Morton’s Neuroma: Controversial to Say the Least

What really pushed me over the edge when it came to Morton’s Neuroma (MN) was watching Steven Tyler on OWN. During his interview with Oprah (okay, I saw it with my wife – her idea!), I realized one, that he’s an awesome dude, but two, he is mislead in thinking his problem is just a MN… he showed one of his “dogs” right there on TV, and a MN, even if he has one, is the least of his worries!

First of all, a MN is not a neuroma at all… and, Morton did not describe Morton’s neuroma! What tha…? Technically speaking, it is perineural fibrosis, sort of a misplaced overgrown protective “scar” tissue surrounding and compressing an otherwise normal nerve. And this choking effect of the common digital nerve is what produces the pain. Durlacher described “Morton’s” neuroma, but I guess Morton’s neuroma sounded better. I’m certain it is easier to spell.

So, what does MN feel like? It is bottom-of-the-foot, or plantar, pain that usually comes on very slowly — months to years — and never is a result of injury or trauma. At first the pain is vague, and difficult to describe or localize, but in time, over a period of months to years, it will localize and the ability to describe the pain sharpens. You may or may not have numbness or shooting pains out into the associated toes.

Common and characteristic complaints are increased pain with tighter shoes, the urge to take ones shoe off and rub the foot, and/or the feeling that there is a fold in the sock, when there isn’t. It’s a nerve thing. The exam is defined by re-creation of the pain with palpation in the web space and possibly eliciting a pain reproducing Mulder’s click.

When I see a patient and I suspect a MN, it becomes a diagnosis of exclusion, especially if it is in the second web space. This means that all other prospects/suspects are ruled out first, usually by history and exam. BTW, a Morton’s neuroma may “feel” like swelling on the bottom of your foot, but that’s a sense that many get from numbness anywhere. However, actual, real swelling never accompanies MN. Never. The only other diagnostic test available is a diagnostic injection with or without cortisone.

Treatments range from living with it, to surgery. Sorry, but my focus here is not for treatment, but I will make a few brief comments below.

Here is the point. There are three things you don’t know about MN that you might need to know. This is not science and is the culmination of 26 years of experience and observation.

1. An MRI is not a valid diagnostic test for MN!

Let me make this clear, an MRI is in no way able to aide in the diagnosis of a MN. If your doctor suspects a MN and suggests an MRI to “confirm” the diagnosis, or you already have an MRI “positive” for a MN and surgery is suggested based on this info, RUN. In deference to this, if your doc is struggling with the diagnosis of a possible MN and suggests an MRI to help better define other potential problems, then an MRI is probably okay. This gets back to the rule out/diagnosis of exclusion thing. Ultrasound is questionable as well. Here’s the thing, no matter what diagnostic test we use, it is our responsibility to connect the dots. It is called clinical correlation.

2. There is no such thing as “recurrence” of a MN after a surgical excision.

I have always wanted to say that because it’s so controversial and offbeat, but true. Man-o-shevitz, it feels so good to get that off my chest. So what is a “recurrence?” This is simply a case of your pre-op pain returning after surgical excision, or code for: your neuroma grew back. Somehow use of the word “recurrence” makes this failure seem more like magic or bad luck or maybe the patient’s fault. On the other hand, it also implies this is not the doctor’s fault.

The truth is, according to the AO, return of your pain post-op falls into two categories. Misdiagnosis and failure to actually remove a bonafide MN. Accurate diagnosis of a MN by a specialist can be difficult and is at best 95% accurate. That means that when I take you to the operating room, I will be wrong 5% of the time about your diagnosis. Sorry, but that is the best I can do, and I make sure every one of my patients know that. Incomplete removal or no removal at all (air ball, air ball, etc.) is the reason for “recurrence” when there actually is a MN. When the nerve is cut, what results is an true amputation neuroma and if it is left in the WB area you will continue to have pain just like or worse than you had prior to surgery. And if there is an air ball, well, that speaks for itself. When it comes to surgery, get a solid diagnosis and pick an experienced fellowship trained surgeon.

3. Calf stretching might be the answer to MN.

I have found through serendipity that consistent, daily, dedicated calf stretching relieves the pain from MN in about 60% of cases. This is anecdotal for sure, but this surprise in my practice has saved a lot of surgeries. While I have theories as to why this might be true, let’s just say that it is intriguing and would really be awesome if it bears out. Who knows, maybe some smart guy will come along and prove me wrong…or right.

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79 Responses to Morton’s Neuroma: Controversial to Say the Least

  1. Doug says:

    Interestingly, I just went to a CME lecture today where a radiologist showed a large differential of conditions that might mimic a neuroma – ganglion, plantar plate tear, lipoma, etc., etc. However, I agree completely that using MR to diagnose a neuroma is beyond overkill. I don’t take an x-ray either. A characteristic history and a positive Mulder’s click is enough for me.

    I have nearly complete treatment success in treating neuromas by persuading patients to do three things:

    1. Wear double Spenco neoprene insoles beneath their forefoot. The cushioning does wonders for relieving neuroma pain.

    2. Wear the widest shoes possible, allowing the maximal possible spreading of the metatarsal heads and phalangeal bases. I figure that allows the nerve to pass unhindered between the bony structures.

    3. Wear some kind of soft OTC orthotic, preferably sandwiched beneath the Spenco insoles. Even better is attaching a metatarsal pad to the orthotic slightly behind the metatarsal pads to further unweight the forefoot. This is optional.

    Lastly, I recommend a cortisone injection or two, figuring that I skewer the neuroma directly and get some intralesional atrophy. However, I’m not offended when patients refuse this because I strongly prefer that they take the 3 steps mentioned above.

  2. aoeditor says:

    First, you’re right on — great to see someone with your knowledge who has some common sense, too. Second, it sounds like you’re doing some great work. I appreciate your thoughts! – AO

  3. Ariel says:

    Hello.  I live in Cincinnati, Ohio.  I am 36 year old female and in pretty good shape.  I have had left foot pain gradually worsening over the last year.  I was recently diagnosed with capsulitis of the 2nd and 3rd metatarsal, tried one cortisone shot, and Powerstep Orthotics with a buildup to off load the two met heads.  After 8 weeks, no change ( not running and jumping but still doing some weight training) I sought an ortho.  She did an MRI and said I have a Morton’s neuroma 7 mm x 3mm and said I should have surgery.  No mention of alcohol injections or any other options.  Do you have any suggestions?

    Thanks!,

  4. Hanie Hartman says:

    Hello,

    I have had pain between toes three and four that was diagnosed as a morton’s neuroma last summer. Since I have also had bunions for MANY years, I had surgery to fix the bunion and remove the morton’s neuroma in August of 2011.

    I still have pain in the front of my foot whenever I walk/run. It is mostly between toes two and three. The key word here is ‘mostly’. I also occasionally have pain/burning between one and two. I also occasionally have pain across the back part of almost the entire ball of my foot. In February of 2012, I had surgery to remove the pin for the bunion surgery. Then I had an MRI. According to the MRI, there is nothing grossly wrong with my foot.

    I have seen two different podiatrists. Neither one of them knows what to do with me. When the poke and prod my foot, I don’t have a spot that consistently produces a pain reaction.

    I don’t know where to go from here. Do I try a neurologist? An ortho? If so, how does one go about finding the right person to see.

    Any help that you can provide would be greatly appreciated.

    • Julia Coonan says:

      Hi
      I’ve just been to Mayo hospital in Jacksonville FL. Surgeon said my non-contrast MRI taken in Dec were not good enough. So just had more done – with contrast.
      Have had 2 double foot surgeries for neuromas – one Dec 2011 and then Oct 2012 – now in more pain than before I started.
      I spoke with assistant of someone who lectures at Johns Hopkins about cutting into arch of foot – about 3inches and taking the nerves and attaching them to muscle in the arch – so not walking on them any more – he said I’d be able to fly home in 3 days – unlike Mayo method of dorsal cut to remove neuroma and then not being able to put foot down for 3 weeks.
      I’ve now likely got 4 stump neuromas – about 2 surgeries I can’t imagine that only 2 grew back – so I’m betting on all four.
      Has anyone had any experience with method of redirecting the nerves to sit under the arch – makes sense to me but I’m not a doctor. thanks for any info anyone has.
      I’m told that after already having had 2 double foot surgeries I likely will only have one shot at getting fixed – before becoming a foot cripple.Julia

  5. Angryorthopod says:

    Hi Hanie,

    Sorry about your problem and I can assure you you are not alone. To find the right doc go to

    http://mmax.aofas.org/scripts/4disapi.dll/4DCGI/directory/person.html?Action=AOFAS&AOFAS_Activity=Directory

    I have two questions. Are you worse in shoes (especially tighter) or barefoot?

    Do you have a history of plantar fasciitis, aka heel pain?

    The AO

    • Hanie Hartman says:

      Hello AO,

      I do not have heel pain. I have not worn a tight shoe in several months. So, that would be a tough call. I would not say that going bare foot makes my foot hurt more than usual.

      I went to the website that you gave me and found some drs. I have one more question before I choose one of them.

