Morton’s Neuroma-Revised Rewound Rebuffed Revisited
Thank you all so much for your comments and support. I have received a lot of feedback and fantastic questions about Morton’s neuromas (MN) and your problems with diagnosis and treatment of such. This area of the foot can indeed be terrifically confusing and difficult to diagnose. I want to help you all as much as I can with this conundrum, and I would love to answer each and every one of you individually, but I just can’t and shouldn’t in this setting. As always refer to AOFAS for specific help.
If you have been labeled with the diagnosis of a Morton’s neuroma and various treatments are not working so well, maybe you don’t have a Morton’s neuroma.
The MN diagnosis is made way too often. Why? Here are some misconceptions that surround the dreaded Morton’s neuroma and lead us astray:
- MN’s are really common. Actually they are not common, especially a 2nd web space MN (15%). Even 3rd web space MN are not common. If your doc is indicating a 2nd web space MN, question it and consider the much more common 2nd MTP synovitis (inflammation of the central ball joint). If they are thinking 1st or 4th web space, RUN.
- MN diagnosis is SEXY. We docs just got to make that diagnosis. “You have a Morton’s neuroma”. It has teeth. It sounds so definitive and sure. It is like a golf ball set up on a tee just waiting to be shanked.
- MN’s are easy to diagnose. Actually, they are not easy to diagnose. I have done this for 27 years and now more than ever, I am now even more cautious and I respect making this diagnosis ore than ever. It is actually a diagnosis of exclusion. This means that I rule out the other possibilities to the best of my ability before making the call of a MN. Too many good docs jump right to this diagnosis. It has to be the last diagnosis, and even then I am often not as sure as I would like to be normally.
- “You have a Mulder’s click”. This is a physical finding that is rarely helpful, but boy, do we really like it.
- The MRI and more recently, ultrasound have not helped matters either. In fact, those who rely on these tests are trying to increasingly make a claim regarding their diagnostic prowess, which is not true. Stick to old fashion history and exam.
- MN may be all your doctor knows.
Basically, central forefoot (2nd, 3rd, 4th metatarsal head region, not 1st or 5th) pain that starts in an otherwise normal foot can be divvied up into four basic diagnoses the great majority of the time. There are several more diagnoses that are uncommon and frankly, outliers that are not discussed here such as Freiberg’s infraction, inflammatory arthritis (rheumatoid), etc. Here are the names and the diagnostic criteria, according to the AO. Keep in mind that the majority of these can be diagnosed by history alone and an MRI or an ultra sound is generally not needed in any of these. Waste of time and money. If your doc is quick to say they need an MRI to make the diagnosis consider another route. I’m not sayin’, I’m just sayin’.
Exam is important, but only to support and confirm the history. By the way, no matter what you think or hear, none of these ever have a history of actual causative acute trauma. If you have a history of trauma and you have one of these I would say True-True-Unrelated.
Finally I am not discussing treatment. The treatment of each of these is clearcut as long as one is confident in the diagnosis, which what this is about.
Intractable plantar keratosis (IPK) or plantar corn or callus
- Generally older, 50 yo plus, but can be any adult
- Pain is on the bottom
- Insidious slow onset, present for some time
- Visible seed, small tight callus that is exquisitely tender to touch.
- No swelling
- You would have to be brain dead to miss this one.
- Pain only with weight bearing
- Worse on barefoot, better in shoes
- When it comes to trauma, this one could be the exception. If there is bonafide past or remote trauma to your foot/metatarsal or previous surgery that leads you to have a residual unevenness to the weight bearing surface of your metatarsals, then you could develop an IPK form that.
- X-rays negative
- Can be confused with a plantar wart.
Metatarsal neck stress fracture
- Ages
- Military recruits, boot camp, “march fracture”
- Distance runners, any age, training error
- 50+ female>>male
- Recent rapid onset
- Recent rise in activity level, especially number of steps! Normal activity to many more steps per day, vacation, new exercise program, etc. Or lower activity as in being down from prolonged inactivity, i.e.illness, heading back to your normal activity level. Jumping out of the back of a pick up truck and breaking your metatarsal is an acute fracture, not a stress fracture, and is different.
