It is caused by irritation of the digital nerve between the 2nd, 3rd, or 4th metatarsal bones. At this level, the nerve divides into two branches that provide sensation to the toes. The nerve runs beneath the intermetatarsal ligament between the heads of two adjacent metatarsals. During walking, the nerve is either compressed between the metatarsal heads or against the ligament, producing pain that can radiate across the entire forefoot.
Diagnosis of Morton’s syndrome is mainly clinical in typical cases. Treatment is initially conservative if the symptoms are recent, and surgical if conservative therapy fails or if there is a nerve swelling (Morton’s neuroma). The term “neuroma” refers to a benign swelling of a nerve. In reality, continuous irritation causes thickening of the surrounding tissues (fibrosis) around the nerve. This perineural fibrosis forms what is known as Morton’s neuroma.
Therefore, when we specifically refer to Morton’s neuroma, we are talking about perineural fibrosis.
Several risk factors have been identified, including hallux valgus, hammertoe, flatfoot or high-arched foot, tight or high-heeled shoes, and neurological disorders.
The main symptom of Morton’s neuroma is pain, which may be very intense. It most often occurs between the 3rd and 4th toes (75% of cases) and less commonly between the 2nd and 3rd toes.
This pain, often described as an electric shock, worsens during walking, especially when wearing tight shoes, and subsides when the shoes are removed.
Morton’s syndrome may also present with sensory disturbances, such as numbness, tingling, cramps, or burning in the forefoot.
More rarely, Morton’s neuroma can cause pain while driving, a foreign body sensation, or the impression of walking on pebbles.
Removing shoes often brings immediate relief, as does mobilization of the toes, which is a constructive diagnostic sign. A local foot massage can also help alleviate pain.
The diagnosis is primarily clinical, based on provoking pain during specific maneuvers such as applying pressure over the metatarsal heads or the intermetatarsal space. Loss of sensation between the affected toes is also common.
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Suspicion of Morton’s syndrome should be confirmed before any treatment is initiated. Simple weight-bearing X-rays are recommended to exclude other pathologies. MRI is the gold standard, as it allows easy diagnosis and precise localization of Morton’s neuroma, although the absence of findings does not rule it out.
The treatment of Morton’s neuroma is mainly conservative, using orthopedic insoles that elevate the metatarsal heads, thereby increasing the space and decompressing the nerve. These insoles must be thin so they do not overcrowd the shoe. Wearing wide shoes and avoiding high heels is also recommended. In the acute phase, rest and reduced physical activity (long walking or running) are advised.
Local corticosteroid injections into the painful intermetatarsal space can provide significant long-term relief in mild cases. However, if a large neuroma is present, injections are usually ineffective.
If conservative treatment fails, surgery is required to remove the neuroma. Through a small dorsal incision between the metatarsal heads, the space around the nerve is released, and the pathological tissue is excised. If there are abnormalities of the metatarsal heads, this may be combined with metatarsal osteotomies. After surgery, walking with a special shoe is permitted, and full return to activity is usually possible after about four weeks.
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