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.
I discovered your blog about a year ago when suffering from the oft-described shooting pain from the ball of the foot to the toes. Since at first the pain only happened when I ran, I curtailed my running and substituted cycling (then it even happened when cycling, though!). Then it invaded my walking (anything more than half a mile).
I’m a 61 year old man with a long history of athletic activity of the sort which would abuse my feet, including competing in the long jump, basketball, running, and snowboarding, so it’s not like was surprised.
I have applied some of the recommendations from you and the other bloggers and here are the results:
-Larger/wider shoes.: Went from size 10 1/2 to 11: Good! Helped avoid the worst pain in daily life.
– Stiffer-soled shoes: It sounds counter-intuitive, but it’s pretty effective for hiking and basketball. Soft shoes seem to give too much flex and only minimal protection.
-Orthotic pad behind the ball of the foot to spread the toes a little: Also good, but the pads have to be just right, and they move out of position when putting on and taking off shoes. Also, the spreading creates a very painful callous on the outside of my left foot.
-Calf stretching: Done it fairly religiously for almost a year now, and maybe it’s helped, maybe not. I’ll keep doing it because there are other benefits from it like increased agility and general flexibility. I also credit calf stretching with alleviating chronic lower back pain.
Finally last month I saw a podiatrist, and he recommended 3 things:
1 – inserting small, custom made orthotics cut from adhesive-backed 1/4″ foam on the BOTTOM of my shoes’ footbeds. (Why didn’t I think of this!) It helps quite a bit.
2- Daily regimen of ibuprofen for 1 week: Huge help. Who would have thunk it? Now it remains to see how long the benefit lasts.
3- Daily icing of the bottom of the foot: Shame on me. I still need to get a proper bucket and some washcloths to hold the ice and actually do this.
Anyway my goal is to be able to run and jump again without this awful pain, and I think it’s starting to happen.
Hi Dan,
I have heard this story thousands of times and it usually comes from too many varied opinions, both medical and from the internet.
I will say your comments on shoes are dead on. Of course longer and wider is better. Through years of trial and error in myself and many patients I also agree that stiffer shoes are more comfortable. I also agree on counter intuitive.
Before I fully get started on my rantish response I am going to lay a bit of additional diagnosis based thought, but I doubt I am right. Your story and failure could be related to incorrect diagnosis, of which none was given BTW. Please have your doc consider “claudication”. There are two types, vascular and neurogenic. While neither is exactly dangerous, both can knock your quality of life on its behind and have far different solutions. Without getting too technical, vascular origin is a narrowing of the arteries and thus there is not enough blood/oxygen delivered to the muscles to keep up with the demand. The other is called spinal stenosis. Obviously feel free to investigate and ask your doc just in case.
Just in case this is all too common mechanical source of foot pain I am going to go out on a limb here and say if you were doing the stretching exactly according to my method the odds are very high you would not be sending this comment. But I am glad you did. There are a significant number of patients who can’t commit to a particular primary treatment and feel they must keep doing a bit of each and as a result they don’t do justice too any. Here is my final word on this for you and all here. Do as many things you want to do, fully or half-assed, just don’t ignore the calf stretching. For some strange reason it seems too many people will gladly try everything except for calf stretching. I have had many patients return for the third or fourth visit mind you after spending oodles of time at each previous visit expressing the utter importance of stretching as their definitive treatment. Then I just wait for it as they predictably say, “Oh, were you really serious about me doing that stretching?” This was after they proudly and somewhat defiantly told me about the laundry list of additional treatments they had undertaken. In this case you might see a smoldering orthopod. Here is the thing, almost 100% of those who finally got it, chose wisely and actually did the stretching finally found the relief they were looking for.
So Dan, stretch and check on those other possibilities. All the other treatments you mention have no evidence based track record, but do them if they help in some way. Just keep in mind, obfuscation is what keeps most of us doctors busy, while some of us try to make it simple, and fewer hand it out for free.
Stay healthy my friends,
AO
So a year on Dan, how is it going? I have exactly the same symptoms as you describe.
Hi Ann,
I agree, Dan, how the heck are you doing?
AO
Hi, I discovered your blog today searching for MN. I am not sure I have one as I have not being diagnosed. However, the past week I have a feeling that I’m stepping on a pebble or there is a bubble under my left foot between my big toe and the one next to it.
I’m not experiencing any pain but it is just bothersome the feeling of stepping on something mostly when I am walking barefoot.
