Morton's Neuroma and Morton's Syndrome

Learn the causes behind Morton's Neuroma, plus its treatment and prevention.

Morton's Neuroma, also sometimes referred to as plantar Neuroma or intermetatarsal Neuroma, may occur as a result of irritation, injury, pressure - such as from wearing tight fitting shoes, or repetitive stress. It also frequently arises from unknown causes.

If you suffer from Morton's Neuroma or are seeking to prevent its occurrence it is important to follow the information in this article. In addition, making stretching a part of your fitness regime will have a significant impact. To get you started on a safe and effective stretching routine learn more about The Stretching Handbook and how it can improve your fitness.

What is Morton's Neuroma?
Neuromas are generally benign or non-cancerous growths of nerve tissue, developing in various parts of the body. Morton's Neuromas are confined to the nerves of the foot, most commonly, between the third and fourth toes. The condition involves a thickening of the tissue around one of the digital nerves leading to the toes and does not qualify as an actual tumor. The affliction causes a sharp, burning pain, usually in the region of the ball of the foot. A patient's toes may also sting, burn or exhibit numbness. Often, the symptoms have been likened to "walking on a marble."

Properly resting the foot in addition to the use of appropriate footwear including, as necessary, pads and arch supports, often brings relief from Morton's Neuroma, without resorting to surgery. A physician may also recommend anti-inflammatory drugs, cortisone injections and, should the condition fail to resolve itself, surgery.

While Morton's Neuroma has been an ongoing topic of clinical investigation, the condition is in some cases difficult to either treat or prevent. Experimental efforts involving the injection of muscle or bone with chemicals such as alcohol, as well as suturing, and covering affected areas with silicone caps have been attempted, with varying success.

Surgical treatment has provided relief in some cases while poor results and surgical complications have resulted in other cases. It is believed that ligament weakness, as opposed to the pinching of nerves in the foot, may be to blame for recurrent pain in these situations. For reasons which are not fully understood, the incidence of Morton's Neuroma is 8 to 10 times greater in women than in men.

Anatomy Involved
When a nerve is pinched between bones, the result is swelling of the nerve. It is this swelling which is referred to as a Neuroma. When the condition occurs in the foot, it is known as a Morton's Neuroma. Morton's Neuroma is technically not a tumor. Rather, it is a thickening of the tissue that surrounds the digital nerves leading to the toes. These nerves allow for physical sensation on the skin of the toes.

The region of inflammation is found where the digital nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. Morton's Neuroma commonly develops between the third and fourth toes, generally as a result of ongoing irritation, trauma or excessive pressure. In some cases, the second and third toes are involved. Morton's Neuroma is confined to one foot in most cases, though it can occur in both, particularly in athletes such as runners.

Mortons Neuroma image from Clinical Guide to Sports Injuries
by Roald Bahr, Sverre Maehlum and Tommy Bolic.

The resulting pain is caused by an enlargement of the nerve sheath of an intermetatarsal nerve in the foot. The reason this tends to occur in the third intermetatarsal space, the space (between the third and fourth toes and metatarsals) is that the third intermetatarsal nerve is the thickest, resulting from the joining of two different nerves.

Occasionally, those given a diagnosis of a Neuroma, or nerve entrapment, undergo multiple surgeries to alleviate the entrapment, though numbness may be a result of weakness of tendons or ligaments rather than nerve pinching.

What Causes Morton's Neuroma?
There are a number of common causes for Morton's Neuroma, (though the condition can arise spontaneously for reasons still unknown). The Neuroma often occurs in response to irritation, pressure or traumatic injury to one of the digital nerves leading to the toes. A thickening of nerve tissue results as part of the body's response to the irritation or injury.

Abnormal foot movement used to compensate for bunions, hammertoes, flatfeet and other conditions can lead to irritation and development of Morton's Neuroma. Pronation of the foot may cause the heads of the metatarsal bones to rotate slightly, thereby pinching the nerve running between the metatarsal heads. Chronic pressure or pinching causes the nerve sheath to enlarge, becoming increasingly squeezed, producing worsening pain over time, if not addressed.

Morton's Neuroma can be exacerbated when tight shoes providing little room for the forefoot are worn. Activities which over-pronate the foot (such as walking barefoot in sand) may increase the pain associated with Morton's Neuroma, as will any high-impact activity, such as jogging.