- Pain on top of foot
- Swelling top of foot
- Usually 2nd metatarsal, next to big toe metatarsal
- Pain with weight bearing, with or with out shoes
- X-rays negative in first 21 days, then new reparative bone formation is seen and sometimes the fracture is seen.
Morton’s neuroma
- Adults, peak age 40’s thru 50’s.
- Insidious onset, often years.
- Unlike all the others, at first and often even later, the location of the pain can be vague; can’t pinpoint. Can be frustrating for patient and doctor alike. However, knowing this can ultimately be helpful if used correctly.
- Pain mostly on bottom.
- Can take a while to get started with standing/walking.
- Worse in confining shoes, better in sandals or barefoot.
- NO SWELLING…………..EVER. Whoops, caps lock on again.
- Can feel swollen however. Numbness can feel like swelling. Remember the last time you got home from the dentist and you looked in the mirror because you were sure that your tongue was hanging out of your mouth only to find out all was well. I rest my case.
- There can be a sensation of actual, perceptible numbness between the two affected toe which border the neuroma. This sensation or finding by your doc is extremely variable and unreliable. It’s presence or absence really means nothing. I ignore it basically except to support my other findings.
- Mulder’s click is a useless finding. It’s absence means nothing. While I do dismiss it, a Mulder’s click may be supportive if when performed it exactly recreates your pain.
- 3rd web…85-90%, 2nd web 10-15%, 1st or 4th web…….not.
- These are two things that get my attention and often have meaning, but only supportive with other findings and history:
- feeling of folded sock bottom of foot
- urge to take off shoes and rub foot. Does not matter whether you actually ever do it, it is just the urge part.
Second MTP synovitis (AKA, capsulitis)
- Majority in specific demographic, 55 +/- yo female
- Not mentioned as differential diagnosis on Mayo or WebMD sites, but capsulitis is right there on Wikipedia.
- By and far the most common of these four diagnoses
- Primarily 2nd metatarsal. Infrequently the 3rd.
- Insidious onset, few days to weeks.
- Swelling top and bottom often, but not always.
- Painful “lump” or “rock” under ball of foot. Pain on bottom.
- Worse on hard floor barefoot, better on carpet or cushioned shoes.
- Sometimes there is the perception of some form of trauma, but any trauma is just the “straw that broke the camels back” phenomenon. For instance dancing at a wedding in heels to get it started. But here is something you MUST know; it was going to start eventually anyway because it is a result of:
- mostly these occur as a result of calves that are too tight which places more pressure on the forefoot/metatarsal heads. This represents a more recent change and why this is happening now and not before.
- in a very small part due to the anatomy because the 2nd metatarsal is the most prominent in almost all of us. This has been your anatomy forever and has not changed. Your doctor might refer to your 2nd metatarsal that is “too long”, but it has been that length all your life. Seriously, it isn’t as if your metatarsal magically grew longer recently. Now, refer back to calves.
- Transfer metatarsalgia secondary to a bunion. Often blamed, but the calves that are too tight are the larger reason this is going on at this point in your life.
- When this problem is left untreated, eventually a hammertoe will develop if the swelling is allowed to persist. Hey, here is a novel idea. The great majority of isolated 2nd and/or 3rd hammertoes result from MTP synovitis which comes from calves that are too tight, which is almost completely preventable as long as you stretch your calves.
- Often the inflammation from the 2nd MTP synovitis can irritate the adjacent 2nd web space nerve causing neuritis, which is a secondary thing and not a Morton’s neuroma.
If you are reading this, chances are you fit in one of these four groups. Certainly you’ve gotten loads of information from the stranger on the bus next to you, or your nosey neighbor (everybody is an expert), or from the internet, or even your doctor. Again, the mere fact that you are reading this means things probably aren’t going so well. No matter what you have heard from these sources statistically your problem is second MTP synovitis, and not a Morton’s neuroma.
IPK, seed callus under second metatarsal head
AP radiograph right foot 2nd metatarsal stress fracture, oldest with mature fracture callus; 4th metatarsal stress fracture, newer with early maturing fracture callus; 3rd metatarsal stress fracture, newest with minimal fracture callus
3rd web space Morton’s neuroma, plantar or bottom view
3rd web space Morton’s neuroma, dorsal or top view
Pedobarograph, 2nd metatarsal overload
2nd hammertoe
Hi how can one differentiate between plantar plate ligament issue and MTP synovitis if there is not a large deformity, shift in toe or instability much different than the uninjured but worse looking foot ??