About two-three months ago I remember running on the treadmill and feeling as I had bruise the ball of my foot. I was in some pain for a few days but that went away. Last month I went dancing twice with high heels ( I hardly ever wear them) and again, I was not in pain afterward but about two weeks later the pebble sensation started. I do have pretty high arches and extremely tight calves. I’m going to go to the doctor as soon as possible but I would like to hear what you think. Should I just go ahead and get some insoles right away?
Hi wannabefit,
Wow, am I late. All I can say is I hope you have been doing the calf stretching I have had a handful of patients who have a painless Morton’s neuroma. While they can be annoying, they should be left alone. I do think the stretching could resolve your annoying snapping.
Stay healthy my friends,
AO
Dear Angry Orthopod,
I am struggling with MN and tarsal tunnel syndrome. One neuroma was excised from my left foot. I also have one in my right foot, along with TTS. I reay want a baby. Can pregnancy make this worse because of foot changes? Do you have patients like this?
Also, is there any treatment for stump neuroma (I have it in my left foot?)
Thank you!!
Hi again Alexandra,
I have had lots of patients like you. I actually wrote a definitive article long ago defining the source of Morton’s neuroma recurrence. I also wrote about here. As far as TTS, that is iffy at best and that is most I will comment on that. All I can say is calf stretchingis your hope for both, not to mention the second MTP synovitis already answered. As for the recurrence the often omitted nonoperative treatment of cross friction massage going right at the neuroma. You could consult Youtube or a physical therapist to learn methods to get this done. Much like calf stretching it can take time so you have to be patient and stick with it. Good things most often take time.
Stay healthy my friends,
AO
Dear AO, I’ve been trying to locate a good foot Dr. and anyone that can help me. It’s a bit of a long story, but: I fell in 2010 & the Ortho Dr. set 1 of 2 fractured foot bones, leaving the other to grow back on its own.
2 yrs ago I fell from a tow truck (no, not a fall risk, just misjudged distance). Since then, I’ve had severe pain, and toes curling up so can no longer wear enclosed shoes on that foot & feels like I’m walking on a rock. I’ve been to Several Drs over 2 yrs ~ Podiatrists, Reconstructive Podiatrist, Orthos. 1 Podiatrist Surgeon & 1 Ortho said it was a MN & hammertoe; 1 Pod. Surgeon said it was the fractured bone that was not set in 2010 which had grown back wrong, and grown toward the bottom of my foot, like a V which is causing my pain and hammertoe. Only that Podiatrist Surgeon made the most sense to me. However, he said that operation to break & reset it could go very good or very bad.
With your experience, could you advise me on anything regarding this? Or know how to find a truly good foot Dr./surgeon to help me? I know you wouldn’t make decisions for me, but I’m very lost & many I’ve spoken to in all areas of Georgia have horrible stories of being crippled for life from foot surgeries. I can’t risk being in a wheelchair or in worse pain.
Thank you for any help.
Hi Lynn,
This makes me cross. I have to agree with your podiatrist and their honest discussion of the prospects of this often unpredictable surgery. While in your particular case I do not think calf stretching will solve your issues, I am certain it will improve things. You have to reflect on your quality of life and what you have done non-operatively to this point. At some point, surgery may be worth the risk. I also agree it is scary. Probably the best way to choose a surgeon is, if possible, ask the people who works with them under pressure, the operating room personnel. Unfortunately few of us have that luxury.
Part of a problem like yours, and so many foot issues, is no one understands what you are going thru. I do and that is why I do what I do. I feel the ire welling up.
Stay healthy my friends,
AO
Hi-so glad to find this!! I have had a MN off and on for years (depending on footwear and activity) but it always went away-about two months ago it was constant and extremely painful
All the time!! I had about 3 cortisone injections so far and while it is far from as bad as it was it is still something that is painful and interrupting daily life-is this common? What else can I do? Thank you in advance!
Hi Tracey,
Glad you found me Tracey. If you have read my site at all you know what I am going to say, stretch your calves. Try something I know you have not tried.
I have a question. Have you had plantar fasciitis in the past?
Be patient and the odds are greater than 90% your issue will go away completely.
Stay healthy my friends,
AO
Hello Angry Orthopod,
I hope that you still read these comments. I’m writing because i have a problem with feeling like nerve moving on the side of the middle toe when I stand on my forefoot. It starts hurting if I walk more than 10 minutes. It’s very important to point out that I don’t have any pain in my forefoot as I can see that is very common symptom for MN.
