Mikael Sveen and Tony Kearns

PT II Presentation 8/11/06
Dr. St. Claire

MORTON'S NEUROMA
Definition:
Focal fibrous enlargement of the interdigital nerve commonly found in the web space
between the 3rd and 4th metatarsal heads. It is important to note that
Morton's
neuroma is NOT actually a neuroma, but a perineural fibrosis.
Neuroma--A tumor arising in nerve cells; benign growth originating on a nerve
Perineural Fibrosis--Excessive scar formation surrounding a nerve
Pathophysiology:
Interdigital nerves are composed of communicating branches from the lateral and
medial plantar nerves. At the level of the metatarsal heads, the interdigital nerve passes
inferior to the intermetatarsal ligament. At this site, the nerve may be
compressed or
stretched from repetitive movements, such as toe flexion and extension.
Incidence:
-Female to male: 5:1
-Age: 15-50
-Athletes: runners,
-Biomechanical stresses: hyperpronation, bunions and/or callus formation caused
by conditions such as hallux valgus and gastrocnemius-soleus flexibility
-Ambulatory people with tight, ill-fitting shoes (i.e.: narrow toe box), which puts
abnormal pressure on toes, specifically metatarsal heads
-Inflammatory conditions such as RA and gout
Clinical Presentation:
-Patient complains of sharp, burning pain on the sole of the foot.
-Onset is insidious
-Pain is often intermittent, but may be associated with occasional numbness
-Patient reports less pain when barefoot and/or non-weight bearing
-Patient may often describe a feeling of "walking on a marble"
Physical Exam:
-Palpation: Not always clinically significant. Pain may or may not be reproduced
during the physical exam. Most reports agree that the reproduction of pain
depends entirely on the patient's tolerance and severity.
-Orthopedic test: Squeeze test- squeeze around metatarsal heads which may
reproduce pain. Mulder's sign- passively extending first three metatarsal heads with
one hand and passively flexing the fourth and fifth metatarsal heads with the other hand,
producing a "click."
-Sensory deficits may be noted, but there are NEVER any motor deficits with
Morton's neuroma. If any motor problems present, the clinician must look for
differential diagnosis.
-Plantarflexion of the joints will relieve patient's pain.

-Special studies: x-ray (standing, A-P, lateral and oblique), MRI (T1 weighted image
in the coronal plane), and diagnostic ultrasound. Most research indicates that MRI is the
best imaging technique because of the
Treatments/Management:
-Forefoot mobilization: adjustments of the tarsal bones, MCP, PIP and DIP.
-Casted Orthotics
-Proper fitting shoes: soft-soled, low heeled, shoes with wide toe box
-Plantar pads under the metatarsal heads both medial and adjacent to the neuroma
-xylocaine injection
Physical Therapy:
-Cryotherapy--ice pack, submersion, or ice massage no longer than 20 minutes to
decrease the associated inflammation.
-Ultrasound--continuous at 1MHz for 8-15 minutes; 1.5-2.0 W/cm2
-TENS--5-20 minutes with pads placed over 1st & 5th metatarsal heads OR along
the plantar nerve (medial and lateral branches), to patient tolerance.
-Deep tissue massage--Graston, cross friction, etc
-MNS--5-20 minutes, 90-100 cps subthreshold, pad placement: 1st & 5th
metatarsal heads OR along the plantar nerve (medial and lateral branches).
-Iontophoresis--continuous smoothwave LVG for 5-20 minutes, 0.5-1.0 mamp/in2 of
active pad, reverse polarity for 60 sec. Possible ions to consider: hydrocortisone,
xylocaine, and iodine
-Phonophoresis-- may be used to drive cortisone (whole molecules) into tissues with the
intent of decreasing pain & inflammation
-Stretching/Strengthening Exercises-- stretch toe extensors, flexors, and plantar fascia
and strengthen gastroc and soleus. Patient may also benefit from additional
ankle
proprioceptive training.
Additional Treatments:
If all above conservative treatments fail to alleviate patient's symptoms, surgery must be explored
as the last option.
Works Cited:
1) Arnheim, D. and Prentice, William (2002). Principles of Athletic Training: A Competency Based
Approach. 11ed. Boston, MA: McGraw - Hill.
2) Prentice, William E. (1999). Therapeutic Modalities in Sports Medicine. 4th ed. Boston, MA: McGraw
Hill.
3) Souza, Thomas. (2005). Differential Diagnosis for the Chiropractor. 3rd ed. Sudbury, MA:
and Bartlett Publishers
4) St. Claire, Susan. (2005). Physiological Therapeutics.
5) Website(s):
http://www.mdia.com/medterm-footankle.html
http://www.wheelessonline.com/ortho/mortons_neuroma_interdigital_perineural_fibrosis
http://www.emedicine.com/pmr/topic81.htm
http://www.podiatrychannel.com/mortonneuroma/

Jones