I’ve had ball of foot pain at 3rd MTP joint worse on bare floor . Not bad if my met heads are raised in shoe with Orthotic or Birk type platform.
Walking is painful over time but in a walk can come and go
Top.of the joint line is tender as well.
Not much swelling that I can tell (I’m a physio which makes self diagnosis worse !)
Awaiting x-ray and ultrasound results but doc thinks it may be plantar ligament but I’m leaning more towards and hoping joint capsuliits .
If I stay off the impact and walking etc and stay in good shoes do you think this type of things can settle within a month to six weeks?
I’m cycling and doing weights for now and to be honest think my run days are limited having had failed bunion surgery.i think this issue started from wearing toe spacers which were too wide …. Pain started in muscles in between 1st/2nd and 2nd 3rd spaces .
Anyway any insight ???
Hi Elise,
The very first thing, while your story is albeit a bit complex it is being driven by equinus. Thus stretching is ultimately be your answer.
I have two questions for you:
-Do you have a history of plantar fasciitis? 75%+ chance
-Was your 2nd toe worked on with the original surgery?
I love that you are a physio! Most you guys can diagnose better than your average orthopod or podiatrist. Not to mention paying attention to root cause instead of treating the more obvious end result.
To answer your initial question you can’t differentiate between second MTP synovitis and plantar plate rupture because they are a continuum of the exact same thing. And in a way, who cares, unless one (your surgeon) is looking to perform one of the truly lame surgeries, plantar plate repair. And they still never address the cause, equinus. I can hear it now, “Your scan shows you have a plantar plate rupture and I recommend we repair it.”
Please follow my logic here. Second MTP synovitis (capsulitis) is always the first domino to fall and plantar plate rupture, if it happens, always comes later. Then comes the hammertoe, followed by subluxation and then dislocation. Here is the thing, you want your “problem” to go away so you can get on with it back to running. But what is your problem? It is equinus. Treat that and if your synovitis, or plantar plate rupture or whatever will solve itself the right way. Of course, symptomatic treatment is needed such as cushioned shoes, avoid impact and intraarticular cortisone injections. BTW, the mechanism of plantar plate rupture formation is the intraarticular swelling the synovitis produces. The cortisone injections not only make you feel so good but in my opinion mitigate plantar plate rupture. Just don’t leave out the main ingredient, calf stretching. Nobody would treat a brain tumor that is causing as the only symptom headaches with acetaminophen. Why would one treat plantar fasciitis, second MTP synovitis, non-traumatic midfoot arthritis, several other foot problems and not treat the equinus?
True story. My own wife had this same thing and a plantar plate rupture by MRI. She did all of the above 10 years ago, yes stretching, and still stretches daily (she better) and no hammertoe, no restrictions. In the words of Mel Gibson in “Braveheart”, FREEDOM. I have had hundreds, maybe thousands, of patients take this route as long as they stretched. The ones who took the same route, but did not stretch (sadly too many, human nature) progress to a predictable surgery and worse outcome. Pity.
I am glad to say your problem did not start with toe separators. If it did, then we are quite frail, aren’t we? And your running days are probably not over. I have seen it many times.
Finally, it might take longer than 6 weeks, so be patient and persistent. Or you could just have a plantar plate repair. Really?
Stay healthy my friends,
AO
Oh and forgot to say it’s always worse in the morning first thing.
I went for an MRI and it showed the following: there are subtle signal changes extending plantarly from the second metatarsal interspace suggestive of a small Morton’s neuroma. My foot hurts really bad and has for 3 years not, sometimes the pain is worse than others but a few weeks ago I was limping in pain so dr. did an MRI and this is what was found. Can the exercises help me at all at this point? Thanks.
It is hard to tell, but this is basically the usual noncommittal result of a forefoot MRI. Basic history and physical exam and X-rays are far and away the best way to determine the diagnosis accurately. Maybe the pain has been there for 3 years because the underlying cause, equinus, has never been treated or corrected. Please stretch your calves every day.
