Morton’s neuroma injections: what to expect

When shoe changes and padding haven’t settled the burning in the ball of your foot, an injection is often the next option someone brings up. It helps to know what it is meant to do, how well it works, and what to expect in the weeks afterward.

What the injection is

For Morton’s neuroma, the injection usually combines a corticosteroid, which calms irritation, with a local anesthetic. It is placed near the thickened nerve between the toes. The trials in the Cochrane review compared a corticosteroid plus anesthetic mixture with anesthetic alone, and compared injections given with and without ultrasound guidance.^[2]

Does it work?

Mostly yes, for a while. A systematic review of ten studies with 695 people found a moderate short- to medium-term benefit on pain, a low rate of side effects, and better results than usual care. The authors noted that the quality of the evidence is low, that it is unclear whether a steroid does better than anesthetic alone, and that injection was less effective than surgical removal of the nerve.^[1]

Other reviews point the same way:

• A pooled analysis of two trials found that corticosteroid injection decreased pain more than a control treatment. In a comparison with footwear changes and padding, injection had higher odds of treatment success.^[4]
• In a randomized trial, 82% of people treated with steroid injections had complete or partial relief at 12 months, compared with 63% of those treated with shoe modifications alone, although the difference was not statistically significant at one year.^[5]
• The Cochrane reviewers were more cautious. Comparing a steroid-plus-anesthetic injection with anesthetic alone, they found it may make little to no difference in pain at three to six months, and they rated that evidence as low certainty.^[2]

Why ultrasound guidance matters

The strongest finding in the Cochrane review is about technique. Two trials compared injections given with ultrasound guidance to injections given without imaging. At six months, ultrasound-guided injection probably reduced pain and improved function more, with moderate-certainty evidence.^[2] Ultrasound lets the person giving the injection see the nerve and place the medicine beside it.

What to expect afterward

• Timing. In a review of injection studies, pain relief was greatest between one week and three months afterward.^[3]
• Not everyone responds. First-line treatment for Morton’s neuroma includes activity changes, orthotics and injection, and about 30% of people don’t respond to conservative treatment.^[6]
• Surgery may still come up. In the review of corticosteroid injections, 140 of 469 people (almost 30%) eventually had surgery because of persistent pain.^[3]

Side effects and limits

In the Cochrane trials, adverse events in the steroid groups included mild skin atrophy (3.9%), lightening of the skin (3.9%) and thinning of the fat pad under the foot (2.6%). No adverse events were seen with anesthetic alone. The reviewers called the evidence about adverse events very uncertain.^[2] A systematic review also pointed out that the safety and effectiveness of repeated injections at the same site have not been well studied.^[3] That is why the number of injections is usually kept small.

Where injections fit in the bigger plan

An injection works best as one part of a plan. Roomy shoes and a pad behind the ball of the foot take pressure off the nerve, and the injection calms it down while that happens. Our guide to shoes for Morton’s neuroma covers the footwear side. If pain returns or never improves, the next steps include reconsidering the diagnosis and discussing surgery. See Morton’s neuroma, neuroma treatment and Morton’s neuroma surgery.

When to see a specialist

Consider an evaluation if pain in the ball of your foot lasts more than a few weeks despite changing your shoes, limits walking, work or exercise, or has returned after an injection.