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 had planters fasciitis in my right foot years ago and it went away on its own. I now have some numbness in my second and third toe on my left foot and it feels like my sock is wadded up around the ball of my foot. The pad in the ball of my foot feels thick. The toes on my left foot are beginning to curl under just slightly. My foot doesn’t hurt it just feels strange. After doing some reading it sounds like I have MN. I have not gone to a doctorand am wondering what can I do on my own to try and correct the problem. Thank you!
Hi Kris,
Something tells me you might be right. However, second MTP synovitis can look like Morton’s neuroma early on. Here is the good news, calf stretching is effective for all and that you can definitely do on your own. It is likely no coincidence that you had plantar fasciitis years ago. A buddy of mine, Jim Amis, described this phenomenon as the “Gateway Disorder“. Interestingly, I just reread my 2012 blog Morton’s Neuroma: Controversial to Say the Least and saw that my percentage of calf stretching for Morton’s neuroma was 605. I can tell you that in the following couple of years after that post I took calf stretching more seriously as a primary treatment for Morton’s neuroma and the rate is now up around 90%. Sound familiar?
Stay healthy my friends,
AO
I had a total knee replacement 4 months ago. I spent the first two months at home wearing socks and walking around my house with a cane to exercise the new knee (did that change my gait). At the six week mark I started to get strange pains in both of my feet. They became excruciating pains in between the big toe and second toe of the surgical leg. I then had similar but less painful pains in the other foot. Fast forward now to four months out and the first podiatrist gave me a cortisone shot saying it was probably a Neuroma > Going for second opinion in a couple of weeks. I still have the pain in between the big toe and the second toe of the surgical leg. The worst pain is under the second toe, both 2nd and 3rd have a “pulling/stretching kind of feel” and the feeling of “crumbled socks” in the ball of my foot. There is no burning or stinging pain anywhere. After reading all of your comments I am now leaning towards this being a Capsulitis. It does not make sense that the non surgical leg (with similar symptoms) is a nerve related problem. I have been stretching my calves since reading your posts. I am also using orthotics with met pads. Your thoughts are greatly appreciated.
Hi Pam,
Finally, I respond and I am pretty fired up over this one. How are things going? Unfortunately, your story is just ridiculously common. First, you were predictably told it was a Morton’s neuroma and it may be, but my statistics say otherwise. Here is how this happened to you. People who undergo reduced activities for a period of time, such as surgery recovery or a heart attack recovery or they just get lazy, start moving again. During the “down time” the muscles (and to lesser degree tendons) are not used normally and quickly shorten according to the Law of Davis. The calf is particularly prone to this. Then when it is time to move, the shortened calf exerts its abnormal forces upon the foot as I have described in previous posts. To be clear your problem is not your foot, it is your calf, so please stretch and keep stretching and the foot will take care of itself, if not resolved already. Sadly so many other palliative treatments are prescribed for the foot and any treatment aimed at the real problem, the equinus, is left out. If I had my way my people would just know to start stretching ASAP after your surgery and avoid these problems altogether. I can tell you that you will not hear this from the medical professionals.
Stay healthy my friends,
AO
In addition to my primary care doctor, I have been to a podiatrist, a physiatrist, a vascular doctor and will be seeing a neurologist and an endocrinologist for a thyroid issue. I have had several tests including MRI of both feet, ultrasounds of both legs, compression tests of both legs and lots and lots of blood work. Everything (except for cholesterol) has been NORMAL. The docs all believe it is nerve related. I was put on Gabapentin and had every negative side effect possible, so I am weaning off of it. Going to see a different physiatrist in two weeks. I am expecting to have an EMG and possibly other testing to determine what the “nerve” problem is. I am not diabetic. Since I have cut the Gabapentin down to only 200 mgs. per day, I occasionally feel tingling in the ball of one foot. Pain and occasional burning on both feet. So frustrating that I do not yet have an accurate diagnosis and possible remedy. I have been to a chiropractor. I stretch, walk and exercise daily. I am hopeful that I will get better. It is very difficult when there are problems with your feet.
