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Morton's Metatarsalgia

Morton's Neuroma

Morton's metatarsalgia is a form of paroxysmal neuralgia affecting the third digital nerve of the foot, most commonly occurring in the middle-aged women.


Presentation

Isolated reports showed that up to a third of patients are asymptomatic [4], but in many individuals, pain originating from the nerves of the affected foot is present. The pain may be extreme enough to prevent patients from walking [1].

Toe Pain
  • Morton's neuroma is most commonly found in the forefoot with symptoms between the third and fourth toes. Pain is limited to the plantar (bottom) forefoot.[myfootshop.com]
  • Pain walking barefoot, burning into the toes, pain with running or jumping and the sensation of a rock in your shoe. In my clinic I treat and fix this condition on a regular basis. First I perform a thorough history and physical examination.[sdri.net]
  • Symptoms Symptoms typically include pain, often with pins and needles on one side of a toe and the adjacent side of the next toe.[sportsinjuryclinic.net]
  • Numbness or pain in the toes. Pain in the feet that worsens when barefoot.[actonfootandankle.com]
Wound Infection
  • Complications The most common complication results from wound healing, keloid formation, or superficial infection. 8 In one series, 1.1% of patients had a wound infection, while 2.2% had keloid formation over the scar. 8 Recurrent neuroma formation is[orthopaedicsone.com]
Chronic Fatigue Syndrome
Metatarsalgia
  • RESULTS: Morton's metatarsalgia admissions were almost three-fold higher for women in the population compared to men. The rate of admissions for Morton's metatarsalgia was the highest for the total population in the 55- to 59-year-old age group.[ncbi.nlm.nih.gov]
  • To confirm Morton's metatarsalgia, however, either ultrasonography or MRI can be performed and both procedures show very good results.[symptoma.com]
  • Abstract In an attempt to improve the accuracy of diagnosis, 16 patients suffering from Morton's metatarsalgia were investigated clinically and electrophysiologically. The histological findings were related to these observations.[ncbi.nlm.nih.gov]
  • Early metatarsophalangeal synovectomy for rheumatoid arthritis decreased in need of operations for Morton's metatarsalgia from 4.5 to 0.6 operations per year and can be recommended as a prophylactic procedure.[ncbi.nlm.nih.gov]
  • Of 50 patients in whom Morton's metatarsalgia was diagnosed during an 18-year period, 12 (24%) had rheumatoid arthritis at the time of presentation.[ncbi.nlm.nih.gov]
Foot Pain
  • Ball of Foot Pain with Normal Shoes Ball of Foot pain can also occur when wearing normal footwear, especially during long walks or standing for longer periods of time.[footminders.com]
  • It almost always affects other joints too, so foot pain will probably not be your only symptom. Wearing suitable footwear can reduce the strain on your joints.[haroldhillfootclinic.com]
  • Numbness is also possible in fingers and front of the foot. Pain will rise if wearing high heels or tight shoes.[physiobook.com]
  • Foot pain is the principal symptom and some patients may report excruciating pain that reduces their ability to walk normally.[symptoma.com]
  • But this article is not about hippies or STDs, it’s about foot pain, so let’s get back to walking barefoot.[acuroots.com]
Suggestibility
  • It is suggested that inflammatory changes in this bursa could account for the pathological and histological findings in this condition.[ncbi.nlm.nih.gov]
  • This suggests that the characteristic nodule and fibrotic changes seen in the interdigital nerves of patients with Morton's neuroma cannot account for the symptoms and that the changes seen in the neurovascular bundle are degenerative in origin and are[ncbi.nlm.nih.gov]
  • The evidence suggests that Morton's metatarsalgia is associated with rheumatoid arthritis and is the basic etiology in a significant number of patients.[ncbi.nlm.nih.gov]
  • Once the pain and swelling subsides, sports injury specialist will suggest strengthening exercises to regain lost strength of the arch of foot.[epainassist.com]
  • A review of the literature suggests that there are other causes of pain in the forefoot. Usually the pain is diffuse by when it is localized, Morton's metatarsalgia is diagnosed.[ncbi.nlm.nih.gov]

Workup

The diagnosis should be rather easily made, as a compression test of the foot can reveal the painful site and determine the affected web space [2]. To confirm Morton's metatarsalgia, however, either ultrasonography or MRI can be performed and both procedures show very good results [5].

