Morton's neuroma, often involving the common digital nerve between the third and fourth metatarsal heads, is a painful condition characterized by the thickening of tissue around the nerve. This results in sharp, burning pain and significant discomfort in the affected area. This condition can be exacerbated by tight footwear or repetitive stress, so proper diagnosis and treatment are essential for relief. Morton’s neuromas are relatively common, with experts estimating that approximately 1 in 3 people will experience a Morton’s neuroma at some point in their life (Cleveland Clinic).
Recommended Approach:
Our recommended approach for treating Morton’s Neuroma involves a combination of cortisone injections (if needed), manual therapy, acupuncture, and a functional exercise program. This integrated approach often achieves significant results, with success rates exceeding 80%, and is far more effective at avoiding surgery than relying on any single treatment modality alone.
Article Index:
Introduction
Symptoms and Causes
Patients often describe symptoms as a burning or sharp pain in the forefoot, with possible tingling or numbness in the toes. These symptoms are typically exacerbated by walking or wearing tight shoes.
Biomechanical Causes:
Footwear: High-heeled or narrow shoes increase pressure on the forefoot, exacerbating nerve compression.
Foot Deformities: Conditions like bunions, hammertoes, flat feet, or high arches disrupt normal foot mechanics, increasing stress on the interdigital nerves.
Repetitive Stress: High-impact activities, such as running, place continuous stress on the forefoot, contributing to neuroma development.
Diagnosis
The diagnosis is primarily clinical, involving a physical examination in which the healthcare provider may elicit a clicking sensation and pain by squeezing the metatarsal heads together (Mulder’s sign). Imaging techniques like ultrasound or MRI can confirm the diagnosis and rule out other conditions.
Combining Therapies for Better Outcomes
Cortisone Injections:
Cortisone injections provide anti-inflammatory relief directly at the site of the neuroma. This can quickly reduce pain and swelling, though the effects are typically temporary, lasting a few weeks to a few months.
Manual Therapy:
Manual therapy, including joint mobilization and manipulation, can alleviate pain by redistributing pressure and enhancing proprioception. These techniques can help normalize foot mechanics and reduce nociceptive inputs, thus providing symptomatic relief. (Nociceptive inputs are signals sent to the brain when your body detects potential harm or injury, which can cause the sensation of pain.)
Acupuncture:
Acupuncture modulates inflammation and pain by stimulating specific acupoints, influencing immune responses and neuroplasticity. It can be an effective adjunct treatment, particularly for managing chronic pain associated with neuromas.
Exercise Therapy:
Strengthening and stretching exercises improve foot stability and function. Exercises targeting the toe flexors and intrinsic foot muscles, such as toe curls and calf stretches, help maintain proper foot mechanics and reduce stress on the neuroma.
Cortisone Injections: A Temporary Solution
Cortisone injections are a commonly used treatment for Morton's neuroma. They offer temporary relief by reducing inflammation around the affected nerve. The injections deliver a potent anti-inflammatory steroid directly to the site of pain, decreasing swelling and pressure on the nerve.
Effectiveness:
Research indicates that cortisone injections can offer rapid and significant pain relief for patients with Morton's neuroma. However, these effects are often temporary, lasting only a few weeks to several months. Studies suggest that approximately 30% of patients may eventually need more invasive treatments, such as surgery, as the benefits of injections wane over time. In my view, surgery should be considered a last resort only after more conventional treatments have been thoroughly explored.
It is also important to note that using the combination of injections, manual therapy, acupuncture, and exercise will lower the need for surgery in most cases. This multimodal approach addresses the underlying biomechanical issues, reduces inflammation, and enhances long-term pain management, potentially lowering the need for surgery to less than 10-20% of patients.
Risks and Limitations:
While cortisone injections can be highly effective in the short term, they are not without risks. Potential side effects include:
Fat Atrophy: Repeated injections can cause the fat pad in the foot to thin, reducing natural cushioning and potentially causing more pain.
