What is a Morton’s Neuroma?

Published on May 20, 2022

Foot pain can be debilitating and stop even active people in their tracks. This morning we’ll review Morton’s neuroma and how we treat that problem at Regenexx. Let’s dig in.

What is a Morton’s Neuroma?

The term neuroma means that there is swelling in a nerve. A Morton’s neuroma is swelling in the interdigital nerve of the foot. These travel between the bones called the meta-tarsals. When one of these nerves gets irritated, that can cause the sensation of walking on a pebble or more severe radiating pain that can be made worse by wearing tight-fitting shoes.

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What are the Treatments for Morton’s Neuroma?

The most common treatment for Morton’s neuroma is changing shoe type (i.e., avoiding high heels or shoes with a tight toe box), physical therapy, and/or activity restriction until the area is no longer painful. If that fails, then a steroid shot is often used, but the evidence that this is effective is of low quality, even though this is a common treatment (1). The other issue is that the results of steroid injections are commonly short-lived, and new research demonstrates that this type of therapy, in general, may lead to a higher likelihood of chronic pain (2). Alcohol injections to kill the nerve are also used. Finally, surgical excision of the interdigital nerve (neurectomy) is often performed if the problems persist. This procedure works 77% of the time, but 71% of patients still can’t wear the shoes they want even after the surgery (3,4). Complications are possible, including chronic pain due to nerve injury, infection, or foot numbness.

Is There a Different Treatment?

As already reviewed, blocking inflammation via a steroid shot is a common treatment for Morton’s Neuroma. However, recent research has demonstrated that this may lead to a higher likelihood of chronic pain due to the steroid medication killing off white blood cells that are needed to resolve inflammation and heal the area. Hence, what if the injection went the other way? Meaning instead of killing off local cells with a powerful anti-inflammatory, the goal was to improve the health of the nerve and regrow critical new blood vessels to the damaged nerve? That’s the goal of precise platelet-based injections around the injured nerve.

Ultrasound-guided hydrodissection is when the doctor uses sophisticated ultrasound imaging to precisely place a medication around the injured nerve. Research has shown this to be a cost-effective treatment for Mortons Neuroma (5). However, rather than injecting steroids, Regenexx clinics use the patient’s platelet-derived growth factors to help the nerve heal. These injections contain nerve growth factor and VEGF, a cytokine that can help build new blood vessels (14-18). While research on things like platelet-rich plasma on the interdigital nerve is still in the early stages, this treatment has been shown to be effective in multiple randomized controlled trials treating carpal tunnel syndrome, a similar condition in the wrist (6-13).

What does ultrasound-guided hydrodissection look like from the doctor’s perspective? Above is an example of what this procedure looks like around the median nerve.

A Runner’s Morton’s Neuroma Journey

Regenexx is a national provider network that uses interventional orthobiologics (aka interventional orthopedics). What does that mean? See my video below:

This patient treatment journey comes to us from Dr. Papas in Tampa. His patient was a 31 yo female long-distance runner who presented with wierd sensations in the 3rd and 4th toes. Initially, she noticed it when she would run more than 5 miles, so she saw a Podiatrist who diagnosed her with a Morton’s neuroma and treated her with steroid and Alcohol injections. These would help very briefly, and then she would return for more and more injections, eventually undergoing more than 20 procedures. Unfortunately, her condition worsened the more injections she received. By the time she presented to Dr. Papas, she couldn’t walk barefoot without severe pain. When he performed a hand-on exam, she had obvious atrophy of the muscles in the feet, likely due to the injections that she had received. Dr. Papas treated her with 3 rounds of ultrasound-guided platelet lysate injections around the Morton’s neuroma and physical therapy. After each round, she gradually increased her running tolerance, and the atrophy resolved completely.

The patient is now back to running and setting personal records. Recently, she ran all of the races at the Gasparilla fest, including the 5K, 8K, 15K, and Half Marathon – some of these were run back to back. She is back to being pain-free with long-distance running.

The upshot? Morton’s neuroma is a problem that can disable weekend warriors. Getting steroid or alcohol injected or surgery may not be the best option. Instead, our network is focused on procedures to help the nerve heal instead of damaging it or the surrounding tissues.

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References:

(1) Edwards SR, Fleming S, Landorf KB. Efficacy of a Single Corticosteroid Injection for Morton’s Neuroma in Adults: A Systematic Review. J Am Podiatr Med Assoc. 2021 Jul 1;111(4):Article_13. doi: 10.7547/20-151. PMID: 34478534.

(2) Parisien M, Lima LV, Dagostino C, El-Hachem N, Drury GL, Grant AV, Huising J, Verma V, Meloto CB, Silva JR, Dutra GGS, Markova T, Dang H, Tessier PA, Slade GD, Nackley AG, Ghasemlou N, Mogil JS, Allegri M, Diatchenko L. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022 May 11;14(644):eabj9954. doi: 10.1126/scitranslmed.abj9954. Epub 2022 May 11. PMID: 35544595.

