Examination: Morton’s Neuroma

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Who you are:
You are an FY2 in GP surgery.

Who the patient is:
Elaine Perasons aged 30 has presented with some concerns.

What you must do:
Talk and address concerns.

Patient indormation:

  • Dr I have pain in my left foot.
  • You are a distance runner athlete.
  • Pain in between the 3rd and 4th toe, gradual, dull pain, shooting pain, no radiation, worsened by running, severity 5/10 .
  • duration 2 months.
  • Effects: not been able to run well.
  • Otherwise well and fit .

Approach

GRIPS - SOCRATES for Pain

DDs

  • Stress fracture
  • Morton’s Neuroma
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Osteomyelitis

PMAFTOSA + ICE + EFFECTS

Examination:

  • Inspect, Palpate tenderness, Neurovascular status, Loss of sensation to affected toes, Palpate dorsalis pedis and posterior tibialis.
  • Joint movement, Perform Mulder’s Click = Grip the neuroma between the forefinger and the thumb - thumb on plantar aspect of the foot with the other hand squeeze simultaneously the metatarsal heads. A click can be felt and heard as the nerve stabilises between the metatarsal heads.
  • Findings: Tenderness +ve

Diagnosis

  • Thickening of the digital plantar nerve usually between the 3rd & 4th toe at the ball of the foot.
  • Mostly due to repetitive stress eg. wearing high heels, running, wearing constriction toe box shoes, shoes with thin soles.

Management

  • NSAIDs (Ibuprofen).
  • Advice to avoid high heels and shoes with constriction toe box or thin soles.
  • Advice to use metatarsal pad, pad should be placed just proximal to metatarsal heads.
  • Offer leaflet.
  • Explain that if symptoms may persist after 3 months, we will refer to specialist (orthotist).
    • The specialist may offer Orthotic device.
    • If orthotic device does not work, then you would refer to the orthopaedic surgeon for other treatments such as corticosteroids or alcohol injections and surgery.
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Morton’s Neuroma :foot:

What is Morton’s Neuroma?
A Morton’s neuroma is swelling and inflammation of a nerve that lies between two metatarsal bones (toes) of your foot. It causes pain in the ball of your foot and possibly your toes. This swelling causes thickening of the nerve tissue that surrounds the digital nerve that leads to the toes. It is usually found at the base of the third and fourth toes.
This condition can be exacerbated when wearing tight or high heeled shoes which can play a role in symptom cause and certainly make the symptoms worse. The lump (neuroma) is not dangerous, and will not cause problems other than in the foot. Occasionally people have Morton’s neuromas in both feet.

What causes it?

  • The nerves become trapped between the metatarsal bones causing pain. This is often
    due to ill-fitting footwear and the regular wearing high heeled shoes.

What kind of Symptoms do you feel?
The main symptoms of Morton’s neuroma include: ​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​
:point_right: A shooting, stabbing or burning pain.
:point_right:A feeling like a small stone is stuck under your foot.
:point_right:Some people may have tingling or numbness in their foot.
General Advice
Many of the problems above can be helped by addressing the factors below:
-:white_check_mark:It can sometimes be treated with simple measures such as comfortable shoes with a soft insole.
-:white_check_mark:Possible weight loss where appropriate as being overweight or obese increases stress on your foot and toe joints.
-:white_check_mark: Wear soft insoles and take simple pain tablets as guided by your GP or Chemist. Your chemist will be able to guide you regarding soft pads for your shoes (ask for metatarsal pads).

  • :white_check_mark:Conservative treatment brings people with Morton’ neuroma relief 80% of the time. Research has been shown that 41 percent of people who changed their footwear required no further treatment.
  • :white_check_mark:Recovery time can be variable depending on the severity of your Morton’s neuroma and the type of treatment you receive. For some people a change to wider shoes can give quick relief. Others may require injections and pain killers to get relief over time.
  • :white_check_mark:Surgery recovery times vary depending on the type of surgery required.
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