Skin Depigmentation: In some cases, the skin around the injection site may lighten, particularly in darker skin tones.
Tissue Damage: Overuse of cortisone injections can weaken tendons and ligaments, increasing the risk of rupture or other injuries.
Guidelines for Use:
Cortisone injections should be used judiciously to minimize risks. It is generally recommended that no more than three injections per year be given in the same area. Ultrasound guidance can improve the accuracy of the injections, ensuring the medication is delivered precisely to the target area and thereby reducing the likelihood of side effects.
Cortisone injections can be a valuable component of a comprehensive treatment plan for Morton's neuroma, particularly for providing rapid pain relief. However, due to their temporary nature and potential risks, they are best used with other treatments, such as manual therapy, acupuncture, and exercise, to achieve more sustained and long-term improvements.
Manual Therapy: Addressing the Mechanical Aspect
Manual therapy encompasses a range of hands-on and instrument-assisted techniques to improve the function and mechanics of the foot's osseous (bone) and soft tissue structures. For Morton's neuroma, manual therapy can be highly beneficial in alleviating pain, improving mobility, and addressing the biomechanical imbalances contributing to the condition.
Osseous Manipulation:
Osseous manipulation involves techniques such as joint mobilization and manipulation that target the bones and joints of the foot. These techniques aim to:
Restore Joint Alignment: Proper metatarsophalangeal (MTP) joint alignment can reduce abnormal pressure on the interdigital nerve. Techniques such as dorsal and plantar glides of the MTP joints can help achieve this alignment.
Improve Joint Mobility: Mobilizing the foot joints can enhance overall foot function and reduce stiffness. This is particularly important for the metatarsal heads, where restricted movement can contribute to neuroma symptoms.
Redistribute Load: Osseous manipulation can help redistribute the load across the metatarsal heads by improving the alignment and mobility of the foot joints, decreasing pressure on the neuroma.
Soft Tissue Techniques:
Soft tissue techniques focus on the foot and lower leg muscles, tendons, and fascia. These techniques can include:
Myofascial Release: Treatment Systems such as MSR integrate multiple strategies to target and release tight fascia, reducing compression on the interdigital nerve.
Trigger Point Therapy: Identifying and deactivating trigger points in the foot and calf muscles can reduce referred pain and muscle tightness, which is common in neuroma cases.
Acupuncture/Acupressure: Stimulating specific acupoints can help relieve pain and improve circulation in the affected area. This technique, often integrated with other manual therapies, can relieve pain and support healing.
Instrument-Assisted Soft Tissue Mobilization (IASTM): Using instruments to apply precise pressure to the soft tissues can help improve fascial mobility and reduce neuroma-related pain.
Clinical Evidence:
Studies and clinical evidence support the use of manual therapy for managing Morton's neuroma. Manipulation and mobilization of the foot and ankle joints have been shown to decrease pain and improve function. Research indicates manual therapy significantly increases local pressure pain thresholds and enhances functional mobility. Additionally, acupuncture reduces inflammation and pain, while targeted exercises improve overall function and reduce discomfort. This comprehensive approach should be considered before surgical intervention is suggested, as it effectively manages symptoms in most cases.
Demonstration Video
Facial Expansion: MSR Foot Pain Protocol
Using fascial expansions to treat Morton's neuroma offers a holistic approach that integrates a modern understanding of fascia's role, kinetic chain relationships, and essential principles from acupuncture and traditional Chinese medicine.
This method links fascial lines with acupuncture points such as ST44, LV3, LV2, K3, and B60, creating a cohesive treatment plan. Combined with osseous manipulation and a functional exercise program, this comprehensive strategy addresses immediate pain and inflammation, enhances tissue mobility, reduces scar tissue, and helps restore optimal function to the foot and surrounding tissue.
