Morton's Neuroma: Causes, Symptoms & Treatment

Despite its name, a Morton’s neuroma is not technically a tumor — it’s a perineural fibrosis, a thickening of the tissue that surrounds the common digital nerve between the third and fourth toes. The name comes from American surgeon Thomas George Morton, who described it in 1876, and the term neuroma is used colloquially even though it isn’t a true neoplasm.

In our podiatry practice, Morton’s neuroma is one of the more satisfying diagnoses to make and treat — because the right treatment approach produces excellent results and most patients get significant relief within weeks of appropriate management.

Symptoms of Morton’s Neuroma

Morton’s neuroma produces a characteristic symptom complex that makes the diagnosis relatively straightforward when present:

• Burning, electric, or cramping pain in the ball of the foot — typically in the 3rd interspace (between 3rd and 4th toes) but can occur in the 2nd interspace (between 2nd and 3rd toes)
• “Pebble in shoe” sensation — many patients describe feeling like there’s a stone or bunched sock under the ball of the foot
• Radiation to the toes — electric-type shooting pain or tingling that extends into the 3rd and 4th toes (or 2nd and 3rd for 2nd interspace neuromas)
• Relief with shoe removal — symptoms typically worsen with shoes on (especially narrow, tight shoes) and improve or resolve immediately when shoes are taken off
• Activity-related — worse with prolonged walking, running, or standing; better with rest

Causes

Morton’s neuroma results from chronic irritation and compression of the common digital nerve as it passes beneath the deep transverse metatarsal ligament. The most common provocative factors:

• Narrow toe box footwear — compresses the metatarsal heads together, squeezing the interspace and the nerve. High heels further load the forefoot, increasing compression.
• High-impact activity — runners and athletes with repetitive forefoot loading are at increased risk
• Foot deformities — bunions, hammertoes, and flat feet create abnormal forefoot mechanics that increase interdigital nerve pressure
• Hypermobile metatarsals — excessive movement at the 3rd–4th metatarsal junction allows the ligament to repeatedly traumatize the nerve

Diagnosis

Morton’s neuroma is primarily a clinical diagnosis. The Mulder’s click test — squeezing the metatarsal heads medially while placing dorsal-plantar pressure on the 3rd interspace — produces a palpable click and reproduces the patient’s pain in the majority of cases with a neuroma. Interdigital space compression (placing direct pressure into the 3rd interspace from the plantar surface) also reproduces symptoms.

For ambiguous cases or when surgical planning is considered, MRI is the imaging study of choice — it characterizes the size of the neuroma and identifies any associated intermetatarsal bursitis. Ultrasound is a faster and less expensive alternative with comparable diagnostic accuracy in experienced hands, and can be performed in our office.

Treatment

Treatment follows a stepwise approach from conservative to interventional:

1. Footwear modification — wider, lower-heeled shoes with adequate forefoot width. This is the single most impactful conservative change. Many patients with mild neuromas achieve excellent symptom control with footwear alone.
2. Metatarsal pad — a teardrop-shaped pad placed proximal to the 3rd–4th metatarsal heads (NOT under them) splays the metatarsals, decompressing the interspace. Can be added to OTC insoles or incorporated into custom orthotics. Custom orthotics with a built-in metatarsal pad are our preferred approach for persistent neuromas.
3. Cortisone injection — corticosteroid injection directly into the 3rd interspace provides rapid, significant relief in 60–70% of patients. Effects typically last 3–6 months; repeated injections (2–3 maximum) are reasonable. More than 3 injections risks fat pad atrophy and plantar skin thinning.
4. Sclerosing alcohol injections — a series of 4–7 dilute ethanol (4%) injections into the neuroma causes gradual fibrosis and nerve desensitization. Response rate of 65–80% in studies. Less risk of plantar fat pad atrophy than corticosteroids. Performed at 2-week intervals; results develop over 3–6 months.
5. Surgical excision — for neuromas that fail comprehensive conservative management, surgical excision (neurectomy) provides cure in 80–85% of cases. The neuroma is removed through a dorsal or plantar incision. Plantar incision provides better access but leaves a scar on the weight-bearing surface. The main side effect is permanent numbness between the affected toes (expected and generally well-tolerated).

Frequently Asked Questions

Can Morton’s neuroma go away on its own?

Small neuromas can improve significantly with conservative measures (especially footwear change) and may become asymptomatic. However, the structural thickening doesn’t resolve — it becomes manageable. Large neuromas and those with significant symptoms for more than 6 months rarely resolve completely without interventional treatment. Prompter treatment — cortisone injection or sclerosing series — generally produces better outcomes than prolonged conservative management for symptomatic neuromas.

What does Morton’s neuroma pain feel like?

The most common descriptions are: burning pain in the ball of the foot, electric shock or tingling sensation radiating into the 3rd and 4th toes, a feeling of walking on a pebble or bunched sock, and cramping in the forefoot during activity. Pain typically worsens in tight shoes and heels and improves with shoe removal. Nighttime pain is less typical of Morton’s neuroma; if pain is severe at rest, consider other diagnoses.

Sources

1. Thomson CE, Gibson JN, Martin D. “Interventions for the treatment of Morton’s neuroma.” Cochrane Database of Systematic Reviews. 2004;3:CD003118.
2. Kilmartin TE. “Sclerosant injection of Morton’s neuroma.” Foot & Ankle Surgery. 2013;19(4):249-255.
3. Hughes RJ, Ali K, Jones H, et al. “Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases.” American Journal of Roentgenology. 2007;188(6):1535-1539.