In this painful condition one of the small nerves that supply the toes with sensation becomes swollen and scarred. As the swelling increases the nerve will be pinched with normal activity and cause severe pain in the forefoot. Curiously the pain is often intermittent and in the early stages it is difficult to localise the symptoms in the foot.
We do not understand the reason why people get the problem, but do know that the nerve damage is typically that of chronic trauma. Patients are often slightly embarrassed when describing the symptoms as they are vague and it is virtually impossible to reproduce them when looking at and feeling around the foot. When diagnosing a Morton’s neuroma it is essential to have a proper history of the onset and effects of the symptoms. A simple test can be performed in clinic called a Mulder’s click which is highly indicative of the problem. Often ultrasound scanning is used to confirm the position and size of the neuroma, particularly if intervention is planned.
Injection of the neuroma under ultrasound guidance is used to calm any inflammation and reduce the bulk of the nerve tissue. My preferred technique is to use steroid and local anaesthetic for this as it has a long track record and has few complications or side effects when used sensibly. The procedure can be repeated, but I rarely use more than two injections over a six week period. If the symptoms have not cleared after this time then we need to look at other options.
Surgical excision of the neuroma is used for those cases where standard conservative treatment has been ineffective. The surgery is normally performed from an incision on top of the foot and deepened to the level of the nerve. The nerve is examined and if possible repaired, usually by the time of surgery however the damage is too great and a section of the nerve is removed. The clinical diagnosis is confirmed by sending the excised nerve tissue to the laboratory where it will be examined under a microscope; following this a confirmatory pathology report is generated.
The surgical wound will heal quickly as it is soft tissue but, due to the nerve being involved, it can feel very bruised and sensitive for a time. Soft shoes can normally be worn within a couple of weeks, but smarter shoes will take longer. I always warn my patients that there is likely to be a permanent change in sensation to one of the affected toes, particularly if the nerve has to be removed. This is normally only noticeable when drying between the toes in the long-term and will not cause problems with the toe function.
By following the advice and rehabilitation programme advised by Lyndon and his team you will have the best possible chance of gaining an amazing outcome.