 FOOT AND ANKLE
Outcomes following excision of Morton’s
V. Bucknall,
D. Rutherford,
D. MacDonald,
H. Shalaby,
J. McKinley,
S. J. Breusch
From Royal
Infirmary of
Edinburgh,
Edinburgh, United
Kingdom
 V. Bucknall, MBChB,
BMSc(Hons), MRCS, Trauma
and Orthopaedic Registrar
Department of Trauma and
Orthopaedic Surgery
 D. Rutherford, MBChB,
Foundation Year Doctor
 D. MacDonald, BA (Hons),
Clinical Researcher
 H. Shalaby, MD, FRCS (Orth),
Consultant Trauma and
Orthopaedic Surgeon
 J. McKinley, MBChB, BMSc
(Hons), FRCS (Orth), Consultant
Trauma and Orthopaedic
Surgeon
 S. J. Breusch, MD, PhD, FRCS
(Orth), Consultant Trauma and
Orthopaedic Surgeon
Royal Infirmary of Edinburgh,
Little France Crescent, Old
Dalkeith Road, Edinburgh EH16
4SA, UK.
Correspondence should be sent
to Miss V. Bucknall; e-mail:
vittoria.bucknall@doctors.org.
uk
©2016 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.98B10.
37610 $2.00
Bone Joint
J 2016;98-B:1376–81.
Received 31 December 2015;
Accepted after revision 4 May
2016
1376
interdigital neuroma
A PROSPECTIVE STUDY
Aims
This is the first prospective study to report the pre- and post-operative patient reported
outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.
Patients and Methods
Between May 2006 and April 2013, we prospectively studied 99 consecutive patients
(111 feet) who were to undergo excision of a Morton’s neuroma. There were 78 women and
21 men with a mean age at the time of surgery of 56 years (22 to 78). Patients completed the
Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF-12) and a
supplementary patient satisfaction survey three months pre-operatively and six months
post-operatively.
Results
Statistically significant differences were found between the mean pre- and post-operative
MOXFQ and the physical component of the SF-12 scores (p = 0.00081 and p = 0.00092
respectively). Most patients reported their overall satisfaction as excellent (n = 49, 49.5%) or
good (n = 29, 29.3%), but ten patients were dissatisfied, reporting poor (n = 8, 8.1%) or very
poor (n = 2, 2.0%) results. Only 63 patients (63%) were pain-free at follow-up: in eight
patients (8.1%), the MOXFQ score worsened. There was no statistically significant difference
in outcome between surgery on single or multiple sites. However, the MOXFQ scores were
significantly worse after revision surgery (p = 0.004).
Conclusions
The patient-reported outcomes after resection of a symptomatic Morton’s neuroma are
acceptable but may not be as good as earlier studies suggest. Surgery at several sites can
be undertaken safely but caution should be exercised when considering revision surgery.
Cite this article: Bone Joint J 2016;98-B:1376–81.
Morton’s neuroma is a benign fibrous enlarge- verse ligament, the intermetatarsal bursa and
ment of the tissue surrounding a common plantar soft tissues.9-11 Histologically, the digi-
plantar digital nerve, most frequently in the tal nerve adopts the characteristic features of
second and third intermetatarsal spaces.1-3 fibrosis of the soft tissues, endoneurial fibrosis
The condition is characterised by pain and of the nerve and demyelination.12
burning in the interdigital webspace, which is Ultrasound and MRI can be used to aid
exacerbated by periods of walking, standing diagnosis and exclude other causes of metatar-
and wearing constrictive footwear.2,4-7 Ten- salgia. However, the incidence of asympto-
derness, even on light touch, can adversely matic Morton’s neuroma on imaging is
affect activities of daily living. A palpable relatively high with some studies quoting rates
mass can often be felt in the intermetatarsal of up to 54%.13,14 Consequently, the clinical
space. Axial compression may be accompa- history and examination remain the most sen-
nied by a demonstrable painful click known sitive and specific methods of correctly diag-
as Mulder’s sign.2,8 nosing a neuroma.13,14
The aetiology of this condition is still uncer- Morton’s neuroma can be managed conserv-
tain. It is thought that a traumatic entrapment atively with modification of footwear, orthoses
neuropathy causes an inflammatory process or injections of local anaesthetic and steroid.
which results in local symptoms. It has been However, due to the low response rate to these
suggested that the digital nerve is subjected to methods of treatment, excision of the interdig-
repetitive compression between the deep trans- ital nerve is often recommended.2,15,16
THE BONE & JOINT JOURNAL
 OUTCOMES FOLLOWING EXCISION OF MORTON’S INTERDIGITAL NEUROMA 1377

To what extent do you agree with the following statement? Tick one box for each question where:

1 = Strongly agree, 2 = Agree, 3 = No opinion, 4 = Disagree, 5 = Strongly disagree

Question 1 2 3 4 5

(1) I am satisfied with the outcome of my foot surgery

(2) I no longer have pain in the area operated

(3) My ability to undertake daily tasks is now improved

(4) I am able to participate in sports/ heavy work

(5) The surgery has met my expectations

(6) I would have the surgery again if needed

(7) I would recommend this surgery to a friend

Fig. 1

Supplementary patient satisfaction survey.

