Morton's Neuroma: Diagnosis & Treatment

Morton's neuroma is a painful irritation and thickening of a small nerve in the ball of the foot, most often between the third and fourth toes. It can cause burning or shooting pain, tingling, numbness, or the feeling of walking on a pebble or a folded sock. Despite the name it isn't a true tumour. Treatment is normally introduced gradually: the first steps reduce pressure on the forefoot through footwear changes, activity modification and, where appropriate, a metatarsal pad or orthosis, with an injection considered if symptoms stay troublesome. Surgery is usually reserved for persistent pain that limits walking despite good non-operative treatment.

What is Morton's neuroma?

Morton's neuroma is not a tumour. The symptoms are thought to come from repeated irritation or compression of one of the plantar digital nerves, the small nerves that run to the toes, beneath the ligament connecting the metatarsal bones. Over time the nerve thickens and becomes painful, typically in the space between the third and fourth toes, though the second and third web space can also be affected.

Confirming the diagnosis

Morton's neuroma is usually diagnosed from the history and examination. Typical features include:

• burning or shooting pain in the ball of the foot;
• pain spreading into the adjacent toes;
• tingling or numbness;
• a feeling of walking on a pebble or a folded sock;
• symptoms that worsen in tight, narrow or high-heeled shoes;
• relief after removing the shoe or massaging the foot.

Other conditions can cause similar symptoms, including metatarsalgia, intermetatarsal bursitis, a plantar-plate injury, arthritis, a stress injury or nerve irritation elsewhere in the foot. An ultrasound scan can help confirm the diagnosis, assess the surrounding structures and guide an injection; MRI is occasionally useful when the diagnosis is uncertain or another condition is suspected. Scan findings are always read alongside the symptoms, because an enlarged nerve can sometimes be present without causing pain.

First-line: footwear, pads and activity

Reducing pressure around the irritated nerve is usually the most useful place to start.

Footwear

Reducing compression of the forefoot is usually the most practical first step. Helpful footwear generally has a wide, deep toe box with room for the toes to spread, a low heel, a cushioned sole, secure fastening so the foot doesn't slide forward, and enough space for a metatarsal pad or orthosis. Narrow, pointed shoes and high heels increase pressure under the forefoot and commonly aggravate symptoms, a wider shoe should give space across the ball of the foot, not just extra length. The trial evidence is limited, but a clear improvement after changing shoes is also useful information about how much mechanical compression is driving the pain.

Activity modification

A complete stop to activity is rarely needed. The aim is to reduce the activities that repeatedly reproduce the nerve pain while keeping your general fitness. During a flare it can help to temporarily reduce running, jumping or prolonged walking, avoid barefoot walking on hard surfaces, swap high-impact exercise for cycling or swimming, take breaks before the pain builds, and rebuild activity gradually as symptoms settle. Persistent numbness, worsening symptoms, or pain even without weight-bearing should prompt a reassessment.

Metatarsal pads and orthoses

A metatarsal pad spreads the metatarsal heads and reduces pressure around the painful web space. It sits just behind the ball of the foot, not directly under the painful spot, correct positioning matters, because a pad placed too far forward can make things worse. A prefabricated insert may be enough, though a podiatrist can provide a more tailored orthosis when foot shape, altered loading or another forefoot problem is involved. Evidence for any particular design is limited, so comfort and your symptom response matter more than choosing an insert simply because it's expensive or custom-made.

Exercises and rehabilitation

Exercise doesn't remove the thickened nerve, but it can help with stiffness, strength or movement patterns that increase forefoot loading. A programme might include calf stretching if ankle movement is restricted, gentle toe and forefoot mobility, foot-intrinsic muscle work, balance and lower-limb control, a graded return to walking or running, and a review of running technique or training load where relevant. Exercises shouldn't repeatedly reproduce sharp, burning or electrical pain into the toes, rehabilitation should complement pressure reduction rather than force the irritated nerve through painful loading.

Evidence: limited trial data, but reducing forefoot pressure is a sensible, low-risk first step

Pain-relieving medication

Simple pain relief or a short course of anti-inflammatory medication may be appropriate when medically suitable, though these don't remove the mechanical pressure on the nerve. Oral anti-inflammatories aren't right for everyone, kidney disease, previous stomach ulcers, cardiovascular disease, anti-inflammatory-triggered asthma, anticoagulants and other medicines all need to be considered. Medication is best used to support comfortable activity while the footwear and loading factors are addressed.

Corticosteroid injection

A local injection may be considered when symptoms stay troublesome despite appropriate footwear changes, pressure relief and activity modification. It usually contains local anaesthetic with corticosteroid. Some people get useful short-term relief, but the response varies and symptoms can return.