      Are there truly other people out there who have post surgery pain when they walk but not a ‘predictable’ pain. When I say ‘predictable’ I mean that poking/squeezing the foot does not cause a sharp reproducible/consistent pain in the foot? Because this is what is putting me at odds with the podiatrists.

  6. Doctor, and what if all of the above treatments for PF have failed?! Extreme rest, minimal to no walking, stretching, icing, anti-inflamitory cream, crutches, the boot, 2 cortisone shots, custom orthotics, weeks of physical therapy (Ultrasound, deep tissue massages, Graston technique, E-STIm), severe symptoms for over 6 months with inability to perform every day normal tasks. Is there no hope?!

    I have not been diagnosed with MN, but rather Plantar Fasciitis. There was no single event that caused an injury though. Is it possible this is MN?

  7. Shelley says:

    Thank you for such great info. I had surgery for MN over 3 years ago and my foot hurts just as bad as well as my entire right leg from walking differently I guess. I have pain everyday…all day and even during the night. My Dr said I may need the second surgery which is done from the bottom of my foot and has a longer recovery time. As it was my first surgery took 3+ months of recovery. My initial instinct with regards to my Dr should have made me look for someone else to do the surgery. At one point he was giving me a cortisone shot in my foot from the bottom between my toes and when I looked down I saw the top of the needle coming out of my foot and liquid spraying out. Ouch! I almost passed out. Anyway is my only real option now another surgery?

    Thanks for listening

  8. Russell Rottino says:

    I have PF in both feet. I have done everything possible you can do for PF. That is, stretching, cortisone shots, epidurals, boots, every kind of orthontics ever made, and finally surgery on the left foot. Nothing! Still live with the pain. Now I have MN between 2 and 3 on the right foot. Sucks to be me. I found another podiatrists recently and he tells me he can fix the PF once and for all. He cuts the faciia all the way across. Completely severes it. Most sergeons will only cut 1/3. I have never heard of this before. By the way. If you do have Plantar Faciitas, the best shoes to buy are MBT’s. No orthontics needed. I won’t wear anything else. I’ve been living with PF for over 20 years now. Your thoughts on this surgery??

    • aoeditor says:

      I am going to keep this simple. Don’t let them cut any part of you PF. The problem is that your calves are too tight! Either stretch your calves for no less than six consecutive months (my protocol is stretch hanging off of a step 3 min, 3 times per day EVERY day) or have your calves surgically lengthened. Below is a reference for a recent technique that seems promising and safe. As far as shoes, wear what is comfortable to you. There is no right shoe!

      Proximal Medial Gastrocnemius Release in the Treatment of Recalcitrant Plantar Fasciitis
      Ali Abbassian, FRCS; Julie Kohls-Gatzoulis, FRCS; Matthew C. Solan, FRCS
      Surrey and London, UK
      Foot & Ankle International/Vol. 33, No. 1/January 2012

  9. LumpyFeetMc'Limpwit says:

    Hello ducklings! I have been having this bothersome pain that appears to be between my 3rd and fourth toes- but it’s inflammed like a lump, and came on suddenly. Not only this, but it’s been almost a month, and it hasn’t really improved. What the heck is it and what should I do about it?

  10. MyRightFoot says:

    I was diagnosed w/ Mortons Neoroma 8-9 yrs ago. Dr. wanted to perform surgery that sounded extreme. No Way! Tried custom orthotics – worthless; pads on ball of foot provided relief along w/ more comfortable footwear, but problem still there and seriously affecting my comfort when walking. Different foot doctor diagnosed MN again (between toes 2 & 3, right foot) and he discouraged surgery. He performed cortisone / alcohol injections 4 times over a period of 2-3 months. To this day, I’m happy to say that it is 98% “cured”. Only very occasional discomfort with certain types of shoes and when barefoot on hard surfaces. Glad I didn’t go for surgery. Moral: get 2nd opinion and start conservative.

    Now a Question: MBT shoes – looking to by a pair for fitness walking and notice medical disclaimer Not To Use if you have MN?? Wondering why. Anyone w/ experience w/ MBT shoes & Morton’s?

    • aoeditor says:

      You are singing to the choir. While surgery is often the end result in treatment of MN, that is exactly what it should be, the last resort. I am not a fan of alcohol injections for good scientific reasons, but the alcohol or something certainly worked for you and I commend you for your perseverance and resolve.

      MBT shoes might work for you. MN and MBT’s warning makes not a lick of sense, but follow my logic below. In general, MBT$$$ shoes or Sketcher Shape-Ups$, both of which are basically identical, as a shoe design/concept is quite possibly the silliest thing I have seen in years. A classic “rocker bottom” shoe (MBT did not invent this concept) has its role, but that role is very narrow. For instance, the rocker bottom design can be useful in treatment of ankle arthritis or smoothing the gait after an ankle fusion to name a few. The rocker bottom design for the rest of us with basically “normal” feet and foot structure these shoes is questionable at best.

      Here is my philosophy when it comes to shoes in general, which includes flip flops, 5″ stilettos, MBT’s, army boots, name brands, leather, sneakers, Crocks……..you name it………TO EACH HIS OWN! Never let someone else, particularly a shoe company or a doctor, tell you what is the best shoe for you to wear. Decide for yourself what works best for you, which might take a little trial and error; but you decide for yourself. Professionally, I get asked every day about this shoe or that shoe and here is my standard response: do I look like a shoe salesman and most importantly, IF IT LOOKS GOOD AND IT FEELS GOOD, WEAR IT!

  11. Kirt says:

    Left foot pain between 2nd and 3rd metetarsal x 2 years. MN removed in 2012. Still having foot pain. Expensive orthodics, steroid injections and PT and nothing has made it better. My work requires me to stand at an exam table up to 4-6 hours at a time without sitting. Pain is terrible. I am wearing the widest shoe possible with no relief. Only relief is when I have no shoe on. Physician who did my surgery says ” I have to live with it and there is nothing more that can be done”. Looking for answers. saw that some Physician is doing nerve removal and re-transplant. Any suggestions? Also what is the best way to image my problem. MRI, US, X-rays? Any suggesitons would be appreciated.

  12. Stephanie Goldman says:

    I had Mortons Neuromas excised from both feet in 2009. They have returned (gradually) and are now excruciatingly painful (especially in my left foot). After I had the procedure to remove them, the surgeon remarked that they were “the largest tumors I have ever removed!” Post-op, in “booties” and on crutches for 3 weeks, I was relieved of the pain. One year later, I experienced discomfort – although there was numbness in the area, of course. Now, 4 years later, the pain is extreme (especially in the left foot). It is just as painful, if not worse, than before these neuromas – or tumors – (they were diagnosed as Mortons Neuromas; it was explained to me that because I’ve been a dancer & an athlete since I was a child, frequent & extreme activity e.g. “pounding on my feet” caused this). I am now 58 years old & still very active. I wear the “best” athletic shoes, do not wear tight shoes or high heels, wear Birkenstocks – basically I have every type of “good” shoes imaginable. Still, after 1-3 hours on my feet – even doing stressless activities – I have pain. The onset can be sudden, or can come on gradually. It is ALWAYS acute pain. Actually, when I REMOVE my shoes (again, the left foot is more painful than the right), that is when the pain is MOST EXTREME. It is intolerable to the point where I must stifle screaming when in public. In private when this occurs, I do indeed scream out in pain. I have had many cortisone injections. They are not effective anymore. The 1st & 2nd times I had injections, they helped for a week or 2 (1st injection relieved pain for 2 weeks; 2nd injection relieved pain, and less so, for 1 week). I had a 3rd injection which provided no relief whatsoever. I am searching on-line for a podiatrist (I have moved to SW Florida since these “neuromas” were excised in 2009 in New York) to “fix” me. I can not tolerate this pain any longer. However, if I am off my feet – e.g. working at home wearing Birkenstocks or even going barefoot – I have NO pain at all. When this pain occurs, as I’ve described, I find the nearest place to take off my shoes (again, at the moment I remove my shoes – usually the left shoe – the pain is MORE EXTREME for a few minutes than it was before I removed my shoe(s) – only after 1-2 hours of being off my feet allows the pain to subside, and finally go away. Any advise would be appreciated.

    • aoeditor says:

      Sorry this has happened to you. The sad truth is that Morton’s neuromas (MN) is that they are not easy, but they are regarded by us as being no big deal. Here is some good general info about MN your doc either will not tell you , or more likely he/she does not know. There are only two reasons surgical excision of a Morton’s neuroma fails.

      The most likely reason is misdiagnosis. MN’s can be very difficult to diagnose, in fact for me it is a diagnosis of exclusion, i.e., everything else your pain could be is considered and ruled out first. There are only three tests for MN: accurate detailed history (by and far most important), exam, and provocative injection in the MN area. MRI, EMG/NCS, ultrasound, etc. are a total waste of time and money.

      The only other reason is failure to adequately resect the neuroma back to the NON-weight bearing area of the foot. There it will form an amputation or real neuroma, but will not bother you, provided the diagnosis is correct. I have probably revised 300 neuromas in 27 years and without fail I find the nerve totally intact (never touched) or it has been cut and the amputation neuroma is in the weight bearing forefoot area. Ouch!!! http://fai.sagepub.com/content/13/3/153.full.pdf

      • Leanne says:

        What is a provocative injection? What is the relationship between heel pain and MN? I ask because you asked someone if they have heel pain. I’ve been diagnosed with MN and am convinced of a correlation between my calves, ankle & MN. I am going to do your 3x a day calf stretches! My MN is very mild. I rest it a lot which has narrowed my fun. Thx for this site.