Hi Pam,
I feel your pain in your foot and your angst with no diagnosis. I am downright angry actually. And you are actually smarter about this than most in that you see the need for a diagnosis. Your problem is I would agree, sounds sort of complex. Neuropathy seems to be a standard go-to for docs who can’t figure it out. Equinus related problems are ridiculously misdiagnosed and could be your problem. I would say get after calf stretching, my way. On the other hand, if you do actually have a neuropathy, Type II diabetes could still be in the picture. Neuropathy secondary to diabetes can precede any other signs or testing by several years, so at least keep it in the back of your mind. Finally, go ahead with EMG, but be prepared to be more confused and underwhelmed. I like the way you think and you need to continue to believe in yourself and follow your instincts.
Stay healthy my friends,
AO
I am a 62 year old woman who has suffered from foot pain for the last six years. The pain started after I broke my ankle (nonweight bearing for 6 or 8 weeks). The orthopedic doctor that treated my broken ankle sent me to physical therapy. It may have helped some but didn’t cure it. I tried accupuncture. It was better but didn’t cure it. I saw a podiatrist. He diagnosed it as a mortons neuroma. He gave me a cortisone shot which did absolutely nothing and then told me surgery was the only option for treatment, not something I’ve been willing to consider thus far. Cold exacerbates the pain. I live in Northeastern Washington (state) so winter isn’t a lot of fun. Last summer I wore Correct Toes and went to wearing “natural foot approved” shoes or going barefoot when possible. That was the best my foot has felt since the problem started.
The pain seems to be concentrated in the ball of the foot/at the base of the toes toward the outside of center.
Five months ago I ran across your blog. I’ve been doing the calf stretches as recommended every day for five months now. So far, I’m not seeing any real improvement.
Is there any hope of curing my foot pain? Do you recommend a doctor in the Spokane, Washington, area?
Hi Connie,
Sorry for your problems. First please see my response to Erica on the blog comments for Plantar plate repairs and the pre-dislocation syndrome: what the f$@% (Part 2). I would say that calf stretching almost always works, but you may have a physical block to ankle dorsiflexion in the ankle joint resulting from your ankle fracture. No amount of calf stretching can undo that restriction I am afraid. Check to see how high your ankle can go up (dorsiflex) with your knee bent. Also, three other signs of ankle restriction of motion can be preference for slight heels, problems going barefoot and issues going downstairs. I know Brian J. Padrta, MD is very good. Best of luck. Keep stretching just in case.
Stay healthy my friends,
AO
A little more data I left out in my post above: I wore Superfeet arch supports in my shoes for a year or more after I saw the podiatrist (until I started wearing Correct Toes and natural foot approved shoes). It may have helped some but not noticeably that I recall. I’m short (Just under 5′) and when I sit on something, if my feet can’t set firmly flat on the floor/ground, that exacerbates the pain. Getting off my feet and putting them up (recliner, sleeping in bed) seems to give the most relief. I rarely have pain at night, while sleeping in a bed and it’s usually better first thing in the morning.
A podiatrist diagnosed me as having a MN, and I do have the parathesias and clicking – but not pain. And, it is mostly exacerbated by walking barefooted – not by high heels. Do you think I should get a second opinion or is this a known variant of the symptoms?
Hi Kristina,
Relax girl. The symptoms, while not the usual, are part of a snaping nerve. I am not sure I would call it Morton’s neuroma, but it is a kissing cousin. I have seen this several times and as far as I remember no one ever had actual quality of life-altering symptoms. Mostly it presented a nuisance. So, I would do some calf stretching and ride it out and resist the need to know. Best of luck.
Stay healthy my friends,
AO
Suffering from plantar fasciitis for over a year made shopping for shoe a difficult task. I had read about Orthofeet and thought I would take a gamble. They are by far the BEST shoe for me. I had cleared my pain up over the winter months and was ready to get back into my walking routine. I bought my Orthofeet and absolutely LOVE them. Can walk three miles and have no pain afterwards. My walking shoes have turned into my working shoes. I will order another pair as soon as I have time to look and decide.