My podiatrist had doubts if it’s MN and he sent me on MRI. MRI didn’t show anything, no signs of MN or anything else. I know what is your opinion on MRI…
My question is – can it be something else other than MN? Because I couldn’t find any other explanation, escpecially when I don’t feel any pain in my forefoot, only middle toe and it’s more feeling of nerve moving on the side of my middle toe when I walk that starts hurting after a while.
Every other foot/toe related problem that I came across on the internet has forefoot pain in combination with toe pain. So I’m little bit confused…
English is not my first language so I hope that I haven’ made too many mistakes and that you can understand what I wanted to ask.
Thanks in advance.
Hi Vlad,
Well, you could have fooled me because your English is outstanding. I am jealous, which fires me up a bit.
So, this pain is on the “side” of your third/middle toe, correct? Morton’s neuroma can be and is often experienced only out into the toes. Is your pain on the lateral (pinky toe) side of your third/middle toe or the big toe side? Is the pain that begins after 10 minutes of walking worse or better in certain shoes or barefoot? Is there any tenderness, meaning is there a place you can push on with your finger and create pain? Final question, do you have any toe deformities (hammertoe, etc.), or does your foot look unchanged from when you were younger?
My three picks:
1. It still could be a Morton’s neuroma. Worse, with tighter shoes will help determine this diagnosis.
2. Neurilemmoma of the lateral digital nerve third toe. This is a rare tumor of a peripheral nerve. It is thoroughly benign. I have resected 2 in 30 years in the location you describe. More in other locations. They are tender to touch and can send a “zing” out to the end of the toe when tapped (Tinel’s sign). Of note, this is one place where an MRI shines as these light up like a light bulb. So, if you had a neurilemmoma, why would your MRI be normal? Either they did not scan the toes or the cuts were thick and missed (skipped over) the neurilemmoma. It could be as little as 1-2mm in diameter and could be missed.
3. Hammertoe or osteoarthritis of the toe joint (PIP or DIP joint). I doubt this one the way yo describe it, but easy enough based on appearance.
The AO is looking for answers, don’t let me down. Foot and ankle problems can be vexing for sure, so don’t feel too bad.
Stay healthy my friends,
AO
Hi AO
Thank you for quick response.
So you asked me several questions, I will try to answer all of them.
First, the pain/nerve moving is on the big toe side of my middle toe, and only on that side. I ordered some orthotics and when I wear them it’s better, I can walk longer without severe pain but also isn’t great because I feel all the time some strange sensation in that area while walking. Barefoot is definitely worse so I totally stopped walking barefoot even in my house.
I noticed that I can recreate the nerve moving when I push on with my finger the ball of the foot near the base of the 2nd/3rd toe, which is maybe a sign of MN…
I have some very mild subluxation of metatarsophalangeal joint from 2nd to 5th toe (that was only what podiatrist read from MRI images) but my foot and toes looks pretty much the same as always I think. All I can say is that I haven’t noticed any major difference in my foot from my childhood years… And I’m still young, 29 years old.
This corona virus situation also makes it harder to get a correct diagnoses from specialist so thank you for spending some time trying to figure out what’s wrong with my foot!
Hi there Nikki,
The good news is you are not alone, sister. The bad news, you are are not alone. Unfortunately, you have been “running” with the rest of the herd (95%*) that treat at the wrong culprit, the plantar fascia. Sure, the plantar fascia is what hurts, and thus it is logical to handle it, but does that make it right? You mention, as do so many, the sexy quick fixes endorsed vehemently by the herd. These misaimed treatments might help the symptoms, but they don’t address the actual underlying problem, equinus.
I am glad you found me, and I am sure you will be over this soon if you do the stretching. Stay the course and be patient. Here are a few caveats for you:
* Starting, to modify the stretching intensity, which means how hard you stretch your calf. This equates you how much your foot is off the step. Tennis shoes and carpeted steps are the kindest to your foot, especially in the beginning.
* Starting out, modify the time you stretch. While many can start right at 3 minutes, some cannot. Baby steps! And build as you can. Again, patience, please.
* Beware of 6 months! According to my colleagues, you are now in the chronic state of plantar fasciitis because you failed conservative treatment (whatever that is?). This means there is just one more treatment left, surgery. Consider this, at least in my not so humble opinion; you have never treated your problem, equinus. Thus, you have never treated your plantar fasciitis. Sure, you probably stretched a bit in PT, but did you stretch? I would say you stretched almost none. Calf stretching done the right way almost always works, but it definitely won’t work if not done.
