Physiotherapy for Morton's Neuroma

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Introduction[edit | edit source]

Civinini Morton’s Syndrome (CMS) is more commonly known as Morton’s neuroma. Interdigital neuritis is another term that was proposed by Weinfield and Myerson[1] which more correctly describes the pathology of this condition. The presence of inflammatory tissue in histological examination justifies description of Morton's neuroma as perineurial fibrosis. Pain and abnormal forefoot sensation are clinical symptoms that helps with the diagnosis. Conservative treatment including lifestyle adjustment may not always be effective and patient can choose surgery or various types of ultrasound guided percutaneous injections as an option.

Clinically Relevant Anatomy[edit | edit source]

Magnetic resonance imaging (MRI) shows the medial and lateral plantar nerves arising from the posterior tibial nerve. [2] The tibial nerve terminates in the foot by giving branches to medial and lateral plantar nerves. This bifurcation occurs inside the retinaculum or proximal to the flexor retinaculum. [3] The two plantar nerves penetrate the tunnel made of the deep fascia of the abductor hallucis muscle and the fibrous septum connecting the fascia to the bone. [3]

The medial plantar nerve (MPN) is the larger of the two plantar nerves. It originates under the laminate ligament, passes between abductor hallucis muscle and flexor digitorum brevis. Upon reaching the bases of the metatarsal, it divides into three common digital plantar nerves.[4]MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the first lumbrical.

The lateral plantar nerve (LPN) innervates abductor digiti minimi muscle, flexor digiti minimi brevis muscle, quadratus plantae, 3 lateral lumbricals of the foot, adductor hallucis muscle, plantar interossei muscles, and dorsal interossei muscles.

The common plantar digital (CPD) nerves pass under the intermetatarsal ligaments, go through the plantar aponeurosis and divide into 2 branches supplying the plantar skin of the toes. Smaller portions of the CPD nerves innervate the adjacent metatarsals, metatarsophalangeal joints and plantar skin, under the metatarsal heads. [5]The third common digital nerve begins as the medial plantar nerve and receives a communicating branch from the lateral plantar nerve. Because it passes in the narrow space deep to the transverse metatarsal ligament it becomes less mobile, especially during weight bearing activities.

The branches of the common digital nerve in the third planter webspace are most commonly affected. The location of this nerve near the narrow space of the transverse metatarsal ligament may be a possible explanation for the development of the Morton's Neuroma pathology within the third intermetatarsal space.[5]

Neuroma[edit | edit source]

Neuroma is also referred as pinched nerve. Morton's neuroma is a compressive neuropathy of the common plantar digital nerve caused by an entrapment of the nerve between the intermetatarsal ligaments.

Aetiology[edit | edit source]

There are several aetiopathogenetic theories behind the development of Morton's neuroma. It include:

  • chronic traction damage[6]
  • chronic, repetitive trauma [6]
  • ischemia of vasa nervorum[5][6]
  • entrapment or mechanical compression [7][8]
  • inflammation due to intermetatarsal bursitis [7]

One of the theory explaining the occurrence of Morton's neuroma is based on the notion that the third common digital nerve is thicker than the others as the result of an anastomosis between two nerve trunks. The inflammation theory is explained by the increased mobility of the fourth ray compared to the third.[5]The compression theory is based on the finding that the plantar nerve is compressed by the distal metatarsal transverse ligament.[7]

Epidemiology[edit | edit source]

Morton's neuroma is characterised by female predominance, with a female to male ratio of 5:1. [5] It affects about 30% of the population, an average patient's age is 50, the pathology affects both feet, in most cases the third intermetatarsal space is involved, followed by the second (Hauser’s neuroma). [9]Multiple locations are very rare. [5]

Mechanism of Injury / Pathological Process[edit | edit source]

The most frequently mechanism of injury supported by the literature is nerve entrapment. [8] The third common digital nerve is thicker as a consequence of fusion between the medial and lateral plantar nerves. This leads to its entrapment by the surrounded ligament. [8] Entrapment neuropathy is causing perineural fibrosis and nerve degeneration. [8]The thickening of the nerve progresses as a result of vascular hyalinisation which causes more trauma to the nerve and more entrapment. Adding to the pathological process is the use of high heel shoes forcing the excessive forefoot weight bearing.

Clinical Presentation[edit | edit source]

There are two types of clinical presentation in Morton's neuroma: clinically symptomatic and clinically asymptomatic.