This comment is from our concerned friend Akshay. It is so kind of Akshay to let us know about OrthoFeet shoes and that he LOVES them so much. It’s a freaking miracle, seriously? Oh, did I mention that Akshay’s email address is orthofeet@gmail.com? Oops, busted. Hey Akshay, I think you should order 100 more pairs. You can Zelle the promotional fee right to the comments on the blog or stay off my friend. And yes, I am angry. HA.
Stay healthy my friends,
AO
Lol. Thanks for keeping an eye out for us! Love it that you left it up.
It’s all good. Thanks.
Stay healthy my friends,
AO
Hello, I wanted to ask a question. I had the MN surgery on my right foot at the end of May. I asked the doctor what he found and he said that the nerve itself was the size of a
piece of linguine when it should look like a thin piece of Spaghetti. So he cut the nerve out. He told me he did not suture the nerve end into the muscle or anything, he said he has had better luck just cutting the nerve and leaving it be to heal. So not when rub the bottom of my foot on the ball of my foot where the cut end is, I can feel it twinge on me. It does not really hurt (knock on wood) but it is bothersome. Also when I walk it feels kinda weird in that spot on the pad of my foot, is that normal? Will that get better over time? I got to the point I could not even walk hardly with the nerve in the foot so opted to do the surgery. I’m just hoping my surgeon did it right, I am concerned he did not. Also if that nerve end become painful over time, what are my options to correct it?
Hi John,
I think you are with a heck of a surgeon who is honest. I have been convinced on a few that a patient had a Morton’s neuroma only to find Spaghetti. The right move is to remove it as planned and not make a second guess judgment in the OR. Most of these patients did just as well as those with a Ravioli for a nerve. I agree 100% to cut the nerve proximal to the weight bearing metatarsal head or ball area of the foot. The suturing of the nerve in muscle is not necessary if the nerve is cut “high” enough. I actually wrote a landmark article on this very subject. Okay, enough bragging. That twinge is the stump end of your cut nerve, more evidence your guy did good, and it is trying to regenerate which is normal. It will likely die down in a few weeks but might do better with direct message to the twinge area. As far as next options, it can be revised, but your odds are good you will end up fine. You got a keeper in your surgeon who unfortunately does not anger me.
Stay healthy my friends,
AO
Dear Angry Orthopod,
I have been having foot pain between my third and fourth toe for about two years now. The pain is like pins and needles or like a burning stabbing sensation that has been getting stronger. I have the pain at rest sometimes and it is also responsive to heat and cold on the skin and to touch. For 6 weeks now, the pain has been truly terrible. I can walk for 1-2 hours, then the pain gets unbearable. My foot is not swollen at all. Three doctors told me I had Morton’s neuroma and to get ready for surgery as soon as the MRI was complete. The MRI showed that there is nothing abnormal in my foot and my nerve is fine according to the radiologist. My planned MN surgery was cancelled. Another doctor diagnosed a stress fracture, but my x ray didn’t show anything abnormal and also no new bone growth. I cannot work as the pain is so bad (I work standing all day) and no one can tell me what my foot diagnosis is. My parents are starting to believe the pain is all in my head and want me to consult a specialist for psychosomatic pain. Cortisone injections with an anaesthetic brought me instant relief until the anaesthetic wore off. Do you maybe have an idea what this could be? I understand this is not a proper diagnosis or anything like that as it is over the Internet, I was just hoping you might have a suggestion as to what condition might mimic MN or if the chance of having MN with a negative MRI is to be considered. I am at my wit’s end and the pain is killing me. I really want to get back to my life. Maybe getting a surgeon to just cut open my foot and see if I have MN or not is a viable idea in my case? I understand it sounds stupid, but I just can’t take it anymore.
Thanks so much for reading and for your time.