Lymphocytic Infiltrate
  • Tissue from the web spaces of patients with classical Morton's metatarsalgia often shows lymphocytic infiltration, with additional fibrinoid necrosis of the bursal wall.[ncbi.nlm.nih.gov]
Fibrinoid Necrosis
  • Tissue from the web spaces of patients with classical Morton's metatarsalgia often shows lymphocytic infiltration, with additional fibrinoid necrosis of the bursal wall.[ncbi.nlm.nih.gov]

Treatment

Modification of footwear, injection of corticosteroids or local anesthetics and use of custom-made orthoses are conservative measures currently used to relieve symptoms of metatarsalgia [3] [6], but in severe cases, surgical neurectomy (with a maximal success rate of 83%) may be necessary to alleviate pain [3]. A significant difference between non-surgical and surgical approaches was not observed, however [1], and an individualized approach should be favored.

Prognosis

Patients present with a varying severity of symptoms, but pain may be so severe that is can markedly impair the quality of life, which is why early recognition of the disorder and appropriate treatment is necessary.

Etiology

The exact cause of Morton's metatarsalgia remains unknown, but various conditions have been described, including ischemia, bursitis, and chronic trauma [3]. The term Morton's neuroma is often used to erroneously suggest a neoplastic origin of the condition, but histological examinations have revealed the presence of inflammatory tissue and perineural fibrosis [6], implicating that other events are responsible for its development.

Epidemiology

A significant predilection toward middle-aged women was observed, presumably due to using inadequate footwear that induces substantial anatomical malformations of the foot [2] [6]. The exact prevalence rates in the population are unknown.

Sex distribution
Age distribution

Pathophysiology

Mechanically-induced neuropathy, occurring on the grounds of substantial disruption of the normal foot physiology by improper footwear, is the most probable pathogenesis model [2].

Prevention

Wearing appropriate footwear that provides comfort and maintains a regular anatomical position of the foot may be recommended as a preventive strategy.

Summary

Morton's metatarsalgia (also known as Morton's neuroma) is considered to be a mechanically-induced neuropathy of the foot, most likely involving the third digital nerve of the toes [1] [2]. The exact cause, however, is yet to be determined, as chronic trauma, ischemia and bursitis have been described in the pathogenesis as well [3]. The condition is most prevalent in middle-aged women wearing high heels, supporting the fact that mechanically-induced damage through wear of fashion shoes that are not in accordance with the physiological position of the foot results in this condition [2]. The clinical presentation ranges from the presence of few symptoms to a severely debilitating pain that impairs normal walking [4] [5]. A physical examination supported by ultrasonography or magnetic resonance imaging (MRI) is sufficient to make the diagnosis [3] [5]. Footwear modifications, use of orthoses, steroids or local anesthetics are conservative measures described in therapy [6], whereas neurectomy may be performed if all other modalities fail [3].

Patient Information

Morton's metatarsalgia is a condition that denotes the appearance of pain in the middle aspect of the foot, most commonly as a result of inadequate footwear and subsequent nerve compression and injury. The fact that the condition is most prevalent in middle-aged women who wear shoes with high heels that disrupt the normal anatomy of the foot, further supporting this theory. The exact cause and mechanism of disease, however, is yet to be determined, as other conditions such as bursitis, ischemia and trauma have been associated with Morton's metatarsalgia. Foot pain is the principal symptom and some patients may report excruciating pain that reduces their ability to walk normally. The diagnosis should be made during a regular physical examination, but either ultrasonography or magnetic resonance imaging can be used for confirmation. Treatment initially consists of conservative measures - footwear modification, use of local anesthetics and orthoses, while surgical procedures to remove damaged nerve tissue are performed as a last resort.

References

Article

  1. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma. Cochrane Database Syst Rev. 2004;(3):CD003118.
  2. Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. 2000;12(2):131-142.
  3. Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005;71(6):646-655.
  4. Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic? AJR Am J Roentgenol. 2000;175(3):649-653.
  5. Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol. 2015;25(8):2254-2262.
  6. Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013;6(4):307-317.

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Last updated: 2018-06-22 01:21