Despite the frequency with which this surgery is under-
taken, there is little information regarding surgical out-
comes. Furthermore, where validated patient-reported
outcomes and satisfaction scores have been described,
many of the patient cohorts are small and the data collected
retrospectively.1,17
This is the first prospective study to report the pre- and
post-operative patient-reported outcomes and satisfaction
scores after excision of a Morton’s neuroma in a large
cohort of patients.
Patients and Methods
Between May 2006 and April 2013, 108 consecutive
patients who were to undergo excision of a suspected Mor-
ton’s neuroma were invited to take part in the study. One
patient died four months following surgery and eight were
lost to follow-up. The remaining 99 patients (111 feet) were
included in the study. There were 78 women and 21 men
with a mean age at the time of surgery of 56 years (22 to 78).
Conservative treatment was undertaken pre-
operatively in 75 patients (75.8%): five (7%) of these
received steroid injections, 14 (19%) tried orthotics
alone and 56 (75%) used both steroids and orthotics.
The mean interval between presentation and surgery was
25 months (3 to 91).
All operations were undertaken by one of four specialist
foot and ankle consultant surgeons (SB, JM, HS and G.
Keenan) at two centres in the United Kingdom; The Royal
Infirmary of Edinburgh and St John’s Hospital Livingston.
With the patient under general anaesthetic and a tourniquet
applied, a dorsal approach to the neuroma was used in each
case.
In total, 137 neuromas were excised from 111 feet
belonging to 99 patients: 39 patients underwent excision of
a neuroma from the second webspace in isolation, 46 from
the third web space and 26 patients underwent simultane-
ous excision from both the second and third web spaces on
the ipsilateral side during the same surgical sitting. A total
of 12 patients had operations on both feet. The left foot
was involved in 45 patients and the right foot in 66. Of the
99 patients, 24 were for surgery of a single webspace due to
recurrence.
Of the 99 patients undergoing excision of a Morton’s neu-
roma, 12 underwent concurrent surgery to the foot. These
procedures included cheilectomy (n = 1), first ray osteotomy
(n = 3), Weil’s osteotomy (n = 3), proximal interphalangeal
joint fusion (n = 3), Lapidus fusion (n = 1) and BioPro hemi-
arthroplasty (Port Huron, Michigan) (n = 1).
All patients were examined and outcome measures
including the Manchester-Oxford Foot Questionnaire
(MOXFQ),18 the Short-Form 12 (SF-12)19 were recorded
three months pre- and six months post-operatively. The
MOXFQ is a validated scoring system with three main
domains which grade pain, walking/standing and social
interaction during the previous four weeks. There are 16
items with five responses scored from 0 to 4, where 0 is the
best score attainable. The total raw scores out of 64 can be
subsequently converted to a metric scale 0 to 100, where 0
is the best score possible and represents an excellent
outcome.

VOL. 98-B, No. 10, OCTOBER 2016

1378 V. BUCKNALL, D. RUTHERFORD, D. MACDONALD, H. SHALABY, J. MCKINLEY, S. J. BREUSCH

Table I. Changes in pre- and post-operative MOXFQ and SF-12 scores

Pre-operative Post-operative Pre-operative PCS Post-operative PCS Pre-operative MCS Post-operative

MOXFQ MOXFQ SF-12 SF-12 SF-12 MCS SF-12
Mean 59.71 39.53 35.84 42.12 47.14 48.55
Range 13.00 to 64.00 0.00 to 63.00 19.20 to 55.59 21.34 to 56.4 20.61 to 64.49 23.79 to 64.77
Mean difference -20.19 6.28 1.41
SD 18.28 10.66 10.85
p-value 0.00081* 0.00092* 0.200
* Statistically significant
MOXFQ, Manchester-Oxford Foot Questionnaire; PCS, physical component summary; MCS, mental component summary; SF-12, short form-12;
SD, standard deviation

Table II. The effect of surgical parameters on the outcome following excision of an interdigital neuroma

p-value MOXFQ p-value PCS SF-12 p-value MCS SF-12

Multiple site surgery 0.142 0.094 1.000
Second vs third webspace 0.510 0.278 0.116
Revision surgery 0.003* 0.625 0.614
MOXFQ, Manchester-Oxford Foot Questionnaire; PCS, physical component summary; SF-12, short form-12