        • aoeditor says:

          Thanks so much for your follow and compliment. A provocative injection sounds a lot better than it is. Seriously, it is a local with or without cortisone injection strategically placed in the exact location (i.e., ankle joint) of the suspected source of the problem. If it temporarily works then the diagnosis is very likely confirmed. If it does little if anything then the location (again, the ankle joint) is not the problem. While disappointing it is still valuable information. The provocative injection is a very powerful diagnostic tool and in my opinion is use to little today. Definitely stretch your calves every day and get back to having fun. Best, AO

  13. Anna says:

    Hi,

    I am hoping you can help me! I am marathoner and for a few years I would run and the very tip of my 4th toe would go numb and become very painful. Eventually, it got to the point where I could only run for 20 minutes and the pain/numbness would be too great. I tried metatarsal pads, injections, etc. but eventually had Morton’s neuroma surgery. The ball of my foot never hurt, just the tip of my 4th toe. The doctor removed a pretty good sized neuroma.

    Now I’m marathoning again and at about 30 minutes in, the same thing happens. Terrible numbness/pain in the tip of my 4th toe. I’ve tried using a met pad again but it still goes numb. As soon as I stop running the numbness and pain stops and I’m fine. I’m wearing shoes with the widest toe box possible, and have cut the toes off my socks so my toes are free to move around.

    Please help!

    Thanks for taking the time to read this,
    Anna

  14. Jen says:

    I was recently dx with bilateral heel spurs, plantar fasciitis and MN. I do better wearing any shoe with cushion vs bare foot on hard surfaces. But when I am exercising or wearing certain shoes, it feels like I am stepping on a nerve. My doctor sent me to a podiatrist who is recommending Extracorporeal Pulse Activation Treatment. Any thoughts? It is expensive and not covered by insurance. I am going to start with your recommendations above and see how it goes for now. I have to start doing something because I am now having significant knee pain, I suspect from changing how I walk to avoid the pain.

  15. Ben Frakes says:

    Dr.
    I fear that, as suggests above, after my first surgery to resect a neuroma resulted in increased pain, my second surgery performed by one of the top Ortho’s on the east coast for foot surgery has only made things worse. The idea was to “bury” the nerve ending in tissue. This was three years ago. I have been on narcotics ever since to deal with the pain. Having gotten myself off of the pain meds, I have realized just how excruciating the pain really is emanating from the ball of the foot. Undoubtedly from having buried the nerve too close to the weight bearing area. I don’t know what to do next…..going back on heavy narcotics cannot be what I am doomed to for the rest of my life. I have an appointment with one of the foremost Ortho’s at John’s Hopkins but can’t get in until May. What to expect? Can this nerve be cut yet again and buried further back from the ball of the foot? In agony and frustrated.
    Thanks for your insight in advance.

    • Julia Coonan says:

      Hi
      Can you tell me which doctor you are going to see in May?
      My email is exbermuda@gmail.com
      I have had 2 double foot surgeries and now worse than ever.
      Now have to decide between cut into balls of feet (one at a time) – but don’t know how they stop growing back. But said all the little nerve branches have to be cut etc. That’s Mayo in Jacksonville.
      I didn’t ask if they cut the nerve and then anchor it – I seem to go brain dead when talking to a doctor. but cutting into ball of foot means being totally off feet 3+ weeks with lot longer recovery after that.
      Second option – Dellon at Johns Hopkins – he cuts into arch of foot and embeds the nerves under the arch – so they can’t grow back- BUT have been online with lady who had 4 (stump) neuromas done this way but one nerve has come away and is “floating” and so she’s still in pain.
      The plus side on the Dellon method would be (so they say) .. being able to walk and fly home after couple of days!
      Then a negative is – he’s not on my insurance network. He teaches his technique at Johns Hopkins but can’t find out who he teaches to – maybe another surgeon in my network! But they won’t tell – just want $750 consultation to go and find out – which is more cost – flight and hotel etc.
      Would appreciate hearing from you and if you would share your research information. I’ve been thinking of amputation and getting those springy feet – anything better than walking on what feels like big blisters!

  16. Maria says:

    Does Mortons Neuroma never occur in twelve year olds?

  17. Brian says:

    I have had bi-lateral MN for over 5 years and in october of 2012 had a neuroma removed from the 3/4 interspace of my right foot. I was getting severe back and hip pain from walking funny. Within weeks after the surgery I noticed a “lumpy thing” running along the bottom of my foot between the 2/3 interspace right behind the ball of my foot. It seems to be about 1.5″ long. It was not there before the surgery. Recovery was (is) painful and every time I went back for a check after the surgery,I asked the surgeon what it was and he said “I dont know” massage it though.
    He prescribed soft orthotics and put me on 50mg of pamelor each day. The pamelor helps with the pain (actually really reduces the pain of the neuroma in my left foot quite a bit) but it still feels like there is a neuroma in my right foot (but not in the 3/4 space where the excision was ) it feels fine there. It feels like it runs along or is in front of the “lumpy thing”. I requested an MRI at the end of december and the results said nothing about the “lumpy thing” on the mri. It looks like it doesn’t even exist. The mri report said my foot looked “normal” except for some slight edema in the area of the surgery.
    Both a P/T and my massage therapist feel that it is the flexor tendon from the third toe. And both agree with me that it definetly wasn’t there before my surgery becaust they both had worked extensively with my feet. One podiatrist suggested that it was a “fibroma”. I would like to know what it is and do I have another neuroma in this foot. It feels exactly like the neuroma in my left foot. It gets aggravated when I wear socks and shoes and feels exactly like my left foot where there is a known neuroma. It is especially aggravated when pressing the gas pedal on a car. You suggest that MRI cannot see a neuroma, why doesn’t this lumpy thing show up on an MRI ? I don’t know what to do, I certainly don’t want any more surgery if at all possible, I don’t want to keep taking this pamelor as it has made me gain weight, and I want to rid my feet of pain. How would you go about diagnosing this situation, or where should I go for some answers. The surgeon who is well respected and was recommended by one of the top foot and ankle surgeons in the country as a local resource says he doesn’t know what it is. Any suggestion or recommendation would be greatly appreciated.

  18. Lucy Waite says:

    I had surgery for plantar faciatis over a year ago. After reading one of your responses, I was elated that somebody understood what I have been trying to describe for what seems like forever. After the surgery, there is a swollen area on my heel. I would describe it as walking on a “blister.” But, the words “air pocket,” are perfect. But, let me add, an air pocket that extends from one side of the heel to the other, and from the rear of the heel to the instep with spikes inside. The “fold in the sock,”… PERFECT. I don’t know how many times I have taken off my shoe to “fix” a sock that is just fine. This began immediately after surgery, and has never ceased. If I tap on the incision on the inside of my heel, I feel it on the outside of my heel, like an echo from a mountain range. Doc says, “You must be wired differently.” Bare feet? Just shoot me now. Flip flops? Only comparison is natural child birth, which I did four times. After surgery, I now wear two different sized shoes due to the heel extending further back, and the swelling (air pocket?) on the heel. Dr. Dellon says he can fix it, but my insurance does not pay to repair unsuccessful surgery. I wear my brace at night and probably stretch my calf no less than 20 times a day because it feels, SO good to do it. Doc says to wear hard soled shoes. I do that, with gel heel pads stacked one on top of another. Used to get a couple of good hours / day. Now, there is not a step without pain. I take care of my 85 year old mother, and a daughter with Senior Loken Syndrome, post kidney transplant. I need my feet! Help?

    • aoeditor says:

      Hi,

      Here is the skinny on your problem. There was probably a traction (tugging) injury to your calcaneal branch of your tibial nerve in surgery. Unfortunately it is a well recognized problem and happens with some regularity as a result of this surgery, even when done well. This problem is one of the many reasons I do not do this surgery. Your symptoms you describe so well and the distribution are clear cut. Dellon is a very good man, but before you go back under the knife there are 2 things you must do and they will most likely work.

      1) You must do cross friction or desensitizing massage directly at the trigger point, probably over part of the scar. You can tap your finger over the area to find it. Don’t massage over the hypersensitive heel or the area of the nerve distribution as it does no good and only causes senseless pain. For finding a good massage technique (I can’t really show how here), how often, how long, etc., find a P.T. and have them instruct how to do at home. This works in better than 80% of my patients and even in me 20 years ago. In the end you will still be “numb”, but the sting and hypersensitivity will be gone.

      2) Now that a major supporting structure, the plantar fascia, has been weakened in your foot, you must do calf stretches daily. As you may know, I have been saying all along that the calf getting progressively tighter as we age is the cause of plantar fasciitis. So now your original problem remains and it is placing more strain on your weakened plantar fascia. A buddy of mine has a handle and a new product for calf stretching. Check it out.

      One Stretch

      Just to be clear, plantar fascial release is still very accepted and done everyday. This view, calves too tight as the cause, is my own and a few others.