Acupuncture: Enhancing Pain Management
Acupuncture, a key element of traditional Chinese medicine, is highly effective in managing pain and inflammation associated with Morton's neuroma. This therapy can modulate pain pathways, reduce inflammation, and promote healing by stimulating specific acupuncture points with needles, often enhanced with electrical stimulation. Whether a practitioner uses acupressure or acupuncture depends on their scope of practice, and both methods can be effective in the hands of an experienced practitioner.
Mechanism of Action
Acupuncture operates through multiple mechanisms:
Neurotransmitter Release: Acupuncture points can trigger the release of endogenous opioids, serotonin, and other neurotransmitters that help modulate pain.
Immune Modulation: Acupuncture can influence the activity of immune cells, thereby reducing local inflammation.
Blood Flow Enhancement: Increased local blood flow aids in the removal of inflammatory mediators and facilitates tissue repair.
Specific Acupuncture Points for Morton's Neuroma
Several acupuncture points on the foot and lower leg are particularly relevant for treating Morton's neuroma:
SP4 (Spleen 4 Gong Sun):
Location: On the medial side of the foot, in the depression distal and inferior to the base of the first metatarsal bone.
Function: Effective for addressing pain and inflammation in the foot, especially related to nerve issues.
LV3 (Liver 3 Tai Chong):
Location: On the dorsum of the foot, in the depression distal to the junction of the first and second metatarsal bones.
Function: LV3 is powerful for reducing neuroma-related discomfort. It is known for its ability to regulate Qi and alleviate pain. In Western medical terms, "regulate Qi and alleviate pain" means improving the flow of energy in the body and reducing pain through mechanisms such as enhancing blood circulation, modulating the nervous system, and reducing inflammation.
ST36 (Stomach 36 Zu San Li):
Location: On the anterior aspect of the leg, about four finger widths below the patella and one finger width lateral to the anterior crest of the tibia.
Function: It is commonly used to enhance overall pain management and immune response, indirectly benefiting conditions like Morton's neuroma.
GB34 (Gallbladder 34 Yang Ling Quan):
Location: In the depression anterior and inferior to the head of the fibula.
Function: The GB34 acupuncture point can help alleviate symptoms of Morton's neuroma by reducing inflammation, improving circulation, and relieving pain in the affected area.
K3 (Kidney 3 Tai Xi):
Location: In the depression between the medial malleolus and the Achilles tendon, level with the prominence of the medial malleolus.
Function: It helps nourish Kidney Yin and Yang, which is vital for overall nerve health and pain relief. In Western medical terms, "nourishing Kidney Yin and Yang" in Chinese medicine refers to balancing the body's fluid and energy levels, which can be understood as supporting overall hormonal balance, hydration, and metabolic functions to maintain homeostasis and optimal organ function.
ST44 (Stomach 44 Nei Ting):
Location: On the dorsum of the foot, between the second and third toes, in the web margin.
Function: ST44 is particularly effective for clearing heat and alleviating pain, making it useful for reducing the inflammatory aspects of Morton's neuroma. In Western medical terms, "clearing heat and alleviating pain" refers to reducing inflammation and relieving pain, often through mechanisms that lower body temperature and reduce inflammatory responses.
Clinical Evidence
Research supports the efficacy of acupuncture in managing neuropathic pain, including that associated with Morton's neuroma. Studies have shown that acupuncture can significantly reduce pain levels and improve function by modulating inflammatory responses and enhancing endorphin release.
Exercises for Long-term Relief
In managing Morton's neuroma, incorporating a well-rounded exercise regimen is crucial for achieving long-term relief and preventing recurrence. Exercise therapy focuses on improving mobility, reducing tension through myofascial release, and strengthening the intrinsic and extrinsic muscles of the foot. This section will highlight three key types of exercises, each supported by a video demonstration for optimal learning and implementation.
Mobility Exercises (Stretching)
Mobility exercises are essential for maintaining foot flexibility and reducing tension in the surrounding structures. They help enhance the range of motion, which can alleviate pressure on the neuroma and improve overall foot function.
