Pinched nerve in the foot: what to try before surgery

“Will I need surgery?” is usually the second question people ask about a pinched nerve in the foot. The honest answer for most people is: probably not at first. There is a lot you can try, and trying it well is part of the treatment, not a detour.

Start by taking pressure off

Treatment of an entrapment neuropathy aims first at reducing external pressure and inflammation.^[4] First-line treatments for the peroneal nerves include removing anything that may be compressing the nerve, stabilizing an unstable joint, and reducing inflammation, and many entrapments resolve with observation and activity modification.^[5] In practice that can mean:

• changing or re-routing laces, padding around a sore spot, or swapping out boots and straps that press on the nerve
• shoes with a broad toe box and a flat heel, with a sole that isn’t overly flexible
• supporting an ankle that keeps rolling
• a break from kneeling, crossing the legs or other positions that press on or stretch the nerve

Orthotics and bracing

For Morton’s neuroma, an insole with arch support and a pad just behind the ball of the foot can shift pressure away from the nerve.^[3] For tarsal tunnel syndrome, treatment also aims to correct foot and ankle alignment problems that contribute to the pressure.^[4] See shoes for Morton’s neuroma.

Activity changes and physical therapy

A temporary change in how you train or stand lets an irritated nerve settle while you stay as active as you can. Physical therapy adds strength, flexibility and balance work, and sometimes gentle nerve-gliding exercises. Desensitization exercises can calm an over-sensitive patch of skin, such as around a scar.

Medicines for nerve pain

Ordinary pain relievers often do little for nerve pain. The first-line choices are tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors such as duloxetine, pregabalin, and gabapentin.^[6] Their effect is modest on average. In a large pooled analysis, the number of people who had to be treated for one to get at least 50% pain relief was about 6 for the serotonin-noradrenaline reuptake inhibitors, 8 for pregabalin and 7 for gabapentin. Put another way, roughly one person in six to eight gets that much relief beyond what a placebo gives.^[6] Finding the right medicine can take some trial and error. These medicines are prescribed and monitored by your physician, and we coordinate with your primary care physician or other clinicians.

Injections, in selected cases

For Morton’s neuroma, a single corticosteroid injection has a moderate short- to medium-term benefit on pain in a systematic review of ten studies, although the studies were of low quality.^[7] In another review, almost 30% of people who had injections eventually had surgery because of persistent pain.^[8] Our guide to Morton’s neuroma injections goes into detail.

Treat what is behind it

Nerve symptoms can be driven or worsened by conditions elsewhere in the body, such as diabetes, a vitamin B12 shortage or a medicine that affects nerves. The outlook for a neuropathy depends on its underlying cause, so finding and treating that cause is part of the plan.^[9]

How long to try, and when to reassess

Non-surgical care usually takes weeks to months to show its full effect, and studies give some sense of the limits:

• In the tarsal tunnel study, surgery to release the tibial nerve was offered when treatment hadn’t worked after six months. Release appeared beneficial after failure of medical treatment.^[2]
• A review of shoe modifications and orthotics for Morton’s neuroma found that, after about four and a half months and in larger neuromas (over 5 to 6 millimeters), they gave less convincing results and worked more as relief than as a lasting fix.^[3]
• For Morton’s neuroma, about 30% of people do not respond to conservative treatment.^[10]

If you have given good non-surgical care a real trial and are no better, the next step is not automatically surgery. It is a fresh look at the diagnosis: is it the right nerve, is something else going on, and is there a second site involved? See back or foot? finding the source of nerve pain. When surgery is the right answer, you’ll want to know what it involves: nerve decompression and non-surgical treatment for foot nerve pain explain the options.

When to see a specialist

Consider an evaluation if nerve pain, burning, numbness or tingling in your foot lasts more than a few weeks, or hasn’t improved with roomier shoes and rest.