      Hang in there and massage. Best of luck!

      AO

  19. Trekster says:

    In less than eight weeks I will be leaving for Spain to walk the Camino de Santiago. The camino is a thirty day, 500 mile hike with significant elevation gain/loss over a well developed route. In the course of my training I developed a burning/tingling pain in both forefeet with the right foot being the worst. I found that the pain came on after nine to ten miles of a 12-15 mile hike.

    A podiatrist visit last fell resulted in a MN diagnosis in both feet with the one in the right foot being far larger. Saline injections didn’t help a lick so the next step was a custom orthotic for the heel and arch — that helped a tiny bit. When the doctor recommended removing the offending nerves and I put my foot down and said “no”.

    I’ve recently switched from women’s Keen Amblers (size 11) to men’s Ecco Yucatan sandals (size 43) for a little more breathing room, because unfortunately, my 2nd toe is longer than the big toe and I want to keep those toenails. Also, the Ecco soles seem a bit thicker and firmer so landing on sharp stones is not as painful.

    As the time is running out, I’m grasping at straws. Do you have any suggestions?

  20. aoeditor says:

    You either have a Morton’s neuroma (feels better barefoot, no visible swelling, less common) or 2nd MTP synovitis (feels better in shoe, not barefoot, often swells, very common). In either case there are three things you can do in the 11th hour, and one is not surgery (last resort). Stretch your calves EVERY DAY per protocol at onestretch.com and try metatarsal pads by Hapad. Make sure they are in the exact right place just behind your metatarsal heads; not back in your arch or under your MT heads. A cortisone injection, provided placed in the right location based on a correct diagnosis done about a week prior to leaving can be a trip saver. Your choice. As a final note, expensive custom orthotics (chances are you have them already and the odds are they don’t help) are not one of my choices. Best of luck, sounds like an awesome trip.

  21. Katy says:

    I am 8 weeks past MN surgery (I am wondering if I even had them)? removed BOTH feet, now am in terrible pain, how big should neuroma be (stated on pathology report)? Dr cut my nerves all the way back, whatever that means? I am worried this surgery wasn,t needed and that I was misdiagnoised. I started off with horrific calf pain, PF, tendonitius, PT, could not walk without shoes, I felt like I NO padding on the balls on my feet, hot and burning feet, quite a mess, so I agreed to the surgery and now I wish I had just dealt with the pain, now I am miserable. what is fibro fatty tissue 2.5 x 0.2 x 0.2 cm – fibroadipose tissue with nerve showing perineurial fibrosis and disorganization? As stated on path rpt. Please, I value your opinion

  22. docs says:

    I am a 51 year old fit female…..and I have read everything here as I am wits end what to do after reading all of these
    I have had this pain for approx 6 weeks and had an x-ray to rule out a fracture or stepping on something and today I had an ultrasound according to my family doctor this will tell the true story of whether it is MN. I have already lined up a cortisone doctor (i see him for nerve blocks for headaches) as my family doctor is not being proactive in any of this….i drive standard and the pain is my left(clutch ) foot….Now after reading all of this …i am scared and don’t know what to do next….I often can’t walk and was given crutches at the emergency room last week i have a 16 yr old son and work and I have to drive and I have to work…… and i am feeling so very worried that i will not find someone who will know how to treat my symptoms properly

    everyone’s story is different and yet the same and the results are different for everyone.
    I have chosen to get the cortisone just based on reading from the internet (and the fact that I have a doctor who can do this) and i am not waiting for my family doctor …..I truly belive they have NO clue as to the excruciating pain involved in all this….most people look at me like I have ten heads…….

    You seem very knowledgeble and I dont want to rush into surgery and as i am sitting her I am strectching my calfs(as mine becoem sore with driving a standard) if I could change cars i would i just bought this 2. 5 yera ago after a car accident and finances wll not permit me to get another vehicle at this time…but |i truly belive that maunal transmission has been the (driving ) force ..no pun intended behind this…

    I first noticed the pain when I had an FAE(they build a gym in your house and put you through hell for 4 hours 2 days in a row…to prove you are fit as a fiddle and the car accident did nothing.it was done by an O.T. on behalf of the Insurance Company …the pain was felt when I was asked to do squats and then it went from there……it seems all my troubles have come from the darn accident of which I have never had any pain relief and keep getting new issues directly related to.

    I am looking for any and all of your advice AO.

    thank you
    Reply

  23. Neuroman says:

    Thank you for the excellent, honest, no-BS recommendations.

    I have a Morton’s neuroma in my left foot that, when aggravated, produces nearly constant pain as well as very distracting electrical sensations in various parts other parts of the foot. Luckily, my podiatrist is a no-nonsense guy, and refuses to recommend unproven treatments and useless tests. Here’s the protocol I’ve followed (some self-developed through experimentation, and all of which is consonant with the advice above):

    1) wear shoes that apply no pressure whatsoever to the forefoot or midfoot–think shoes that allow you essentially to walk “barefoot” inside of them. Practice a bit actually walking barefoot (even if you can’t or won’t adopt this as a way of life) so that you know how your foot *should* interact with the ground.

    2) stretch the heck out of (firmly but sensibly for several minutes a few times a day) your calves and achilles tendons on a step, and then your feet generally (I press my toes down into a claw with my hand firmly, and then dorsiflect and repeat, holding each position). Loosen those lower legs and feet up!

    3) Lose weight if you’re carrying significant excess pounds! (I know, I know, but seriously–you’ve got to do it!)

    4) Perform resistance exercises slowly and methodically to strengthen all of the lower leg and foot muscles, and also to provide a weighted stretch–carefully!

    5) Wear a soft orthotic with a metatarsal lift and/or a pad–try one for a week or so before deciding whether it’s helpful.

    6) A cortisone shot or two *may* help, but it may not.

    I’m 90% pain-free after 6 months of the above regimen.

  24. Magnus says:

    I did the operation 12 months ago. It was a confirmed neuroma in my right foot between 3rd and 4th toe. It took me some time to recover. I was sore and had the wrinkled sock feeling for about 3 months. So recovery took a while. But then I was totaly pain free for about 6 months. Then one day at the gym I did calf raises with some heavy weights on my shoulders. After the workout I feelt a burning sensation inside my foot and it kind of felt like something bad had happened. From there on it has been going all down hill. I have all the same sensations in my foot as before the operation minus the piercing pain. The wrinkled sock feeling is the worst ever and in the evening my foot feels sore. I am getting a bit nervous since I am not getting any better and it has been 3 months since the ill fated workout. Has anybody else had the same post op experience? What could have happened when I did the calf raises?

    Best regards

    Magnus

  25. Charlotte says:

    Great information provided in this forum. In 2006 I began to experience numbness, tingling, and sharp pain in my third/fourth interspace of my left foot whenever I cycled more than 20 miles. At the time I was a long distance cyclist. Two years following the pain would occur while playing tennis, too. I stopped cycling for other reasons at this time and focused on tennis and running. The pain mostly went away. In 2011 the pain became regular. Over the 5 years i changed to shoes with wider toe boxes, inserts and due to a calf injury learned to stretch regularly. I visited my Primary for the first time in 2011 for this reason and he recommended a cortisone shot. It was magic. But it didn’t last. I had 4 shots in 2 years (3 in 15 months) and my primary felt it time to visit a specialist in early 2013. An ortho foot doctor did an MRI and confirmed a neuroma. I have been advised that cortisone shots should not exceed 3 in a twelve month period. I was at a point where the cortisone was wearing off before the four months had passed. I have decided to have the surgery to remove the neuroma. I do hope it works! I have not been able to play tennis or run without pain for many months.

  26. MKFlorida says:

    Hello, have had pain in both feet for years, had an injury 1/2013 and thru xrays, exam, ultrasounds was diagnosed w/MN, right foot much worse than left. I wake up w/pain when I 1st come out of bed hardly can walk, try to stretch toes, and after reading here will strecth calves. Using insoles in tennis shoes, used to be a runner, love to dance, wear high heels only to go out, after dancing a few minutes it hurts a lot! :( I live in FL, stay at home a lot and barefoot, wear flip flops and if I wear boots /closed shoes is when hurts the most, the most painful moments are early /right when I wake up afetr sleeping, it appears better at night afetr all day? not sure why? dancing, walking a lot, high heels when hutrs the most also. Recommended per Dr the shots but unable to be brave enough to do that yet, I have wide shoes, many inserts/insoles, and do not like to take any meds or think of surgery. I was always an athlet volleyball, dancer, running, etc and now I live a pretty sedentary life, at 51 years old. Please, advise any other thing I could do to better my life at this point? Thanks for your time! God bless you .M.

  27. Pregnant Mom says:

    I was wondering if there was a link between pregnancy and Morton’s Neuroma. I started feeling a little sharp pain, in identical spots, on the balls of both feet, in my second trimester. I am now at the end of my third trimester and the pain in both my feet has gotten worse. I cannot walk barefoot on hard surfaces, I have to curl my feet up and kind of walk on the sides of my feet so I don’t put pressure on the two points of pain. I have a hard little callous in identical spots as well – very easy to feel and even see – on the balls of my feet.