Best Foot Mobility Exercises
The foot is a complex structure comprising 26 bones, 33 joints, and over 100 muscles, tendons, and ligaments. Its arches act as shock absorbers, distributing the forces of all weight-bearing activities.
Myofascial Release
Myofascial release techniques target the fascia and soft tissues of the foot and lower leg to reduce tension and improve tissue flexibility. This approach can help decrease the compression on the interdigital nerve, providing symptomatic relief for Morton's neuroma.
Self Myofascial Release
Foot mobility is crucial for preventing injuries and managing conditions like Morton's neuroma. Regular self-myofascial release techniques can help alleviate pain, improve flexibility, and promote better foot function, addressing the symptoms and underlying causes of Morton's neuroma.
Strengthening Exercises
Strengthening exercises are critical for improving the stability and function of the foot. These exercises focus on the foot's intrinsic muscles as well as the extrinsic muscles that support the ankle and lower leg.
Foot and Toe Strengthening
Strong ankles, feet, and toes are essential for preventing injuries and managing conditions like Morton's neuroma. The anatomy and biomechanics of the foot and ankle complex play a crucial role in maintaining stability, balance, and movement. Strengthening these areas can help alleviate the pain and discomfort associated with Morton's neuroma by improving foot function and reducing strain on the affected nerves.
A comprehensive exercise regimen that includes mobility exercises, myofascial release, and strengthening is vital for managing Morton's neuroma effectively. These exercises provide immediate symptomatic relief and long-term foot health by addressing underlying biomechanical issues. Combining this regimen with osseous mobilizations, soft tissue therapy, and acupuncture/acupressure enhances its effectiveness. For individuals who find manual therapy or exercise too painful, cortisone injections can be considered to reduce pain, enabling them to participate in exercises and receive therapy.
Treatment Frequency Recommendations
Integrating various treatments for Morton's neuroma offers comprehensive relief and promotes long-term recovery. This six-week plan combines optional cortisone injections, manual therapy, acupuncture, and a functional exercise program. This approach is tailored to each patient's needs, ensuring effective and balanced treatment.
Initial Intensive Treatment Phase (Weeks 1-4)
Weeks 1-4:
Frequency: 1 time per week (30 minute Appointment)
Components:
Cortisone Injections (Optional): These are administered at the start to provide immediate pain relief and reduce inflammation, allowing for more effective engagement in manual therapy and exercise. While optional, many cases achieve the best results with combined approaches that include cortisone injections.
Manual Therapy Includes osseous manipulation and soft tissue techniques such as MSR procedures, trigger point therapy, instrument-assisted soft tissue mobilization (IASTM), and acupressure. These sessions focus on improving foot alignment and mobility and reducing soft tissue tension.
Acupuncture: This involves targeting specific points (e.g., SP4, LV3, ST36, GB34, KD3, ST44) to modulate pain and inflammation. Acupressure on these points can also be integrated to enhance treatment. Sessions should be conducted initially twice a week, then reassessed based on progress.
Exercise Therapy: Daily exercises focusing on mobility (stretching), myofascial release, and strengthening. Videos will be provided to guide these exercises at home.
Functional Review (End of Week 4)
A comprehensive functional review will assess the patient’s progress at the end of the initial intensive treatment phase. This review will include:
Pain Assessment: Involves using standardized pain scales (e.g., the Visual Analog Scale) to measure changes in pain levels.
Mobility and Function Tests: Assessing improvements in foot mobility and overall function through gait analysis and range of motion tests.
Patient Feedback: Gathering subjective feedback from the patient regarding their symptoms and overall improvement.
Tailoring Further Treatment Based on Functional Review
Post-Review Treatment Plan:
If Significant Improvement:
Frequency: Reduce treatment to once biweekly for maintenance or end treatment if resolved.
Components: Continue with manual therapy and acupuncture as needed. Focus on advanced strengthening and stretching exercises to maintain and further improve function.
If Moderate Improvement:
Frequency: Maintain treatment at 1 times per week (30 minute appointment) for another 2 weeks.
