Morton’s neuroma

What is Morton’s neuroma?

Despite the name, a Morton’s neuroma is not a tumor and is not cancer. It is a thickening and scarring of the tissue around one of the small nerves (common digital nerves) that run between the long bones of the forefoot — the metatarsals — to the toes.^[3]

The nerve becomes irritated where it passes between two metatarsal heads, just beneath a ligament that joins them. Over time, repeated pressure can cause the nerve to enlarge, which in turn makes it more likely to be squeezed. It occurs most often in the space between the third and fourth toes and less often between the second and third.^[6] It is diagnosed more often in women than in men.^[1]

Symptoms

Symptoms often start gradually and may come and go, especially early on. Common descriptions include:

• burning, sharp or aching pain in the ball of the foot that may spread into the toes
• tingling, “pins and needles” or numbness in two neighbouring toes
• a feeling of standing on a pebble or a fold in your sock
• pain that is worse in narrow, tight or high-heeled shoes, and that eases when you take your shoes off and rub the foot
• sometimes a click felt between the toes when walking

In research studies, a click that people feel between their toes made a Morton’s neuroma more likely, and a lack of tenderness when the web space between the toes is squeezed made it less likely.^[4] No single symptom is enough to confirm the diagnosis on its own.

What causes it?

The exact cause isn’t fully understood. Repeated compression and irritation of the nerve in the tight space between the metatarsal heads is thought to play the main role.^[3] Factors that may contribute include:^[2]

• footwear that squeezes the toes together or pushes weight onto the forefoot, such as narrow shoes or high heels
• activities with repeated forefoot loading, such as running or court sports
• foot shape and mechanics — for example bunions, hammertoes, high arches or flat feet

How it’s evaluated

The diagnosis is usually made from your history and a careful examination. At your visit, we’ll ask where the pain is, what it feels like, what makes it better or worse, and what shoes and activities you do. The examination typically includes gently squeezing the forefoot, pressing between the metatarsal heads, checking sensation in the toes, and looking at your foot shape, joints and footwear.

Several other conditions can cause pain in the same area and need to be considered, including:

• irritation of the joints at the base of the toes (capsulitis) or injury to the plantar plate
• metatarsal stress fractures
• arthritis of the toe joints
• nerve problems elsewhere, such as tarsal tunnel syndrome or peripheral neuropathy

Imaging. X-rays don’t show a neuroma, but they help rule out problems in the bones and joints. When more information is needed, ultrasound or MRI can show an enlarged nerve; a review of studies found the two similarly sensitive for detecting Morton’s neuroma.^[5] Imaging is always interpreted alongside your symptoms and examination.

Treatment options

Treatment usually starts with the simplest measures and steps up only if needed. For a detailed look at each option, see neuroma treatment.

Non-surgical care

• Footwear: shoes with a wide, deep toe box, a low heel and a cushioned or stiffer sole to reduce pressure on the forefoot.
• Padding: a metatarsal pad placed just behind the painful area can spread the metatarsal heads and take pressure off the nerve.
• Orthotics: custom or prefabricated inserts may help redistribute pressure.
• Activity changes: temporarily reducing high-impact activities that load the forefoot.
• Medication: short courses of anti-inflammatory medication may help some people, if they are safe for you.

Many people improve with these measures. The research on non-surgical treatments is limited, with few high-quality trials, so treatment is adjusted to how you respond.^[7,6]

Injections

A corticosteroid injection can reduce pain for some people. A 2024 Cochrane review found moderate-certainty evidence that corticosteroid and local anaesthetic injections given with ultrasound guidance probably reduce pain and improve function; evidence for injections given without imaging guidance was less certain.^[6] Injections have possible side effects, such as thinning of the fat pad or skin changes, so the benefits and risks are discussed first and repeat injections are limited.

Surgery

Surgery may be considered when symptoms persist and interfere with daily life despite a well-tried course of non-surgical care, and when the diagnosis is well supported. The most common operation removes the affected segment of nerve (a neurectomy), through an incision on the top or the sole of the foot. Another approach releases the ligament over the nerve without removing the nerve.^[3]

Published studies report good results for many people after surgery, but no treatment works for everyone.^[8] Removing the nerve leaves permanent numbness in the adjoining sides of the two toes, which most people find they adapt to. Possible complications include wound problems, infection, thickened or sensitive scars, and ongoing or recurrent pain — including a painful “stump” neuroma where the nerve was cut.^[6]

Recovery and realistic expectations

• With non-surgical care, improvement may take several weeks to a few months. Some people get lasting relief from footwear changes and padding alone.
• After surgery, recovery varies from person to person. Most people spend a period in a protective post-operative shoe, and swelling can take weeks to months to settle. Return to regular shoes, work and exercise is gradual.
• Numbness in part of the two toes is expected after the nerve is removed and is usually permanent.
• Some people have ongoing or recurrent pain after treatment. If that happens, it deserves a fresh evaluation rather than simply more of the same treatment.

When to seek care

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
• comes with numbness that spreads beyond two toes, or appears in both feet — which can point to a different problem

If you have diabetes, neuropathy or poor circulation, have any new foot pain, wound or colour change checked promptly.