    I haven’t gone to a doctor because I assumed I was getting this condition, whatever it is, because of pregnancy weight gain, and I would be losing the weight after my baby was born, but I can’t do anything about it until then.

    The pain is in both feet between the first and second toes. I have read that this is rare. But it sounds like Morton’s Neuroma.

    Will it just go away after the baby is born?

    • aoeditor says:

      This does not sound like a Morton’s neuroma. Your history, which is all important, sounds like 2nd MTP synovitis. Please see the new post. Thanks for checking in.

  28. Julie Briggs says:

    Having read the above comments, I wanted to add that in the UK in 1996, after gaining a huge amount of weight during pregnancy and giving birth to two very large babies, close together. I had 2 MN surgically removed, both from 3/4, the results were life changing, no more pain, burning and having to rest after 15 minutes in any shoe, boot or flip flop. In early 2011 I felt the old familiar but disagreeable symptoms returning, this time 2/3 and right foot only. I put up with the pain and finally made an appointment with a French surgeon as by this time, I had moved to France. I was unsure of the French approach, but I gave him my history and in order to rule out anything else I had an MRI. I had a GA to remove a large MN and now post op (11 weeks), although my toes still feel a bit odd, I know from experience that I will get use to it. My experience has been a surgically successful one. Oddly at no time in either the UK or France was I offered injections or exercise.

    • aoeditor says:

      I am glad you have had a good result. Surgery can be an excellent solution and is not really too onerous of a recovery like most other foot & ankle surgeries. The absolute key to MN surgical success is a rock solid diagnosis, which can be tricky (reason for this last MN blog) and cutting the nerve proximal (towards heel) enough so that the eventual amputation neuroma is out of the weight bearing area. Get those two right and you usually have success. Best of luck.

      • Julie Briggs says:

        Can you answer my question. Before the surgery my toes (2&3), were being spread quite far apart/separated by the large MN in between them.
        Since the removal of the MN they have stayed in this position. Is it likely that they will realign? Or with I be left with a second option for the toe post of my flip-flops!
        Julie

        • aoeditor says:

          Now that is funny; I don’t care what you say. With limited info I would say those toes will remain as they are. I will also add that it would be best to not go for broke and try to improve the situation with more surgery. A favorite orthopaedic saying which honest orthopods live by is “the evil of good is better”. Best of luck.

  29. Brina says:

    I’m so happy I found this! I have a question for you. I had a bunionectomy in 2011. I was off running for awhile but was able to start running again around 8-10 weeks later I think. However I developed pain in the same foot behind my second and third toes. My dr believed i had MN. I went for several cortisone shots and tried alcohol shots which did not help, so I agreed to surgery. Afterwards he said he found a neuroma and cut it, but also found some scar tissue that he cleaned up. Anyway, that was in Oct 2012. Since then, I have run 6 half marathons among other smaller races and have many more scheduled, but my second toe (behind it) is KILLING ME! I saw him this week and he took a set of x-rays. He believes that the bunionectomy may have caused my big toe to be shorter than my second toe causing more pressure to be placed on my second toe when I run. It must be by millimeters because they visually look even. Oh, another weird thing is that when my MN was developing, my toes started spreading. After the surgery they came back together, but now they are spreading again and now my second toe is turning inward towards my big toe! It feels better when i tape them together to run. I still have awful pain though. What are your thoughts on this? Thank you in advance for your time.

    • aoeditor says:

      First of all, you have an honest doc for admitting that the bunionectomy shortened the 1st metatarsal. However, I am gladly skeptical of this because you describe an x-ray showing almost equal length. A shortened 1st MT is unfortunately a part of bunion surgery, albeit uncommon. We try to avoid it, but it can happen and it is not a complication. I will admit that you might have a 2nd MT overload/transfer metatarsalgia as a result of the shorter 1st MT. This leads to a “bruising” of the joint deep inside and 2nd MTP synovitis. You know you might have a future in karate. As Billy Ray Valentine (Eddie Murphy) said in Trading Places, “Cause I’m a karate man, see! And a karate man bruises on the inside! They don’t show their weakness.” Now that’s funny, I don’t care what you say. But I digress.

      The synovitis causes swelling in the joint which damages the supporting and guiding ligaments. As a result, the joint kinematics (fancy name for control function of the movement of a joint) are changed and you get angular deviation of the toe. This is usually a hammertoe or a crossover second hammer to (you).

      But here is the rest of the story. The increased pressure now placed on the long 2nd MT, due to the possible surgical shortening of the 1st MT, is being greatly magnified by your calves that are silently too tight. Tight calves, which increases with age and in distance runners, increases the pressure on the front of the foot. Because the 2nd MT is already the longest and the stiffest MT coupled with a possible short 1st MT in your case will cause this. In fact, the great majority of 2nd MTP synovitis patients I see are just normal middle aged people or younger distance runners, but they all have one thing in common; their calves are too tight and iet is the SINGULAR reason for their problem. This knowledge is not out there yet because my colleagues don’t know it, and if they do hereing it from me, they refuse to embrace it. That would explain why you will not find this info elsewhere. In fact, refer to may latest blog Anecdotal Medicine is Alive and Well.

      Now for the punch line: stretch your calves using the protocol at One Stretch and if the joint is swollen (lump under ball of foot or visibly swollen on top) get the joint injected with cortisone. It will make you feel much better and reduces swelling, an as a result, the deforming forces that cause the hammertoe are stopped. Also refer back to the blog. Best of luck.

  30. Terry says:

    I am desperate for some advise I just hope you can help me I am in so much pain and can’t seem to get help anywhere I go, I had a aorta by femoral by pass two years ago due to bad circulation in my leg last year two of my toes were going blue and were very painfully I whent back to hospital in may 2012 when I was scanned they said the by pass was parshally blocked and the op would have to be done again I asked about my toes he said no prolame they would be ok after the op once cirrculation is ok so I had the op and after coming out of intensive care the surgeon said good news all whent well, I asked about the pain in my toes don’t worry he said they will be ok. But days later I said to the nurse I was in pain again they scanned me the surgeon came to me and said sorry bad news the graph we’ve put in is now fully blocked and we have to doit again but you will have to wait two weeks as you have just had major surgery, not a happy chap I said that same thing what about me toes his same reply they will be fine two more weeks of pain whent by and I had my third by pass, I did get told before the first by pass chance of death was one in twenty me being a bit of a gambler in my younger days didn’t take long to realise I might not be seeing my family again, but the sugeon says you will have quality of life after we do this as I am only 50 and love my golf I just imagined playing again and going back to work, I had the op done again nearly died a few times but managed to see it though after 17 days in intensive care my surgeon says it was a success but oh no what’s coming yep I thought so you now have to loose all toes on your left foot, my heart sunk as he was telling me do you wana buy a set of golf clubs I said (joke) I was gutted but had no choice as by now my toes were going black and the pain was unbearable hope am not boring you but here’s my problem, had a forefoot amputation and finally got out of hospital in August last year I have been in pain every day since have not had one full nights sleep, tried every pain killer there is and anti depressing drug there is the surgeon said after i saw him two months after my op I was in severe pain in my foot I could not believe he said he did not know what he had done wrong I said if you don’t know how am I to know, that’s when I went on the Internet and found it seems like I have neuropatic pains next time i saw him I told him what I had he said he still can’t understand what hes done wrong I told him you have done one of two things wrong you have trapped the nerve ends in when sewing my foot up or you’ve left the nerve ends growing I have seen pain relief doctors and neuro specialists whom don’t tell me anything they just write to my surgeon I get to know nothing but the last neuro surgeon I went to see wrote to me and said I have server neuropatic pains after amputation and they now want to put wires up my back but I don’t want this what I’ve read is not great, I’ve now told my surgeon I want what they can do in America and that is try and cut the nerve ends that are trapped this is similar to what you know about I hope, and I really do hope you can give me some advice I live in Liverpool in the U.K and I know surgeons are much more advanced than our surgeons the forefoot amputation I had your surgeons are doing all the time have you heard of anyone whom has experienced anything I have I just need advice what to do where to get help I am sick of pain with no ending as for the quality of life the surgeon gave me I drive a mobility scooter to get around and have still got my surgical shoe that I left the hospital with I can not get a shoe on my foot due to the pain I have to make my own cushion shoe to ease the pain please please help me with some advice. Thank you

    • aoeditor says:

      So sorry this is happening to you. Sounds like you either have resting ischemia due to arterial ischemia which is not my expertise, but this is less likely. Most likely like you allude to this in peripheral neuropathy. There is a surgery for this that is reported to be successful by a doctor A. Lee Dellon. Se if you can find a doc in UK who does his surgery. Best of luck.

