Diagnosing Mortons Neuroma
Overview
Some sources claim that entrapment of the plantar nerve because of compression between the metatarsal heads, as originally proposed by Morton, is highly unlikely, because the plantar nerve is on the plantar side of the transverse metatarsal ligament and thus does not come in contact with the metatarsal heads. It is more likely that the transverse metatarsal ligament is the cause of the entrapment. Despite the name, the condition was first correctly described by a chiropodist named Durlacher, and although it is labeled a "neuroma", many sources do not consider it a true tumor, but rather a perineural fibroma (fibrous tissue formation around nerve tissue).
Causes
Inappropriate footwear is one of the principle causes of Morton?s neuroma. Toe spring and tapering toe boxes are the most problematic shoe design features that contribute to this health problem. Morton?s neuroma occurs when one of your nerves is stretched and pinched, which happens with great frequency in people who wear shoes incorporating these design features. A professional shoe fitting should always be sought if you are struggling with neuroma-related symptoms.
Symptoms
What are the symptoms of Morton?s neuroma? A sharp or stinging pain between the toes when standing or walking. Pain in the forefoot between the toes. Swelling between the toes. Tingling (?pins and needles?) and numbness. Feeling like there is a ?bunched up sock? or a pebble or marble under the ball of the foot.
Diagnosis
An MRI scan (magnetic resonance imaging) is used to ensure that the compression is not caused by a tumor in the foot. An MRI also determines the size of the neuroma and whether the syndrome should be treated conservatively or aggressively. If surgery is indicated, the podiatrist can determine how much of the nerve must be resected. This is important, because different surgical techniques can be used, depending on the size and the position of the neuroma. Because MRIs are expensive, some insurance companies are reluctant to pay for them. If the podiatrist believes an MRI is necessary, he or she can persuade the insurance company to pay for it by presenting data to support the recommendation.
Non Surgical Treatment
Treatments may include rehabilitation measures to reduce nerve Irritation. Switching to low-heeled, wide-toed shoes with good arch support. Wearing padding in the shoes and/or between the toes. Wearing shoe inserts to correct a mechanical abnormality of the foot. Having ultrasound, electrical stimulation, whirlpool, and massage done on the foot. The foot may be injected with corticosteroids mixed with a local anesthetic in order to reduce pain. Relief may be only temporary, however, if the mechanical irritation is not also corrected. Injections with other types of medications such as alcohol, phenol, or vitamin B12 are sometimes used.
Surgical Treatment
Patients are commonly offered surgery known as neurectomy, which involves removing the affected piece of nerve tissue. Postoperative scar tissue formation (known as stump neuroma) can occur in approximately 20%-30% of cases, causing a return of neuroma symptoms. Neurectomy can be performed using one of two general methods. Making the incision from the dorsal side (the top of the foot) is the more common method but requires cutting the deep transverse metatarsal ligament that connects the 3rd and 4th metatarsals in order to access the nerve beneath it. This results in exaggerated postoperative splaying of the 3rd and 4th digits (toes) due to the loss of the supporting ligamentous structure. This has aesthetic concerns for some patients and possible though unquantified long-term implications for foot structure and health. Alternatively, making the incision from the ventral side (the sole of the foot) allows more direct access to the affected nerve without cutting other structures. However, this approach requires a greater post-operative recovery time where the patient must avoid weight bearing on the affected foot because the ventral aspect of the foot is more highly enervated and impacted by pressure when standing. It also has an increased risk that scar tissue will form in a location that causes ongoing pain.
Some sources claim that entrapment of the plantar nerve because of compression between the metatarsal heads, as originally proposed by Morton, is highly unlikely, because the plantar nerve is on the plantar side of the transverse metatarsal ligament and thus does not come in contact with the metatarsal heads. It is more likely that the transverse metatarsal ligament is the cause of the entrapment. Despite the name, the condition was first correctly described by a chiropodist named Durlacher, and although it is labeled a "neuroma", many sources do not consider it a true tumor, but rather a perineural fibroma (fibrous tissue formation around nerve tissue).Causes
Inappropriate footwear is one of the principle causes of Morton?s neuroma. Toe spring and tapering toe boxes are the most problematic shoe design features that contribute to this health problem. Morton?s neuroma occurs when one of your nerves is stretched and pinched, which happens with great frequency in people who wear shoes incorporating these design features. A professional shoe fitting should always be sought if you are struggling with neuroma-related symptoms.
Symptoms
What are the symptoms of Morton?s neuroma? A sharp or stinging pain between the toes when standing or walking. Pain in the forefoot between the toes. Swelling between the toes. Tingling (?pins and needles?) and numbness. Feeling like there is a ?bunched up sock? or a pebble or marble under the ball of the foot.
Diagnosis
An MRI scan (magnetic resonance imaging) is used to ensure that the compression is not caused by a tumor in the foot. An MRI also determines the size of the neuroma and whether the syndrome should be treated conservatively or aggressively. If surgery is indicated, the podiatrist can determine how much of the nerve must be resected. This is important, because different surgical techniques can be used, depending on the size and the position of the neuroma. Because MRIs are expensive, some insurance companies are reluctant to pay for them. If the podiatrist believes an MRI is necessary, he or she can persuade the insurance company to pay for it by presenting data to support the recommendation.
Non Surgical Treatment
Treatments may include rehabilitation measures to reduce nerve Irritation. Switching to low-heeled, wide-toed shoes with good arch support. Wearing padding in the shoes and/or between the toes. Wearing shoe inserts to correct a mechanical abnormality of the foot. Having ultrasound, electrical stimulation, whirlpool, and massage done on the foot. The foot may be injected with corticosteroids mixed with a local anesthetic in order to reduce pain. Relief may be only temporary, however, if the mechanical irritation is not also corrected. Injections with other types of medications such as alcohol, phenol, or vitamin B12 are sometimes used.
Surgical Treatment
Patients are commonly offered surgery known as neurectomy, which involves removing the affected piece of nerve tissue. Postoperative scar tissue formation (known as stump neuroma) can occur in approximately 20%-30% of cases, causing a return of neuroma symptoms. Neurectomy can be performed using one of two general methods. Making the incision from the dorsal side (the top of the foot) is the more common method but requires cutting the deep transverse metatarsal ligament that connects the 3rd and 4th metatarsals in order to access the nerve beneath it. This results in exaggerated postoperative splaying of the 3rd and 4th digits (toes) due to the loss of the supporting ligamentous structure. This has aesthetic concerns for some patients and possible though unquantified long-term implications for foot structure and health. Alternatively, making the incision from the ventral side (the sole of the foot) allows more direct access to the affected nerve without cutting other structures. However, this approach requires a greater post-operative recovery time where the patient must avoid weight bearing on the affected foot because the ventral aspect of the foot is more highly enervated and impacted by pressure when standing. It also has an increased risk that scar tissue will form in a location that causes ongoing pain.