Stay healthy my friends,
AO
Hello. I had MN surgery on my right foot about 2.5 years ago. The surgery was successful in the sense that the neuroma pain is gone. However I still have like fullness/soreness every morning when I get out of bed. Feels like my foot is still swollen. And that foot is definitely still slightly bigger than the other like it carries some permanent swelling. I will take this over the neuroma pain any day but just curious if this is a “normal” long term side effect and if any stretching could help?
HI Hannah,
Outstanding question. Your residual issues can and likely are be a part of a successful Morton’s neuroma excision, and I am glad you can say you are better. The interesting part of your question is regarding the swelling or at least the apparent swelling. Numbness, which should follow a successful Morton’s neuroma excision, can feel less like numbness and more like swelling. Just recall the last time your dentist shot your mouth up with novocaine to do dental work. I know I still have to look in the mirror to confirm my lip or my tongue are not triple their normal size and, voilà, normal size.
As far as true swelling, like one shoe is actually tighter than the other, this is not expected,. However, it can happen and is hopefully no more than a nuisance.
As far as the soreness out of bed in the morning, I have no doubts that it will resolve with daily stretching your calves.
Stay healthy my friends,
AO
Hi – Adding to my above comment- both my husband & I are stretching our calves & impressive improvements
I can bend my toes & the MN is less bothersome although not gone yet!
Hubby has movement in 2/3 toes
First time in years!
We are sticking to it & say Thankyou
Hey Linda,
My pleasure. Exciting, just downright stupid stuff, huh?
ATTENTION AO NATION! Please help your fellow man and spread the word by word of mouth, social media, tell your doc, write your congressperson, or tell a celebrity.
Stay healthy my friends,
AO
Sir –
I have really enjoyed reading your posts. Thank you. I was diagnosed with NM. I was a runner (marathons, etc.) but haven’t run since.
Symptoms – feels like something stuck in my foot and had the “click” during my exam. Subsequently, I have had 5 sessions of alcohol shots in both feet (top). It seems to help… temporary. The last shot was tough….feet super sore for a week. And now, several times throughout the day (shoes or no shoes) when I raise my heal (when walking) or walking down steps – I get a very sharp [quick] pain in the bottom of my foot. This pain is worse than what brought me to the doctor in the first place. Sometimes I wanna ripe my foot off!
So… my question is this – do you think I was misdiagnosed? How many sessions of shot should a person get? And why would I be experience a different (worse) pain after the shot?
Your opinion is greatly appreciated.
Hi Shelley,
It is AO Sir, please. I appreciate the compliment.
I would say if just one of those shots resolved your pain even for a short time, the diagnosis is likely correct. No doubt alcohol and cortisone shots can cause increased pain and new pain. I am not a fan of alcohol shots, but I am a fan of stretching.
My question is, “Why are you not running?” Either your pain is too great or you are able to run, but you were told to stop. If it is the later go back. And definitely calf stretch.
Stay healthy my friends,
AO
AO – Thank you so much for responding!!!! I stopped running because of the pain. That said – I have been stretching… I am a believer! Feet are feeling better and I have started running again.
Really glad that I found this blog…. you are the best! Again – thanks!
Hi AO,
After training more intensely for a Ragnar relay (overnight relay, ran 5-7 miles 3x in about 24 hours), I developed pain in the ball of my foot, towards my middle toe. Went to Duke Medicine, they gave me a sticky thing that immediately fell off my shoe. Went again, had an x-ray and eventually an MRI. They ultimately diagnosed me with Morton’s Neuroma.
In some ways I agree – the pain is worse after I haven’t been walking on it for a while, I have the ‘Mulder’s click.’ But in other ways…it definitely doesn’t feel like a ball or an obstruction in my foot, and it came on REALLY suddenly. Like, one morning I just woke up and it really hurt. I hadn’t changed shoes recently and I never wear heels.
I bought new running shoes, took some time off running, and then eased myself back into it. Things seemed better.
Fastforward seven months. I’m pregnant with my third child. I’m gaining weight (obviously). As you likely know, the joints relax during pregnancy, ligaments loosen, things get crazy.
And my old pain is back with a vengeance. I’m worried that as I continue to gain weight (I’ve only gained six pounds so far) and the pregnancy continues, I’m not going to be able to walk at some point. Any suggestions?? Thanks!
Congrats on number three! Morton’s neuroma pain can vary for sure, and that alone makes me angry. Why can’t it just be consistently obvious?