      AO

  31. Terry says:

    Thanks very much for your help I will look in to this thanks again for replying so soon

  32. Selena says:

    I’m so glad I found this!! Late 2010, I went to a local walk-in clinic due to foot pain & swelling that would not go away. They diagnosed me with Gout at age 37! I went to a foot surgeon for a second opinion. He told me that I absolutely did NOT have Gout! He said that I had Morton’s Neuroma (between my 2nd & 3rd toes on my left foot). He gave me a steroid shot in that spot, and when I returned 2 weeks, later, it was only slightly better, but I had new symptoms with my heel hurting me & not being able to walk on it when I’d get up in the morning. He said that in addition to MN, I also had Plantar Fasciitis! We treated both with the Morton’s Neuroma going away after about 4-6 weeks. Unfortunately I broke my little toe while we were still treating the PF, and that set me back a few weeks. Nothing we tried worked for the PF, so I ended up having surgery on it 3/11/2011. I had a lot of relief, and was even able to start walking in local 5K’s! I still do not have heel pain in that foot, but my arch hurts when I walk too much, even with custom inserts… About 10 days ago, I hurt my foot playing in the creek w/ my daughter. I’m sure I broke my little toe again (even though the x-ray tech said there are no abnormalities). Since then I’ve started having pain similar to the MN pain I’d had before, but this time between the 1st & 2nd toes… I’m curious… Is there a link between MN & PF?????
    Thanks so much!!!!

    • aoeditor says:

      First of all, I would say your original problem was a 2nd MTP synovitis (see my follow up blog) especially if you had any swelling and not a Morton’s neuroma. Second of all you are smart and observant in your question. In my opinion, 2nd MTP synovitis (maybe Morton’s also) and PF have everything to do with each other. The commonality between the two is that both are a result of the same primary or root cause in that the calf has become too tight, which creates abnormal forces in the foot with gait/walking. As a final note and to answer your intuition, your original pain has returned because you never fixed the underlying cause; your calves are too tight. Stretch everyday and use the protocol at onestretch.com

  33. Helen says:

    Hello. Have you treated any children with a mortens neuroma? about a year ago I noticed my seven-year old with an unusually fat 2nd toe. months later i noticed some swelling between 2nd/3rd toe on the top of her foot which is slightly greyish, and both 2nd/3rd toes were swolen. We have had a visit to the doctor about 3 weeks ago who suspected mortons and sent her for an xray, he has also suggested an mri. the xray is clear.

    • aoeditor says:

      I am not sure what this is, but I am sure it is not a Morton’s neuroma. MN does not occur this young. I would see a dermatologist or similar. Best of luck.

  34. Helen says:

    sorry have to add, she has never once complained of any discomfort, thanks.

  35. Isabelle says:

    Hi, I’ve been struggling with MN for two years now, and your blog is pretty eyeopening. I’m 27 years old and started developing a pain in the ball of my foot after living in (and walking around) NYC for 3 years. I didn’t actually wear heels that often, but I suppose I wore flip flops and flat shoes a fair amount. I had pain between my 3rd & 4th toes and 2nd & 3rd toes on my left foot. (Started at 2nd and 3rd toes.) The pain grew from the feeling of a pebble in my foot to a burning sensation and shooting pains into my toes.

    My first podiatrist told me that I have a small bunion which was causing the neuromas (she said she saw it on an ultrasound). We tried custom orthotics, new footwear, physical therapy and cortisone but it just seemed to get worse. My second podiatrist told me the bunion was completely unrelated. We tried a metatarsal pad and alcohol injections. My pain remained the same. She also had me do an MRI and nothing showed up on it. For my third doctor I saw an orthopedist, who told me that I didn’t have a bunion, but rather a bone spur and some arthritis starting in my big toe joint. He gave me a cortisone into both neuromas. The one between the 3rd and 4th toes seemed to go away, but the relief in the 2nd and 3rd toes space was only for a few weeks. The tissue in the area has atrophied significantly and it generally feels like I’m walking on bones without enough padding. I’ve found some shoes that help but inevitably at the end of a long day my forefront area has a burning sensation in it. I also experience pain around the big toe joint. I’ve found the worst pain is in the morning when I get a strange popping sensation like something is being squeezed in between the bones and my 2nd toe gets a terrible shooting pain. I’ve just had a second MRI that showed something in the area that I’m having pain. Surgery is starting to feel like my only option, but I’m still trying to find more info, or at least a better doctor as I seem to get wildly different opinions and attitudes. Any thoughts you may have would be extremely appreciated!

    • aoeditor says:

      Hi,

      You are correct to be cautious. Please refer to my follow up blog Morton’s Neuroma Revisited and see where you might fit. Diagnosis is absolutely paramount and it sounds like you might not have a solid diagnosis yet. BTW, this is a difficult area to confidently diagnose, ergo my blog posts. You do have to be your own patient advocate. If you are still in NYC, you should see Martin O’Malley, MD at HSS. And please tell him the Angryorthopod sent you. To finish with a few points, it sounds with your age and symptoms you might have a third web space Moton’s Neuroma. MRI and ultrasound are not factors in this diagnosis; it is all history and a bit of exam. Best of luck

  36. SHANILLA says:

    Hello there. I have been having sharp shooting pains and numbness on my second toe left foot. After seeing an orthopaedic doctor he diagnosed a neuroma and gave me a cortisone injection. He said it may have been caused by the bunionectomy that I had about eight years ago. He has suggested surgery but I am worried after reading all the comments. There is one thing that is worrying me. My foot stays swollen all the time. Is this normal? or is there something else wrong with my foot. I cannot wear shoes at all.

    • aoeditor says:

      Shanilla, You likely have 2nd MTP synovitis. Morton’s neuroma never causes swelling. If you are tender under the 2nd MT head that is your problem. Please refer to MORTON’S NEUROMA REVISITED Seek an AOFAS fellowship trained orthopaedic surgeon foot and ankle surgeon. Best of luck. AO

  37. Joyce says:

    Hi Doc

    Would MTP Synovitis cause toe separation?

    My foot pain is right at the third met head and is worse in the mornings and gets better throughout the day. Pain with passive and active toe flexionand extension. There has been swelling maybe on two occasions and is has been going on since June 2013 (when I started noticing an uncomfortable feeling in my foot). Lately, I’ve noticed that my 2nd and 3rd toe seem to be separating from each other — that gap wasn’t there before! My doc says it’s MN and wants to do a cortisone injection. I’ve asked for PT to do iontophoresis first as the lesser invasive route of steroids … Four sessions of iontophoresis in two wks with slight improvement. PT has also recommended a walking boot to immobilize foot for a time to lessen irrational with walking.

    I’m a 36 yr old female, fairly active until this foot pain …

    What do you think?

    Thanks

    • aoeditor says:

      To answer your questions directly, yes it certainly sounds like you have 2nd MTP synovitis and it is THE precursor to a hammertoe, which often is associated with a crossover component: separation from adjacent toe. Usually it is the 2nd toe heading towards the big toe. Unfortunately your story is all too common. The great majority of adult non traumatic foot and ankle problems result from calves that are too tight. SO you must stretch your calves. I know that this reasoning appears to be too simplistic and raises the argument “my problem is way bigger than a little stretching will help”. Further, this simple cause of the majority of foot and ankle problems that is silent, is not even in the foot, and is definitely not known by any of my colleagues, except for one, are the exact same reasons why you don’t know about it. How could you know? So now you know. What you choose to do is your decision. You must STRETCH YOUR CALVES EVERYDAY. Keep it that simple. All other treatments may make you feel better, but none will fix the problem, your calves that are too tight. To see the correct protocol please go to One Stretch protocol. As far as an injection, I would have the MTP joint injected, especially if you have had or have any swelling, but good luck on that because your doc has their sights on the only target they know; a Morton’s neuroma. Can you feel my frustration with this whole thing?

      Best of luck

  38. michael says:

    Hello,
    I am impressed with your explanation. I’m curious about your alternative treatments to surgery. I know a smart guy when I read one. I would like to give you a little puzzle. I’m 6’2″ morbidly obese 330 lbs, 55 yrs old, numerous procedures done on both feet dating back to 1978. I’ve had this nerve pain in my feet , mainly in my right foot. Started by just simply getting off the couch. As I was standing up it felt like I just stepped on a piece of glass and it was lodged in the ball of the foot at the base of the 3rd & 4th toes. I went to see the last Dr. that worked on my feet and he shrugged it off as arthritis. Well I can’t live like this so I seek help elsewhere. As your mri advice explained the Dr. suspected MN and got a mri to prove it. Well the radiology report said negative but the Dr. said there was a 1″ MN and surgey ensued. The pain I complained about still here only now I have new ones. In the last 6-9 months I have felt what I believe to be a MN.I can actually feel what feels like a little mass there when I walk. That pain is nothing, I can deal with that. There’s something else or three going on here. I have serious shocks,zaps or whatever you call them and they last so long I get charlie horse in my feet. This usually happens at night when in bed..most every night. The other issue is I think I have another bone spur on the bof because I have a painful (I do clip it) callas there. When I put weight on it….it feels like I stepping right on the nerve. I also feel what I would describe/compare as a gout attack pain in the same area and at the same time pressure is being put on the foot.But it feels/seems like it’s a separate pain. Like a bone or joint pain…to go with the nerve pain. I also get like pulsating needle pricks in the tips of my 3rd & 4th toes. Now these shocks/zaps can also occur after sitting for a while causing spasms or cramps in foot. These issues have caused a major decline in daily activity and my ability to function normally. Quality of life has declined. I basically do as little walking as possible. I do have current back issues and previous back surgery…bone scrape for nerve. After seeing a dozen Dr.’s that didn’t know,said arthritis,suggested Dr. Scholl’s , said I was crazy or my favorite I’m a drug seeker. You damn right I’m seeking drugs….to stop the pain…so I can move. If I’m unable to move around I will never lose any weight and I will continue to destroy my feet. Because I know that my weight is the ultimate issue here. I show negative for diabetes. I feel as though I need a piece of 6″ memory foam to walk on. All these gel pads and inserts and stuff don’t come close to working. I would be interested in your idea of how you would approach and fix this problem that has tormented me for the last 12 years.
    Mike

    • aoeditor says:

      Hi Mike,

      Unfortunately your story is all too common. Let me keep this answer simple and uncomplicated, because complicated is not working. While I can’t be certain what exactly is going on sight unseen, I do know that the great majority of adult non traumatic foot and ankle problems result from calves that are too tight. So, the odds are that your problem falls into this category and it also sounds like it from your story. I know that this reasoning appears to be too simplistic and raises the argument “my problem is way bigger than a little stretching will help”. Further, this simple cause of the majority of foot and ankle problems that is silent, is not even in the foot, and is definitely not known by any of my colleagues, except for one, are the reasons why you don’t know about it. So now you do know. What you choose to do is your decision. You must STRETCH YOUR CALVES EVERYDAY. Keep it that simple. All other treatments may make you feel better, but none will fix the problem, your calves that are too tight. To see the correct protocol please go to One Stretch protocol.