Hi Anna,
Wow, where do I start? First, sorry for the delay, but real money making work is still a priority. There are many forefoot problems that can be tricky to diagnose and I have had my share. I don’t know you, but my instinct even over the internet is that the pain is not in your head and the suggestion by others does make me angry. You know what makes me even angrier, how about that MRI. I have said it many times, but an MRI has absolutely no place in the diagnosis of Morton’s neuroma. In short, it sounds like you have Morton’s neuroma (despite what the MRI read is) especially if the short-lived positive response to the injection was for a Morton’s neuroma. That is really the only solid test available, again not an MRI, ultrasound, or God forbid an EMG/NCS. As far as a stress fracture I seriously doubt it. While an MRI is not the go to test for a foot stress fracture, it would rule it out. Anyway, a stress fracture is a super easy diagnosis to make with just a 2-minute conversation. Please read other related AO blogs and the comments and answers as there might be more there. Believe me, I have answered similar issues before.
So back on track here, I think you might indeed have a Morton’s neuroma and surgery is THE last resort still, so take the pain a bit more. Here is the really cool thing about calf stretching, regardless of what your problem (because we really don’t know at this point) is most non-traumatic acquired foot and ankle problems result from equinus or a calf that is too tight, so calf stretching to the rescue. No matter what you are doing to treat your problem just add stretching and see what happens. I bet you are blown away within 4-6 weeks or less.
Finally, as far as this being in your head, you said the magic words, “I really want to get back to my life”. That speaks volumes. Best of luck.
Stay healthy my friends,
AO
Thank you so much for your reply.
You are an amazing doctor-keep it up!!:)
That is what I keep telling everyone. Now if they would just listen. This is the fun stuff. Best of luck and please check back in so all can learn.
Stay healthy my friends,
AO
I had a Morton’s neuroma diagnosis and surgery done on the second and third metatarsal spaces in 2005(the most painful surgery I have ever had). By 2006, the pain was back, along with a palpable knot in the surgical area. The podiatrist, with a rather dismissive manner, just shrugged it off as a stump neuroma, offered to inject it with alcohol to ‘kill the nerve’. “It’ll only burn for twenty four hours or so”. I declined. Now I have not only the funky pain/numbness at the ball of my foot but have what I guess it plantar fasciitis going on in the heel. Any suggestions?
Hi Holly,
Whoa there, a surgeon being dismissive, OH COME ON.
Do you know the difference between a surgeon and God?
Wait for it.
God does not think he is a surgeon.
There are 4 possibilities here in my mind, and all 4 could exist at the same time. The last three will likely respond to calf stretchingBLOG.
1. A “recurrent” stump end amputation neuroma. All successfully excised neuromas or any cut nerve become amputation neuromas, 100%. It all depends on where it resides. If left near the skin, plantar or sole of the foot in this case, or near things/parts moving then it can be quite a severe problem. All I can say is digging in right at it and doing cross friction massage usually works. Maybe you can take a look at YouTube.
2. An actual recurrent Morton’s neuroma. Stretch calves or face additional surgery, but the level of suspicion by someone a bit less dismissive is vital. Or as I have stated
3. It could be second MTP synovitis in early phases. Please refer elsewhere ion this one as I have written extensively on it by blog and comment answers.
4. Finally, while it does not sound like plantar fasciitis, what the heck, you’ll be stretching anyway.
BTW, good job declining the alcohol, injection that is.
Stay healthy my friends,
AO
I’ve had mortons neuroma fir 3 years. Cortisone shots not helping. Doctor decided to start alcohol shots. I’ve had 8 now with hardly no relief. I definitely don’t want surgery. Help me
Hey Stacy,
Good call on the surgery. Help you huh? When this works, please help me by shouting it out.
Maybe you have a Morton’s neuroma, maybe you don’t. The evidence might exist if one or more of the early injections worked if only for the local anesthetic effect. Forget the really lame, unproven alcohol injections. In fact, even though these treatments do occasionally work there is no logical scientific reason to support the use of this treatment.
Here is the help and it is the most powerful thing you can do, stretch your calves! Here is the really cool thing about calf stretching, regardless of what your problem is most non-traumatic acquired foot and ankle problems result from equinus or a calf that is too tight, so calf stretching to the rescue. No matter what you are doing to treat your problem just add stretching and see what happens. I bet you are blown away within 4-6 weeks or less but do give it longer just in case. Then shout!
Stay healthy my friends,
AO