Clinically symptomatic Morton's neuroma presents with the following symptoms:[8]

  • Pain or paresthesias in the intermetatarsal region, toes, and the dorsal web space. Pain is worsened by weight-bearing or the use of high-heeled shoes. Removing shoes and gentle massaging the forefoot usually relief the pain.
  • Pain is usually sharp, and can become debilitating to the point that the patients is afraid and anxious about walking or even putting their foot to the ground.[5]
  • Patient can complain of burning sensation in the intermetatarsal spaces[10]
  • Mass can be palpated
  • Symptoms can be present as a result of trauma
  • Altered sensation described as “pebble in the shoe”[11]
  • Pain is worsen with walking or running[11]

Presence of the hallux valgus is considered a predisposing factor in development of Morton's neuroma. [11]

Diagnostic Tests[edit | edit source]

Diagnostic Procedures[edit | edit source]

  • Ultrasound (US): high diagnostic accuracy. Technique and experience of a person performing the test are extremely important to make a proper diagnosis. [5][9]
  • Magnetic resonance imaging (MRI): the gold standard investigation to identify a neuroma. [11]Primary indications for MRI are unclear clinical assessment and cases when more than one intermetatarsal space (IMS) is affected. [5]
  • X-rays: essential as a first line imaging approach, to rule out tarsal–metatarsal joint stiffness, metatarsal hypermetria, Frieberg’s disease, toe deformities and MTP instabilities.

Differential Diagnosis[edit | edit source]

The differential diagnosis includes the following conditions:[8]

  • Intermetatarsal bursitis
  • True neuroma
  • Inflammatory arthritis
  • Pigmented villonodular synovitis
  • Osteomyelitis
  • Foreign body granuloma
  • Stress fracture
  • Freiberg's infraction
  • Metatarsophalangeal joint dislocation.

Physiotherapy Management / Interventions[edit | edit source]

Footwear[edit | edit source]

Goal: To limit the nerve compression in early stages of Morton's neuroma

Tools: patient's education, footwear modification

According to the study [5], after 4.5 months since the diagnosis and when neuroma is larger than 5-6 mm, orthotics and/or shoes modifications are no longer effective in symptoms management. They can, however, offer a palliative solution to better manage person's life with pain.[5]

Patient Education[edit | edit source]

Patient to be educated on :

  • avoiding narrow and high-heeled shoes
  • staying compliant with footwear prescription
  • activity modification[14]

Footwear modification[edit | edit source]

The most appropriate footwear should have the following design:[5][15]

  • sufficiently long[5]
  • wide toe box[5]
  • low heel[5]
  • thick external sole which should not be excessively flexible[5]
  • metatarsal padding[15]
  • A rocker-bottom sole may be helpful[16]

Orthotics[edit | edit source]

Goal:

  1. To displace the pressure sites
  2. To provide pain relief
  • The most common orthotics that is provided initially is metatarsal bar. Its purpose is to:
    • spread the heads of the metatarsals to relieve pressure
    • improve symptoms
  • Limited to no evidence of improvement in patient reported outcomes with the use of inversion or eversion insoles (varus/valgus foot wedge). [11]
  • According to de Oliveira et al [17], customised insole with metatarsal and arch support offers pain relief during ambulation and improve function. [17]
  • Custom-made toe inserts modeled in silicone rubber can be added when claw-toe deformity is present. [8]
  • Custom orthotics through foam impression methods. Foot is placed in a neutral subtalar position, with a prolonged longitudinal vault to support the first metatarsal (flat support). Goal: to mimic the physiological pattern of the metatarsal weight bearing, from lateral to medial , before the pressure on the big toe. [5]

Steroid Injections[edit | edit source]

Goal: to provide pain relief

In the management of Morton's neuroma, the use of steroid injections is quite common. The method of injection vary: it is guided by ultrasound or using a landmark technique.

  • Mahadevan et al [18]based on radomised control trial found no statistical difference in patient outcomes after a steroid injection using ultrasound or without.
  • Choi and colleagues[19]demonstrated a satisfactory clinical outcome in pain reduction after corticosteroid injections, but 30% of patient eventually required a surgery for pain management.
  • Lizano-Diez et al[20]found no difference in pain and function between the injection of a corticosteroid plus a local anesthetic versus local anesthetic only.

Modality[edit | edit source]

Manipulation/Mobilisation[edit | edit source]

According to Cashley and Cochrane [22]foot manipulation and mobilisation of other foot and ankle joints can decrease foot pain in patients diagnosed with plantar digital neuralgia (Morton's neuroma). The authors recommend to perform joint manipulation once a week for four weeks followed by two more visits at 14-day intervals. [22]

Strengthening Exercises[edit | edit source]

According to Simpson [14], strengthening exercises for toe flexors and the intrinsics can help with muscle activation during mid stance of gait cycle and prevent the metatarsal heads from dropping.