Back to the diagnostic differentiation, is your problem worse in tighter shoes? This is the most consistent historical finding. I can say Morton’s neuromas never present abruptly as yours did. Typically there is a slow ramp-up time of weeks to months. Let’s assume you do have a Morton’s neuroma. First, stretch you’re calves. You did not mention, but it can be a resolving force 85-00% of the time. Besides, you are a runner, and you should do it for that reason alone. Second, know this, other than severity of symptoms and interruption of lifestyle, there is no urgency to a Morton’s neuroma medically or surgically speaking (keep in mind we are assuming this is a Morton’s neuroma). The last resort, surgical excision, works better later because the patient mentally and physically is needier, thus, by contrast, the result is percieved as better. I have written on this elsewhere.
Hint on ladies and running shoes. The industry lasts (form the shoe is made on) for women’s shoes are more narrow (again dressed elsewhere on AO). Buy men’s running shoes especially if you have a Morton’s neuroma because for any given length they are wider.
Please disseminate the following particular thought as widely as you can. As far as weight gain in pregnancy and foot issues, I can’t agree with that. Foot issues are well noted during and just after pregnancy, particularly plantar fasciitis. Agreed that there are necessary laxities that happen with pregnancy, but the calf muscle and the interstitial connective tissue (the real reason for equinus) seem to be immune. I feel the loss of activity, especially in the last trimester of pregnancy is a set up for increased equinus, which in turn causes the foot issues.
So, here are my suggestions:
* calf stretching
* Men’s running shoes
* Be patient, especially now
BTW, you are in good hands with my Duke buddies. However, I am not entirely buying Morton’s neuroma only because I know what a chameleon it can be.
Stay healthy my friends,
AO
hello I am 64 and until I sustained small tears in my left achilles tendon 2 years ago , had no issues with my feet and still jogged a bit. Rarely wore high heels.
Adopted the wear a low heel and a wedge method and the tendon very slowly healed.
A few weeks ago I walked 14 ks along a beach. Have had a very sore forefoot since.Limping and am a teacher on my feet all day.
Went to a podiatrist ; she said MN. Have no swelling , no feeling of bunched sock.Only pain when I walk. Shoes are a pain sandals are good.
I have had the little seed calluses under the toes pad for years. Pain feels more on the top of my foot.
Have now got a pad and toe loop ( also have a low grade hammer toe) It really doesn’t do much.
Will start the calf stretches tonight-carefully as tendon still twinges at times
Please help
Hi Paddy,
This is so delayed you must be cured by now. I would agree on the Morton’s neuroma likelihood, but possibly not. Of course, I am not going to argue the calf stretching plan. How is it going?
Again, apologies for tardiness.
Stay healthy my friends,
AO
I’m a teacher too. I found the best thing besides the stretching is metatarsal pad that is cut out where the MN is rather than one where the pad is a bump. A good podiatrist cut them for me. Made a difference. Also I got wider, larger size shoes which allowed toes more movement. Also helped.
This is a question I haven’t really found a great answer to online – if it is 2nd MTP synovitis, how long does it take for the initial swelling/pain to go down with rest, taping, etc (and calf stretching of course, but I understand that part takes longer)?
30 years old. I got it suddenly in one foot, was on crutches/hobbling around, got it in the other foot less bad a week later, and now I’m just past 3 weeks from initial onset (2 of those weeks in an air cast on the worse side). Podiatrist diagnosed 2nd MTP synovitis but seems to think it’s taking longer than usual to get better, and ideas like “oral steroids” or “go see a rheumatologist to rule out RA” are being tossed around, which are scaring me.
Hey Caitlin,
This is water under the bridge, but I answer to help all. 2nd MTP synovitis takes a while to resolve. To save me time below is the answer I posted for Dan. I think it will answer your questions.
To Dan…Indeed I am angry, just asking gets me fired up. FIRST, STRETCH. Be patient and you will get to the root cause. Please read my post carefully.The whole crystal thing is just Palin old bullshit my friend. That is an excuse for those who don’t understand the critical role of calf stretching. That includes much greater than 95% of my colleagues BTW.