Now for the AO tirade, and I am mad, but not at you. All too often, I ask myself, “When will someone, some journalist, anyone, finally wake up and get this story straight?”. It keeps me up at night. No one seems to want to believe in calf stretching, let alone discuss the real root cause, equinus. As the Angryorthopod and as myself (there is a real me), I have been pushing this concept for a couple of decades, and just the mention of equinus is tantamount to kryptonite. Mention it on one of the wacky plantar fasciitis Instagram sites (see below), and you are told to get off. Mention it to a journalist, who has little knowledge on the subject, and the lines of communication are shut down…no article, no interview.
Maybe I am wrong, even though the scientific evidence (much I wrote) supports me. I will let the AO Nation judge for themselves. I will leave with a couple of links to articles that are parallel to where I have been in my quest for 25 plus years.
* https://www.theguardian.com/society/2016/apr/07/the-sugar-conspiracy-robert-lustig-john-yudkin
* https://www.bmj.com/content/bmj/351/bmj.h4962.full.pdf
Also, here are a few social media sites to check in on the herd activity.
* https://www.instagram.com/explore/tags/plantarfasciitis/
* https://www.facebook.com/search/top/?q=plantar%20fasciitis%20support&epa=SEARCH_BOX
Nikki, when the calf stretching works, please reach out and let us know, but more importantly, let the herd know.
Stay healthy my friends,
AO
*The 95% is an estimate based on reading basically everything available; scientific papers, journalistic reports, and social media.
I’m a letter carrier doing 20 km a day up and all around a steep small mountain. I usually go three to four hours with ought stopping at a quick pace. my foot pain and swelling has been so bad, its unbearable . I would go home at night and not be able to walk. I saw my dr. He sent e for X-ray ( rule out possible stress fracture ) and an mri. They diagnosed me with mn. He gave me cortisone shots in both feet where they pain was. My right side was ten times worse than my left. I have taken two weeks off to rest. I go back on Monday. Reading this article gave me a lightbulb moment. My calf and quad muscles are rock hard and brutally tight. They cause me pain. even when sleeping, the leg pain wakes me up. I never thought that it would be connected to my foot problems. Thanks for this info. Let the stretching begin.
Hi Ella,
I saw a lot of letter carriers over the years and I must say that you guys are some of my favorite patients. You guys beat the hell out of your feet and bodies, no doubt. I will say the great majority of letter carrier foot and ankle issues resulted from the same thing, equinus! And your problem is most likely the same. As you AO readers read Morton’s Neuroma Revisited you can clearly Ella’s issue is not a Morton’s neuroma and an MRI is not the way to determine this anyway. You are swelling and Morton’s neuroma does not swell. The MRI thing pisses me off royally, sorry just sayin’. MRIs are notorious for finding a lot of things that are not there or are not a problem or related to the problem in question. Ella, this is certainly your case concerning the MRI. Please take a look at the blogs on second MTP synovitis, part 1 and part 2 as well as Morton’s Neuroma: Controversial to Say the Least.
Ask them to look at your MRI for second MTP synovitis and you do your own check looking at the diagnostic sign and symptoms criteria at the end of Morton’s Neuroma Revisited. Second MTP synovitis is my primary suspicion for you especially since a stress fracture has been ruled out. As discussed in many areas of my site, if this is the issue you would likely do best receiving a cortisone shot in the 2nd MTP joint for temporary relief and swelling reduction. At the same time, you are addressing the root cause, equinus, by doing the calf stretching. This takes time, unfortunately. I will recant my wife’s story below, which mirrors most of the thousands of patients I have seen with second MTP synovitis.
One other suggestion for quick relief is shoes to make it feel better. Soft/cushioned shoes will feel the best for you quickly. As much as I hate HOKA shoes, they could be a godsend for you. HOKA shoes make me angry because they have a reputation they do not deserve, but mostly they are not a friend of a normal human gait due to the rocker sole and the walking in “loose sand” cushioning. Let’s just say “joggers” may like them, but runners would never don them. If you go this route, wear them until the calf stretching works then shelve them my friend. If you get them you will soon what I am talking about.
Love your attitude. Keep moving forward.
Stay healthy my friends,
AO