Physioinfo Article

Mortons Neuroma

Mortons Neuroma Description: Morton's Neuroma (MN) is a condition associated with the common plantar digital nerves, caused by entrapment of the nerve and repetitive traction underneath the deep transverse metatarsal ligament leading to epineural and perineural fibrous overgrowth Also known as Morton neuroma, Morton's metatarsalgia, Intermetatarsal neuroma and Intermetatarsal space neuroma, the benign neuroma or perineural neuroma most commonly affects the intermetatarsal plantar nerve of the second and third intermetatarsal spaces (between 2nd−3rd and 3rd−4th metatarsal heads), which results in the entrapment of the affected nerve. The main symptoms are pain and/or numbness, sometimes relieved by removing footwear. Mechanism of Injury: Some sources claim that entrapment of the plantar nerve because of compression between the metatarsal heads, as originally proposed by Durlacher and later Morton, is highly unlikely, because the plantar nerve is on the plantar side of the transverse metatarsal ligament and thus does not come in contact with the metatarsal heads. It is more likely that the transverse metatarsal ligament is the cause of the entrapment. Epidemiology: The onset of MN is usually between 45 and 50 years of age with women affected much more than men. Pain onset is often insidious. However neuromas can be present without clinical signs. One study reported neuromas present in 33% (19/57) of asymptomatic individuals. Differential Diagnosis: There are other causes of pain in the forefoot. Too often all forefoot pain is categorized as neuroma. Other conditions to consider are capsulitis, which is an inflammation of ligaments that surrounds two bones, at the level of the joint. In this case, it would be the ligaments that attach the phalanx (bone of the toe) to the metatarsal bone. Inflammation from this condition will put pressure on an otherwise healthy nerve and give neuroma-type symptoms. Additionally, an intermetatarsal bursitis between the third and fourth metatarsal bones will also give neuroma-type symptoms because it too puts pressure on the nerve. Freiberg's disease, which is an osteochondritis of the metatarsal head, causes pain on weight bearing or compression. Physiotherapy Intervention: Rest and massage, footwear and activity modification are the first line of conservative treatment. Manual therapy has been shown to be effective for pain resolution of symptoms, however there is little evidence to support this. Manual therapy is hypothesized to alter afferent nociceptive barrages, normalize sensori-motor mismatches, activate descending anti-nociceptive pathways. Therefore, utilizing manual therapy in case of pain seems appropriate. Extracorporeal Shockwave Therapy has been shown to be a potentially useful modality to reduce pain in patients with Morton's neuroma.