      Best of luck, AO

  39. Katy says:

    I am 7 1/2 months past surgery now for “SO CALLED MN ON BOTH FEET”, I am in more pain now than ever, I can’t walk much or else I am in ALOT

  40. Katy says:

    I am 7 1/2 past surgery now for “SO CALLED MN IN BOTH FEET”, I am in more pain now than before surgery, I got the surgery so I would not have to get injections every 2 weeks, I am upset that if I don’t get the injections I am in constant pain STILL, only worse, It hurts where the surgery was done (from top) pain also in big toes and bone that runs up, insides of heel/ankle and bottom of foot, a lot of pain btwn 1,2, on bottom where surgery was done, I was under the impression the surgery would ‘CURE’ my pain, now I feel hopeless, I haven’t returned to my pod cuz I’ve had enough of the injections and their side effects, I am at a loss of what to do, just live my life in pain? also the insides of my anke hurt, inside heel, goes up to calf, makes my l knee hurt and my upper back, any advice is truly needed, respectfully considering going to an ortho now, which I wish i’d of done in the 1st place

    • Katy says:

      I am wondering if I encountered the CHRONIC PAIN SYNDROME associated when nerves are surgically cut, can you please remark on the symptoms? What are the typical symptoms? and who can diagnosis it properly? I feel I was misdiagnoised and now live in pain, also feel my sciatic nerve and upper back is a result? Can you please give us some input on this very important SIDE EFFECT of this surgery, I feel some standards need to be imposed on Dr.’s before this surgery is done. I have posted a few posts already, and don’t mean to “over post”, but this is a very painful surgery, long recovery and as for myself, has bought on many more problems than before surgery. I appreciate an Orthos opinion on this matter, now I am an “Angry Pod patient”!

  41. Moi says:

    This year I was diagnosed with Morton’s neuroma. While the pain initially continued after custom orthotics, i was given a shot (steroid) in the nerve. After a few days the pain disappeared from my foot. I also bought a nice pair of new balance leather shoes with a rounded toe for work that are very loose across the toes but seem slightly short. Then I noticed my bunions, that had been barely in the beginning stages, suddenly had gotten worse. My new balance leather shoes with the rounded toes and slight rocker bottom (which i love) seemed to be forcing my toes in to the point that my big toe began to cross over the second toe! Went into the podiatrist and he said that it the increase in my bunion is going to happen as it is genetic and that it turns out I must have had capsulitis (?) and not MN because I responded to the steroid shot. (? is this the diagnositic shot you mention?) Also, that the capsulitis was caused by the bunion (which I didn’t really have much evidence of when first went to him a few months ago). Also, he said that my orthotics raised my heal and thus forced my foot to slide forward into the toe of my shoe, thus causing the bunion to progress more. So, I seem to be in a catch 22 situation with needing orthotics but that they force my foot forward and force my big toe against the tip of my shoe – turning it in more. This really saddens me: I have been wearing silicon bunion inserts to keep my toes separated, but is there any solution to this dilemma? When I wear sandals I cannot wear the bunion silicon inserts and they are not orthotic either and dry the foot out so that they crack. If I buy another expensive pair of shoes with a squarer toe ($250 or more) I’m guessing my foot will still press forward. and the bunion will progress but that might be my only other option. In the meantime, I have cut back on wearing my custom orthotics and use over the counter ones that don’t raise my foot as much, but I’m afraid that is going to cause the occasionally reappearing mild foot pain to get worse and land me right back where I started. Any suggestions or insight?

    • aoeditor says:

      I can’t really answer all of this, but you give a good description. This gives me a chance to comment on orthotics. In general they help very few people, but it sounds like you have been helped. Certainly custom orthotics always help one person: the person who prescribed them. OTC orthotics are Okay and cheaper, but it is always the individuals call as to whether they help or not. For some reason way too many people continue to wear them just because they were told to. I usually do more good by telling patients to stop using them. I know calf stretching is not as sexy as orthotics, but it is free and beats the tar out of everything else including orthotics! Best, AO

  42. Diane says:

    I had a toe joint replacement on my big toe ,it’s fine but my 2nd and third toes are seperated and pain on the ball of my foot can’t walk….I taped the toes together and it’s better…what can the foot doctor do about this……I travel a lot and want to walk , thanks

    • aoeditor says:

      I am sorry, but a first MTP joint replacement is just not a good thing. What might work for the hip and knee does not mean it works for the great toe, and it doesn’t. While the great toe might feel better, you now have the the very difficult to remedy transfer metatarsalgia due to the loss of the necessary windlass effect (please don’t ask me about this as it is outside the scope of this medium) of the first ray/metatarsal. As a result your 2nd and likely 3rd MTP joints now have synovitis due to the transfer/overload, which leads to this characteristic 2-3 separation. The next thing might be 2nd MTP dislocation. Stretching your calves is very helpful and must be done, but you might need an injection or two or three in the swollen MTP joint (2 +/- 3) to reduce the swelling, which is the cause of the deformity and ultimately leads to dislocation. You want the truth, there it is.

  43. Rachel says:

    Doc, thanks so much for this post. It’s easy to forget to try to treat ourselves by stretching etc… because when we’re in so much pain we want it to be gone instantly. I’ve had MN for 6 years now… The pain came gradually on after stubbing my 3rd/4th toes badly. Luckily I live in Florida so I can wear flip flops all year. I quit running but can still go for walks thanks to finding Torin Alta zero drop heel athletic shoes… widest toe box EVER. Still, the pain becomes extremely intense and burning after a while. I injured my other foot last week and had plantar fasciitis years ago, and found this post to be a great reminder of what we need to do to heal ourselves. My plantar fasciitis went away by calf stretching last time, and I never considered calf stretching for MN until reading this but it makes sense. I tried the injection for MN and it did nothing, along with being extremely painful. No thanks. And I don’t want someone cutting on me but was actually thinking about seeing an ortho or pod again to do just that, I was getting so desperate with the pain now that both feet are hurting.

    I wanted to share that doing toe stretches provides some relief for MN… standing up and using the floor to stretch the toes back and forth (like ballet dancers do) helps. I haven’t done it consistently but will be doing that along with the calf stretches regularly now.

    I had a massage therapist once say he could help… and he went crazy stretching the toes this way and that (NOT a relaxing massage). It HELPED, temporarily. I didn’t go back… it was a painful massage. But it did plant the idea of toe stretching in my mind, which I wanted to share.

    It’s such a relief to see an MD providing sensible advice like this and hosting this forum. Thanks again!

  44. Gloria says:

    It answered my question!!!! I was diagnosed with MN a year ago…..cortisone shots, down for six months. I HAVE to stretch my calves everyday, otherwise, I can’t move, and the cramps are unbearable. I have come to the conclusion that it’s the only thing that DOES help….I’m not asking why!!!!

    • aoeditor says:

      Hi Gloria, The power of stretching the calf is really unbelievable and now you have experienced it first hand. I would be interested in how long you have been doing it. Calf stretching’s full effect can take up to 6-8 months, so if you are less than that, there is probably more to come for you. Unfortunately, boring old calf stretching as a “definitive” treatment is not sexy like orthotics or PRP injections or injections and the list goes on, however: unlike all those sexy treatments, IT WORKS! Now all we need is an influential maven to make it sexy. Thanks so much. AO

  45. Sarah says:

    I have had four surgeries (3 in right foot–2 in the 2/3 space, 1 in the 3/4 space and 1 in the left foot in the 3/4 space) to remove MN, with the most recent surgery in 2011. I continue to suffer from symptoms of MN including pain, burning, tingling, etc. I had an EMG last September and the results indicated no abnormalities/dysfunction. Further, I have several other nerve-related issues happening concurrently, i.e., muscle spasms in my upper back and neck, tingling in my arm, an issue behind my left knee (MRI scheduled), and the list goes on. My question is this: is there a correlation between recurrent MN (or symptoms of MN) and multiple sclerosis? A friend of my mom’s has MS and said that I should be tested for MS given all my nerve-related issues. I know that having multiple MN is rare. Any thoughts on the connections would be most appreciated!