Other treatment option[edit | edit source]

A surgery is considered when conservative treatment fails or the patient is no longer willing to adjust their lifestyle to manage symptoms of Morton's neuroma. The following operative and non-operative treatment options are available:

  • Surgical nerve excision (neurectomy)[23]
  • Surgical nerve decompression[24]
  • US guided percutaneous radiofrequency
  • Alcohol injection
  • Percutaneous electrostimulation-guided alcoholization with phenol[8]

Resources[edit | edit source]

  1. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis
  2. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art
  3. Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard

References[edit | edit source]

  1. ↑ Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Nov;4(6):328-335.
  2. ↑ Govsa F, Bilge O, Ozer MA. Anatomical study of the communicating branches between the medial and lateral plantar nerves. Surgical and Radiologic Anatomy. 2005 Dec;27(5):377-81.
  3. ↑ 3.0 3.1 Torres AL, Ferreira MC. Study of the anatomy of the tibial nerve and its branches in the distal medial leg. Acta ortopedica brasileira. 2012;20:157-64.
  4. ↑ Koo GB, Lee JH, Jang JH, Song IH, Kim JY. Superficial course of the medial plantar nerve: case report. Anatomy & cell biology. 2019 Mar 1;52(1):87-9.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art. Acta Biomed. 2020 May 30;91(4-S):60-68.
  6. ↑ 6.0 6.1 6.2 Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005 Dec;71(6):646-55.
  7. ↑ 7.0 7.1 7.2 Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013 Aug;6(4):307-17.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic?. American journal of roentgenology. 2000 Sep;175(3):649-53.
  9. ↑ 9.0 9.1 Mak MS, Chowdhury R, Johnson R. Morton's neuroma: review of anatomy, pathomechanism, and imaging. Clinical Radiology. 2021 Mar 1;76(3):235-e15.
  10. ↑ Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic Accuracy of Clinical Tests for Morton's Neuroma Compared With Ultrasonography. J Foot Ankle Surg. 2015 Jul-Aug;54(4):549-53.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Bhatia M, Thomson L. Morton’s neuroma–current concepts review. Journal of Clinical Orthopaedics and Trauma. 2020 May 1;11(3):406-9.
  12. ↑ Skalina T, Weerakkody Y. Mulder sign. Reference article, Radiopaedia.org. Available from https://radiopaedia.org/articles/mulder-sign (accessed on 14 Oct 2022)
  13. ↑ Cashley DG, Cochrane L. Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases. J Chiropr Med. 2015 Jun;14(2):90-8
  14. ↑ 14.0 14.1 14.2 Simpson H. Morton's Neuroma Course. Plus 2022
  15. ↑ 15.0 15.1 Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. J Foot Ankle Res. 2019 Feb 13;12:12
  16. ↑ Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008 Mar;16(3):152-8.
  17. ↑ 17.0 17.1 de Oliveira HAV, Natour J, Vassalli M, Rosenfeld A, Jennings F, Jones A. Effectiveness of customized insoles in patients with Morton's neuroma: a randomized, controlled, double-blind clinical trial. Clin Rehabil. 2019 Dec;33(12):1898-1907.
  18. ↑ Mahadevan D, Attwal M, Bhatt R, Bhatia M. Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial. Bone Joint J. 2016 Apr;98-B(4):498-503.
  19. ↑ Choi JY, Lee HI, Hong WH, Suh JS, Hur JW. Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review. Clin Orthop Surg. 2021 Jun;13(2):266-277.
  20. ↑ Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton's Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot Ankle Int. 2017 Sep;38(9):944-951.
  21. ↑ 21.0 21.1 Seok H, Kim SH, Lee SY, Park SW. Extracorporeal Shockwave Therapy in Patients with Morton's Neuroma A Randomized, Placebo-Controlled Trial. J Am Podiatr Med Assoc. 2016 Mar;106(2):93-9.
  22. ↑ 22.0 22.1 Cashley DG, Cochrane L. Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases. J Chiropr Med. 2015 Jun;14(2):90-8.
  23. ↑ Samaila EM, Ambrosini C, Negri S, Maluta T, Valentini R, Magnan B. Can percutaneous alcoholization of Morton's neuroma with phenol by electrostimulation guidance be an alternative to surgical excision? Long-term results. Foot Ankle Surg. 2020 Apr;26(3):314-319.
  24. ↑ Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot & Ankle Specialist. 2013 Aug;6(4):307-17.
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