(3) Poppler LH, Parikh RP, Bichanich MJ, Rebehn K, Bettlach CR, Mackinnon SE, Moore AM. Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis. Pain. 2018 Feb;159(2):214-223. doi: 10.1097/j.pain.0000000000001101. PMID: 29189515; PMCID: PMC5997533.

(4) Pace A, Scammell B, Dhar S. The outcome of Morton’s neurectomy in the treatment of metatarsalgia. Int Orthop. 2010 Apr;34(4):511-5. doi: 10.1007/s00264-009-0812-3. Epub 2009 May 30. PMID: 19484237; PMCID: PMC2903131.

(5) Ross AB, Jacobs A, Williams KL, Bour RK, Gyftopoulos S. Ultrasound-Guided Injection Treatments Versus Surgical Neurectomy for Morton Neuroma: A Cost-Effectiveness Analysis. AJR Am J Roentgenol. 2022 Feb;218(2):234-240. doi: 10.2214/AJR.21.26419. Epub 2021 Sep 15. PMID: 34523955.

(6) Senna MK, Shaat RM, Ali AAA. Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome. Clin Rheumatol. 2019 Dec;38(12):3643-3654. doi: 10.1007/s10067-019-04719-7. Epub 2019 Aug 16. PMID: 31420812.

(7) Shen YP, Li TY, Chou YC, Ho TY, Ke MJ, Chen LC, Wu YT. Comparison of perineural platelet-rich plasma and dextrose injections for moderate carpal tunnel syndrome: A prospective randomized, single-blind, head-to-head comparative trial. J Tissue Eng Regen Med. 2019 Nov;13(11):2009-2017. doi: 10.1002/term.2950. Epub 2019 Aug 20. PMID: 31368191.

(8) Shen YP, Li TY, Chou YC, Ho TY, Ke MJ, Chen LC, Wu YT. Comparison of perineural platelet-rich plasma and dextrose injections for moderate carpal tunnel syndrome: A prospective randomized, single-blind, head-to-head comparative trial. J Tissue Eng Regen Med. 2019 Nov;13(11):2009-2017. doi: 10.1002/term.2950. Epub 2019 Aug 20. PMID: 31368191.

(9) Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Huang GS, Chen LC. Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep. 2017 Dec;7(1):94. doi: 10.1038/s41598-017-00224-6. Epub 2017 Mar 7. PMID: 28273894; PMCID: PMC5427966.

(10) Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet-rich plasma ultrasound-guided injection in the treatment of carpal tunnel syndrome: A placebo-controlled clinical study. J Tissue Eng Regen Med. 2018 Mar;12(3):e1480-e1488. doi: 10.1002/term.2566. Epub 2017 Dec 17. PMID: 28873284.

(11) Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet-rich plasma ultrasound-guided injection in the treatment of carpal tunnel syndrome: A placebo-controlled clinical study. J Tissue Eng Regen Med. 2018 Mar;12(3):e1480-e1488. doi: 10.1002/term.2566. Epub 2017 Dec 17. PMID: 28873284.

(12) Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet-rich plasma ultrasound-guided injection in the treatment of carpal tunnel syndrome: A placebo-controlled clinical study. J Tissue Eng Regen Med. 2018 Mar;12(3):e1480-e1488. doi: 10.1002/term.2566. Epub 2017 Dec 17. PMID: 28873284.

(13) Chang CY, Chen LC, Chou YC, Li TY, Ho TY, Wu YT. The Effectiveness of Platelet-Rich Plasma and Radial Extracorporeal Shock Wave Compared with Platelet-Rich Plasma in the Treatment of Moderate Carpal Tunnel Syndrome. Pain Med. 2020 Aug 1;21(8):1668-1675. doi: 10.1093/pm/pnz309. PMID: 31774510.

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(16) Oudega M, Xu XM, Guénard V, Kleitman N, Bunge MB. A combination of insulin-like growth factor-I and platelet-derived growth factor enhances myelination but diminishes axonal regeneration into Schwann cell grafts in the adult rat spinal cord. Glia. 1997 Mar;19(3):247-58. doi: 10.1002/(sici)1098-1136(199703)19:3<247::aid-glia7>3.0.co;2-w. PMID: 9063731.

(17) Höke A, Sun HS, Gordon T, Zochodne DW. Do denervated peripheral nerve trunks become ischemic? The impact of chronic denervation on vasa nervorum. Exp Neurol. 2001 Dec;172(2):398-406. doi: 10.1006/exnr.2001.7808. PMID: 11716563.

(18) Kuffler DP, Reyes O, Sosa IJ, Santiago-Figueroa J. Neurological recovery across a 12-cm-long ulnar nerve gap repaired 3.25 years post trauma: case report. Neurosurgery. 2011 Dec;69(6):E1321-6. doi: 10.1227/NEU.0b013e31822a9fd2. PMID: 21712738.