Components: Reinforce manual therapy, acupuncture, and exercise routines. Consider additional modalities registerted massage therapy or orthotic adjustments. If Minimal Improvement:
If No Improvement
Action: Discontinue the current treatment plan and make an appropriate referral.
Second Review (Weeks 6-7)
A second review will be conducted 2 to 3 weeks after the initial review, depending on the patient’s response to the adjusted treatment plan. This review will again assess pain levels, mobility, and overall function, ensuring the patient is on track for long-term recovery.
Why Choose Our Approach for Morton's Neuroma Treatment
Our comprehensive approach to treating Morton's Neuroma consistently achieves an over 80% success rate in reducing pain and improving foot function. Here's why our method stands out:
Established Expertise: Developed by Dr. Brian Abelson, the MSR methodology is backed by over 30 years of clinical experience and the successful treatment of more than 25,000 patients, ensuring you receive the highest standard of care.
Thorough Assessments: We perform detailed evaluations to identify all contributing factors, including nerve compressions and biomechanical issues that often accompany Morton's Neuroma.
Advanced MSR Procedures: Our Motion-Specific Release (MSR) techniques target the precise areas of fascial restrictions and nerve entrapments, providing targeted and effective relief.
Customized Exercise Programs: We design personalized exercise plans that enhance nerve mobility, strengthen the foot, and restore function, promoting your recovery.
Logical, Evidence-Based Approach: Our treatment protocols combine manual therapy, exercises, and supportive measures, ensuring a comprehensive and lasting solution.
Choose our proven, patient-centered approach for effective, long-term relief from Morton's Neuroma. Take the first step toward your recovery with confidence.
References
American Academy of Orthopaedic Surgeons. (2021). Morton's Neuroma. In AAOS OrthoInfo. Accessed March 16, 2021.
Azar, F. M., et al. (2021). Neurogenic disorders. In Campbell's Operative Orthopaedics (14th ed.). Elsevier.
Bennett, G. L., & Graham, C. E. (2003). Morton's interdigital neuroma: A comprehensive treatment protocol. Foot & Ankle International, 24(5), 431-437.
Davis, C. S., & Christensen, J. C. (2006). Functional outcomes in patients with Morton's neuroma treated with manual therapy. Journal of Foot and Ankle Surgery, 45(5), 283-287.
Fields, K. B. (2021). Evaluation and diagnosis of common causes of forefoot pain in adults. In UpToDate. Accessed March 16, 2021.
Frontera, W. R., et al. (2019). Morton's Neuroma. In Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation (4th ed.). Elsevier.
Furlan, A. D., et al. (2010). Acupuncture and dry needling for low back pain: An updated systematic review within the framework of the Cochrane Collaboration. Spine, 35(8), E473-E481.
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Hyland, M. R., et al. (2006). Myofascial release for Morton's neuroma: A randomized controlled trial. Journal of Bodywork and Movement Therapies, 10(4), 291-296.
Kilmartin, T. E., & Wallace, W. A. (1995). The management of Morton’s neuroma: A four-year follow-up study. Journal of Foot and Ankle Surgery, 34(5), 442-445.
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National Health Service (NHS). (2022). Morton's Neuroma. In NHS Health A to Z. Page last reviewed: 12 January 2022. Next review due: 12 January 2025.
Poon, C., & Tagoe, M. (2009). Morton's neuroma: A clinical review. Foot & Ankle Specialist, 2(5), 249-253.
Thompson, J., et al. (2013). Manual therapy for the treatment of Morton's neuroma: A pilot study. Journal of Manual & Manipulative Therapy, 21(3), 142-149.
Wu, K. K. (1996). Morton's neuroma: Clinical perspectives. Clinical Orthopaedics and Related Research, (326), 207-211.
Zhou, H., & Glick, R. M. (2017). Acupuncture treatment for Morton's neuroma: A case report. Medical Acupuncture, 29(3), 178-181.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 90%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an international best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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