The 2024 Cochrane review included six randomised trials (373 participants) and found low-certainty evidence that adding corticosteroid to local anaesthetic may give little or no extra improvement in pain or function at three to six months compared with local anaesthetic alone. So a steroid injection is an option rather than a guaranteed next step, and it's best considered in the context of your symptom severity, how confident the diagnosis is, previous treatment and your own preference. The potential side-effects are usually minor:

• a temporary increase in pain;
• a change in skin colour;
• thinning of the skin;
• loss or thinning of the protective fat pad under the forefoot;
• infection, which is rare;
• a temporary rise in blood glucose in people with diabetes.

Repeated injections are approached cautiously, because the benefit may lessen and local tissue effects become more of a concern.

Does ultrasound guidance help?

Ultrasound lets me identify the interdigital nerve, tell it apart from an adjacent bursitis, and watch the needle during treatment. The 2024 Cochrane review found moderate-certainty evidence that an ultrasound-guided steroid-and-local-anaesthetic injection probably reduces pain and improves function compared with a non-guided injection, though this rested on only two small studies, so the size and durability of the benefit are still uncertain. (An earlier randomised trial of 45 feet found both guided and non-guided injections improved pain with no significant difference at 12 months, while a later trial favoured ultrasound.) Ultrasound guidance is therefore reasonable when available, and particularly useful if the diagnosis is uncertain, a bursitis or another problem may coexist, the neuroma is small or hard to localise, a previous injection failed, or precise placement matters. A carefully performed landmark injection remains an option when the diagnosis is clear and the clinician is experienced.

Evidence: ultrasound-guided injection probably improves outcomes; steroid may add little over local anaesthetic alone

Alcohol and other injections

Alcohol injections aim to produce a controlled chemical injury to the painful nerve. Some observational studies report improvement, but protocols vary a lot in alcohol concentration, number of injections and timing, and good comparative evidence is lacking. Possible problems include considerable post-injection pain, inflammatory neuritis, damage to nearby tissue and incomplete or temporary relief, so alcohol injection shouldn't be presented as a proven alternative to surgery.

Other proposed treatments include hyaluronic acid, capsaicin, botulinum toxin, platelet-rich plasma, radiofrequency ablation, cryoablation and shockwave therapy. The evidence for these is limited, with few high-quality trials, a 2024 review of injection treatments found some promising signals but concluded that options such as alcohol and hyaluronic acid need further research. These are best regarded as specialist options rather than routine first-line care, and I don't currently offer PRP at Insight MSK. Before choosing any of them, it's worth discussing the quality of the evidence, how long the benefit might last, the risks, the cost, and what would come next if symptoms persisted.

Evidence: limited, specialist options rather than routine care

When is surgery considered?

Surgery may be considered when the diagnosis is reasonably secure, pain keeps limiting walking, work or important activities, appropriate footwear and pressure-relieving measures have failed, injection treatment has failed or isn't wanted, and the expected benefits outweigh the recovery and risks. There are two main operations:

• Neurectomy: the affected section of nerve is removed. This usually leaves a permanently numb patch between the involved toes, the numbness is often preferable to the original pain, but it should be understood beforehand.
• Decompression (neurolysis): the structures compressing the nerve are released while the nerve itself is preserved. This may avoid deliberate numbness, though symptoms can persist and a later neurectomy may still be needed.

A systematic review of mainly observational evidence reported complete pain relief in roughly 74% after neurectomy and 68% after neurolysis, compared with about 43% after injection, though these figures should be read cautiously because the studies varied and weren't high-quality direct comparisons. Potential complications include persistent or recurrent pain, permanent numbness, a painful stump neuroma, scar tenderness, infection or wound-healing problems, swelling and forefoot stiffness, uncommonly complex regional pain syndrome, and sometimes the need for further surgery. Operations can be done through the top or the sole of the foot, and a 2024 review didn't establish one approach as universally better, the choice depends on the surgeon's technique, the location of the lesion, and the balance between early weight-bearing and a possibly sensitive plantar scar. Recovery takes time, and swelling can persist for several months even once the nerve pain has improved.

Evidence: more durable relief than injection for refractory cases, but with trade-offs

A practical treatment pathway

Rather than jumping to any single treatment, I work through a stepwise plan:

1. Confirm the symptoms fit Morton's neuroma and exclude other causes of forefoot pain.
2. Change to wide, low-heeled and adequately cushioned footwear.
3. Temporarily modify the activities that repeatedly provoke burning or shooting pain.
4. Trial a correctly positioned metatarsal pad or a suitable orthosis.
5. Address relevant ankle stiffness, strength or loading factors with tailored rehabilitation.
6. Use ultrasound when the diagnosis is uncertain or another forefoot condition is suspected.
7. Consider an injection if symptoms remain intrusive despite appropriate initial treatment.
8. Use ultrasound guidance when accurate placement is difficult or clinically important.
9. Discuss the uncertain benefits and risks before choosing alcohol, ablation or another specialist procedure.
10. Seek a surgical opinion if persistent pain continues to limit walking and daily life despite comprehensive non-operative care.

Key message

Frequently asked questions

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