Signs and Symptoms
Often, no outward signs (such as a lump or unusual swelling) appear from the condition. Neuroma pain is most often described as a burning discomfort in the forefoot. Aching or sudden shooting pain in the forefoot is also common. All running sports, especially distance running can leave an athlete vulnerable to Morton's Neuroma, which may appear or flare up in the middle of a run or at the end. The sufferer often has the desire to remove his shoe and rub the afflicted foot. Should the Neuroma be of sufficient size, or if footwear is particularly tight or uncomfortable, the painful condition may be present during normal walking. Numbness in the foot may precede or accompany Neuroma pain.

Metatarsal bones will be examined clinically, and often an x-ray will be taken to assess the particular case and ensure against other conditions, including fracture. When the foot is examined by a doctor, he may feel a characteristic "click," referred to as Mulder's sign, and the interspaces between toe bones will often be tender. The doctor may put pressure on these areas to localize the site of pain and test for other conditions, including calluses or stress fractures. Range of motion tests will also be applied to rule out arthritis or joint inflammations. X-rays may be required to ensure there are no stress fractures or arthritis within the joints that join the toes to the foot.

Tenderness in one or more metatarsal bones may imply a pre-stress fracture or stress-fracture. An ultrasound scan may be used to confirm diagnosis of Morton's Neuroma, as x-ray will not detect the condition, (but can confirm that the bones are uninjured).

While the condition may at first only appear during heavy repetitive stress or when wearing particular shoes which aggravate the foot, the Neuroma can become increasingly inflamed and produce more constant discomfort, lasting days or weeks. Runners may experience pain pushing off from starting blocks. Tight or narrow shoes as well as high heels likewise aggravate the Neuroma.

A checklist of symptoms includes:

Burning pain - occasionally numbness - in the ball of the foot.
Radiating pain from the ball of the foot to the toes.
Intensifying pain during activity and when wearing shoes.
Occasional numbness, discomfort, tingling or "electrical shock sensation" in the toes.
Pain between the third and fourth toes, often occurring from the outer side of one toe to the inner side of the adjoining toe.
Pain upon leaving the starting blocks in running sports.

Treatment
Initial treatment for Morton's Neuroma may include:

Non-prescription anti-inflammatory medications to reduce pain and swelling. These may consist of standard analgesics such as aspirin and ibuprofen (Advil, Motrin, others).
Massaging the painful region three times daily with ice.
Change of footwear. Avoid tight shoes, high heels or any footwear that seems to irritate the condition. Low heeled shoes with softer soles are preferable.
Arch supports and foot pads to help reduce pressure on the nerve. In some cases, a physician may prescribe a customized shoe insert, molded to fit the contours of the patient's foot.
Reducing activities causing stress to the foot, including jogging, dancing, aerobic activity or any high impact movements of the foot.
Injections of a corticosteroid medication to reduce the swelling and inflammation of the nerve and reduce pain. Occasionally other substances may be injected in order to "ablate" the Neuroma. (The overuse of injected steroids is to be avoided however, as side effects, including weight gain and high blood pressure can result.)

The above measures are often sufficient to resolve Morton's Neuroma. Should the condition persist or worsen despite these efforts, surgery may be recommended to remove the Neuroma. The surgery requires only a short recovery period, though permanent numbness in the affected toes can result, so such surgery is generally used as a last resort.

Prevention

Always warm-up thoroughly before vigorous athletics.
Avoid activities that cause pain.
Stretch and strengthen the feet through gradual exercise.

Stretching is one of the most under-utilized techniques for improving athletic performance and getting rid of those annoying sports injuries. Don't make the mistake of thinking that something as simple as stretching won't be effective.

And to help you improve your flexibility quickly and safely, you can't go past The Stretching Handbook & DVD. Together they include over 130 clear photographs and 40 videos of every possible stretching exercise, for every major muscle group in your body.

The Stretching Handbook & DVD will show you, step-by-step, how to perform each stretch EXACTLY! Plus, you'll learn the benefits of flexibility; the 7 critical rules for safe stretching; and how to stretch properly. Discover more about The Stretching Handbook & DVD here.

Always wear proper, sports-specific footwear, especially shoes with a wide toe box.
Be careful not to lace the forefoot portion of the shoe too tightly.
Pair socks with given shoes so the fit is consistent during sports.
Maintain a healthy weight. Obesity overstresses the feet.
Allow adequate rest and recuperation time following exercise.

If you enjoyed this issue of The Stretching & Sports Injury Report, please feel free to forward it to others, make it available for download from your site or post it on forums for others to read. Please make sure the following paragraph and URL are included:

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Article by Brad Walker and The Stretching Institute™
Copyright © 2010. All rights reserved.
Brad is a leading stretching and sports injury consultant
with more than 20 years experience in the health and
fitness industry. For more articles on stretching, flexibility
and sports injury management, please visit:
http://www.thestretchinghandbook.com/archives/
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