  46. Ericka says:

    Hi, I had what I was told was a nueroma removed from between the 3rd and 4th toes, through the top. And also had a release of the calf muscel on that same foot done at the same time. This was June 7, 2013. I am in more pain than I was before the surgery the “shocks” are stronger and more intense burning sensation than prior to the surgery. I have talked with my regular PCP and all they keep suggesting is to try Lyrica for the pain, which I am refusing. I was on Nuerontin but it was making me so tired. I can not walk for more than 10-15 mins without being in severe pain. And it makes is dificult to drive sometimes because it is my right foot. I am so much at a loss as to what to do, I did have spinal fusion surgery in 2011 which did leave some nerve damage that originally caused only numbness in my right foot and then about a year after the back surgery the pain started in my foot and thats where I ended up with the nueroma diagnosis.

  47. Joe says:

    I had surgical removal of MN about 7 months ago following over a year of pain and two shots that provided only short-term relief. The surgery and recovery went fine. I’m still trying to re-learn how to walk on my foot properly, because I changed by step for so long trying to avoid the MN pain. In any event, in the last week or so a lump appeared directly under the surgical scar… inch long, about 1/4 inch wide. It’s somewhat soft, not really painful unless I really push on it. What is that? Is it permanent?

    • aoeditor says:

      If the scar is dorsal or on top of your foot, as it should be, the lump might be activation of the normal bursa between the MT heads. If the lump is not part of your pain or secondary gait issues leave it for now. MN excision when done correctly and you actually have a neuroma in the first place should be much better and original pain resolved within weeks. Granted one will get a few months of surgeon induced, expected post op pain. This pain is DIFFERENT and new, but resolves. As I keep saying, MN,s are hard to diagnose, but diagnosed too often. While I or anybody will unlikely ever know your original problem, I would say if the pain you have now is at all like your pre-op pain then MN was not your thing. As I have told so many, regardless of what you had or now have, go ahead and stretch your calves everyday and be patient. You have nothing to loose and everything to gain and I would say you excellent odds that it will do the trick. I like the protocol at .

  48. Karen says:

    Hello, angry orthopod :-)

    I am glad to have found your site. I am a 35 year old pediatric intensivist in Boston, so needless to say, I am on my feet for long hours on call and otherwise. I have had a left foot (amd smaller right foot) bunion most of my life, and was diagnosed via physical exam with MN between my 3rd and 4th metatarsal a couple years ago when I noticed persistent numbness and electrical (“oh, that is what neuropathic pain feels like!”) pain in the area. It is pretty classic, better barefoot, worse in thin-soled shoes, etc. I allowed a podiatrist to inject blindly once at my own hospital, with essentially zero relief. I then saw an orthopod at MGH who basically told me he could operate on the bunion to fix both problems or I could keep getting injected… But 12 weeks out of the ICU for elective surgery on my foot seems insane and far more likely to cause harm than good… (I may be a catastrophizer, being an intensivist and all, but still). I did undergo ultrasound guided injection, which was excruciating and made the pain worse for a couple weeks, then better for nearly a year.

    Questions are:
    1) is it reasonable to have it injected again? How many times is it safe to do this? I am really concerned about local soft tissue atrophy and bone resorption… Is that crazy? I am only 35, so I need these feet for awhile.

    2) I also have this weird, vague right medial ankle/lower leg pain… It is not entirely reproducible by palpating, extends from immediately behind my right medial malleolus and up to about 6 inches above that spot, essentially between the Achilles tendon and the tibia. it is burning in nature, and worse the day after vigorous exercise (worst after jogging or using an elliptical)… Is this related to compensation of my left foot issue? what is this? I am absolutely going to start calf stretches, but this pain is confusing and difficult to localize…

    Thanks for letting me ramble,
    Karen

    • aoeditor says:

      Hi Karen,

      I like “catastrophizer”! In this case you are not. Good results take a lot of time to achieve and are really hard to come by, even in experienced hands. When it comes to foot and ankle surgery, no matter what the other docs tell you, bunions and MN and really most all foot and ankle issues are not an urgency, they are quality of life (QOL) wreckers. As long as you can do what you want to do and what you need to do and suffer tolerable pain, go for it. Surgery is the last resort almost always, which means whether it is done now or much later, the results, the recovery, the down time, etc. do not change with time. There is no window of time that is being passed. But as we talk to these docs, who in my opinion do not have enough respect for the knife, they either by implication or by just coming right out and saying it, press towards surgery. In fact I have discovered that the more needy a patient becomes the results of an elective surgery improve, by contrast. For the all of the readers, a $100 dollar bill is a $100 dollar bill. If Bill Gates sees one blowing down the street, heh, too much effort to go after it. Me, I’m going after that thing like a UConn basketball player diving for a ball in the NCAA final game. So in my angry opinion, your instincts are good.

      Q1. It is OK to have it injected again, but only cortisone. But this is only temporary, vacations, weddings, etc. Don’t do the alcohol thing. And please don’t get me started on ultrasound. When the insurance companies wise up to this unneeded exspense, US for this method of injection will stop. As for little ones in the ICU and US, different deal for sure. Here is the thing, eventually after a few cortisone injections without resolution of the pain (from calf stretching in my opinion) what is the point. Then maybe surgery is needed if QOL is not good.

      Q2. Aren’t you the lucky one! That is sight unseen likely posterior tibialis tendon (PTT) strain. Now don’t get all catastrophizer on me and think it is a rupture. You are too young. For this all you need to do for sure is stretch your calves, and presto, problem solve at the source. As a quick check, try a cuter, small heel for a bit. Should make this pain better (but not always) as illogical and non-intuitive as it sounds.

      Let me see if I can spell this mechanical sequence out. The human arch depresses with standing and gait and the dynamic restraint or controller of arch depression is the PTT, period. The tighter the gastrocnemius is, the deeper and with more force the arch goes down and the harder the PTT has to work. Stretch your calves, you fix the PTT.

      Thanks for letting me ramble also.

      Best! AO

  49. John says:

    I was diagnosed by OS last week. Wore sandals which end seem to relieve foot pain for a few days. Had to move some heavy furniture today. Now MN pain has returned. Also, recurring pain and cramping on outside of calve returned. Does weight “lifting” contribute to the pain factor?

  50. Dottie says:

    I am in the exact same boat! So frustrated and hopeless and in constant pain. I need to get a job, but so limited now. Just want to cry! I have had bunions on both feet done twice, a sesamoidectomy on left, MN upper on right and left and the lower “bury” or repeat MN on the left. I don’t know what to do or where to go. Any recommendation would be appreciated.

  51. Gill says:

    great info thanks! I have been referred by my GP to a consultant next week. Issues I have had eith my left foot exactly as described tingling pain wearing certain shoes (ironically my expensive walking shoes – at first I could wear high heels no problem). Over months, started to experience more tingling, numbness, cramps and feeling of (non existent) lump below my foot. Spent loads of dosh on specially produced inner soles. Started getting hip pain, now gone, but replaced with sharp pain on outside of knee when bending – very irritating for a gardener.

    This us where it gets interesting. Three years ago, I badly tore my calf muscle skiing and was on crutches for several weeks and had physio/ultra-sound to repair damage. Could it be related? Possibly. Intersted to know your thoughts.

    I am def going to try the calf stretching and meanwhile resist any suggestion of surgery, though the injection to relieve pain does hold appeal! Thanks again.

  52. Elizabeth says:

    I stretch regularly, having done so for years out of habit due to making my living as a dancer for decades before disability retired me–(the ability to continue to stretch was one of the few exercises that I could continue to do), but after 15 years of putting up with the pain, I finally had bilateral MN removed in 2009. When I went in to ask the OS about removing the neuromas, you could actually HEAR the clicks from my right foot when I placed it against the floor and pressed it down, and when they were removed, he told me that they were the largest he’d ever seen. Now, it appears that I have another MN developing in my right foot between my second and third toe, and it it tremendously more painful than the previous one was, as the feeling of having a rock in my shoe is that I have a larger stone in it than I did before, but the same electric charge that goes out my toes, and the same click is there, but it’s all seeming to have happened at an alarmingly accelerated pace (or am I noticing it as accelerated because the neuroma was probably there way back when I had my surgery for the other MNs but now it has had time on its own to grow?).

    On top of that, my second and third toes on my left foot have been separating for the last several years, and when I asked the OS about it, his basic response was pretty much “Meh, it could be the sign of something genetic, and you do have a genetic disorder after all …” (yeah, I have Ehlers Danlos Syndrome, which has NOTHING to do with my left foot trying to say “Live long and prosper”). I’m wondering if it’s possible if my third toe could somehow be developing hammertoe and that could be causing this?

    Any feedback would be appreciated, as I am thinking I might need to go back to a new OS about having an MN removed from my right foot at this point because I cannot handle any more steroids (I already have osteonecrosis in my left hip from Prednisone use for my asthma as a child, and was told I can expect my right hip may also start to get it as well because it is often bilateral, therefore, I am avoiding steroids as much as possible now).

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