In my experience, the intraaerticular cortisone not only makes you feel much better, fantastic actually, it temporarily eliminates the cause of the plantar plate tear and ultimately the hammertoe and even a MTP dislocation, THE JOINT SWELLING. I have treated hundreds of patients successfully using stretching (on you everyone), periodic cortisone injections, cushy shoes and staying away from things that flare it up like barefoot on hard floors or activities that provoke it.
My wife had second MTP synovitis on both sides no less. One foot started, and the other followed maybe a month or so later, and of course, we caught hers early because her husband is a talented surgeon. As expected, my lovely bride faithfully stretched. However, the stretching takes time, and her pain and swelling was in the now and in time was going to exact damage to her plantar plate. To mitigate this, I had to inject one side 3 times and the other four times over about 4 months, each about 4-6 weeks apart. As soon as she said it was ”coming back” I injected her quickly before it got too flared up. I was protecting those plantar plates as aggressively as I could knowing the force/pressure under the 2nd metatarsal head would come back to normal once the stretching started to work. Sorry, but the stretching does take some time.
It took about 3-4 months for each side to “resolve.” She said the relief at that point was definite but somewhat iffy. She had a sense it might flare again if she got too active like running, or walking too much barefoot on a hard floor. During this time, while her activity level was near normal, she would wisely back off before it got going again. However, it didn’t flare and about 2-3 months later (6-7 months in) she came in the room one day and said, “It’s gone,” and that was that. She continues to stretch today. Her experience was pretty much the same experience that my patients reported over the years under my guidance.
Finally, the formation of the hammertoe deformity is a function of how long and how much swelling one has had and how early these issues are addressed. Here is the thing, you can be injected ”forever”, but it won’t stop until the cause, equinus, is corrected.
I ask myself everyday, “Am I the only one who gets this?, and I think the answer still is basically yes, except for my wife and the many patients who have seen the success.
Spread the word of the AO nation.
Stay healthy my friends,
AO
Hi AO,
Does a mortons neuroma ever cause bruising and swelling to dorsum of the foot. Long story short I ran a marathon in September, I did not take time off and ran in older shoes following the marathon that felt tight when i put them on. I developed pain around my 4th metatarsal, seen by podiatrist who thought it was a stress fracture, had negative xrays, pain would move between 3rd, 4th webspace, and lateral mid foot around proximal 5th metatarsal. I was given a steroid injection which I am not sure made any difference. I saw a chiropractor who thought peroneal tendonitis. I started running again and could manage the pain. fast forward to February 17th and I did a 5 mile race and had excruciating pain that started soon into the race. At the end of the race my foot was swollen and bruised around the base of mostly the 3rd and some of the 4th metatarsal. xrays were negative, I wore a boot for 4 weeks and when i saw the orthopedic he thought a neuroma, I had another injection. Pain is worse barefoot in the morning. Seems to improve after massage and after wearing toe spreaders. I had a repeat xray after 5 weeks that did not show anything to indicate a stress fracture. MY foot it tender at both metatarsal heads and the web space. The swelling and bruising after the race is really throwing me.
thanks
Hi Kei,
Sounding like a broken record you have my apologies. This sounds like a synovitis and less like a Morton’s neuroma. A MT neck stress fracture is a possibility, but unlikely with a negative 5 week X-ray. I will say it is remarkable how many diagnoses you got. I hope you are doing much better at this point.
Stay healthy my friends,
AO
Dear Angry Orthopod,
I seem to have a second metatarsal head overload according to my pedobarograph. Should I start calf stretching now to prevent second joint MTP? If I do that now,is the risk of me getting it very low (am 27f?)
Also, are orthotic inlays good if I have this overload?
Thanks!
Hi Alexandra,
If you have had a pedobarograph you must [should] have had an x-ray. At 27 you may indeed have a congenitally long 2nd MT. If your 2nd MT is prominent/long then your chances of developing second MTP synovitis are higher in my opinion. There is no published evidence that supports that claim, just 30 years experience. Orthotics can definitely be helpful, but for a female they can restrict shoe cuteness and a re sort of a hassle to keep up with. It is your choice. Here is the thing, orthotics are not the answer as to shoe modification, it is a properly placed met pad, and almost no OTC orthotics have them. Try Hapad metatarsal pads, which allow easier shoe wear, cheap, and deliver the relief where needed.
However, if you want to really make a dent put your efforts where it counts, stretch your calves now.
Stay healthy my friends,
AO