation between the metatarsal heads (Mulder sign)
When to see a doctor
See a GP or podiatrist for persistent forefoot pain not responding to 6 to 8 weeks of footwear modification. Early intervention reduces the need for surgery.
Diagnosis
Clinical diagnosis: Mulder test (squeezing the forefoot while pressing between the web spaces produces pain and click). Ultrasound confirms the diagnosis and measures neuroma size. MRI for uncertain cases.
Treatments
Footwear modification
Switching to wide, low-heeled shoes with good cushioning is the essential first step. A metatarsal dome insole redistributes pressure away from the nerve. Most mild cases resolve with footwear alone.
Corticosteroid injection
Ultrasound-guided injection of corticosteroid and local anaesthetic into the affected web space produces significant improvement in 50 to 80% of cases. Effects may be long-lasting or require repeat injection.
Alcohol sclerotherapy
Series of ultrasound-guided dilute alcohol injections (4 to 7 treatments) causes gradual fibrotic shrinkage of the neuroma. An alternative to surgery with good success rates.
Surgical excision
If conservative measures fail, the neuroma is removed through a dorsal or plantar incision. Success rates are high (85%) but permanent numbness in the affected toe cleft is expected.
Self-care and lifestyle
- Wear wide-fitting shoes with a low heel at all times, not just when symptomatic
- Avoid high heels and pointed-toe shoes entirely
- Use metatarsal insoles or custom orthotics
- Ice the affected area after activity
Prevention
Wearing correctly fitted, wide, low-heeled shoes is the most effective preventive measure. Footwear advice is particularly important for runners and those who wear formal shoes for prolonged periods.