50 surgery were analysed using the paired t-test and factors

45
affecting outcome were analysed using Pearson’s chi-
squared. A p-value < 0.05 was used to define statistical sig-
40
nificance.
35
30 Results
Histological results for eight of the 137 neuromas excised
%

25
20
15
10
5 histological findings (p = 0.24, 0.097 and 0.152 for
0
Excellent Good Indifferent Poor
Fig. 2
Bar chart showing percentage patient satisfaction following excision of
Morton’s neuroma.
The SF-12 is a generic age-dependent measure of health
which incorporates both physical (PCS) and mental (MCS)
components. There are 12 questions. The scores derived
from the responses are converted into a metric scale and
compared with a national norm with a mean score of 50.0
and a standard deviation of 10.0. Scores in the region of
24.0 for PCS and 19.1 for MCS represent poor health,
whereas a PCS of 56.6 and an MCS of 60.8 represent good
health.
Seven supplementary questions involving a five-point
Likert scale where ‘1’ represents an excellent outcome and
‘5’ a poor outcome were also used to assess satisfaction
(Fig. 1).
Statistical analysis. This was undertaken using Microsoft
Excel (Microsoft, Redmond, Washington) and IBM SPSS
statistical software (SPSS, IBM Inc., Armonk, New York).
Non-parametric tests were used where data were not nor-
mally distributed. Changes in scores before and after
were not available. Of the remaining 129 specimens, 100
(78%) had the characteristic histological changes of Mor-
ton’s neuroma. However, there was no statistically signifi-
cant correlation between outcome and the confirmatory
MOXFQ, PCS and MCS, respectively).
Very poor Statistically significant differences were found between
the mean pre- and post-operative MOXFQ and physical
component of the SF-12 scores (p < 0.001) (Table I). The
MOXFQ score worsened post-operatively in eight patients
(8%) by a mean 11.75 points (2 to 34). Of these patients,
five (5%) also had worse SF-12 scores with a mean reduc-
tion of 10.30 in the PCS (9.18 to 12.53) and 15.62 points in
the MCS (4.55 to 24.24).
Using Pearson’s chi-squared test, no statistically signifi-
cant differences in outcome scores were found when com-
paring multiple site with single site surgery (Table II),
Similarly, no statistically significant differences were found
when comparing excision of neuroma from the second
webspace compared with the third or in the subgroup of 12
patients who underwent additional simultaneous ipsilateral
surgery to the foot. However, revision surgery after previ-
ous excision of a Morton’s neuroma gave a poorer mean
MOXFQ score (p = 0.003) (Table II).
Satisfaction was reported by most patients as excellent
(n = 49) or good (n = 29): 11 patients were indifferent and
ten patients were dissatisfied with poor (n = 8) or very poor
(n = 2) results (Fig. 2, Table III). Of those patients who
reported dissatisfaction, nine (90%) had histological con-
firmation of a Morton’s neuroma.

THE BONE & JOINT JOURNAL

 OUTCOMES FOLLOWING EXCISION OF MORTON’S INTERDIGITAL NEUROMA
Table III. Number of patients responding to each supplementary satisfaction question using a 5-point Likert scale
Question
(1) I am satisfied with the outcome of my foot surgery
(2) I no longer have pain in the area operated
(3) My ability to undertake daily tasks is now improved
(4) I am able to participate in sports/ heavy work
(5) The surgery has met my expectations
(6) I would have the surgery again if needed
(7) I would recommend this surgery to a friend
1, strongly agree; 2, agree; 3, no opinion; 4, disagree; 5, strongly disagree
Strongly
disagree
10%
Disagree
Strongly agree
11%
35%
No opinion
15%
Agree
29%
Fig. 3
Pie chart showing patient agreement to relief of pain post-operatively.
Only 63 patients were pain-free at six months follow-up
(Fig. 3, Table III). Of the 21 patients who reported ongoing dis-
comfort, five (24%) avoided long-distance walking and pro-
longed periods of standing, four (19.0%) described shooting
pains and three (14%) had night pain using the MOXFQ tool.
Overall, 25 patients (25.3%) reported no improvement
in their ability to undertake activities of daily living and 26
patients (26.3%) were unable to participate in heavy work.
However, 83 patients (83.8%) said they would undergo the
surgery again and 82 (82.8%) would recommend the sur-
gery to a friend (Table III).
There were post-operative complications in ten patients
(10%): these included tenderness along the scar (n = 4); neu-
ropathic pain (n = 3); superficial wound infection (n = 2) and
splaying of the toes (n = 1): none underwent further surgery.
In all, seven patients underwent revision surgery for the re-
excision of a neuroma after a mean 26 months (9 to 52): five
of the seven were a re-revision.
VOL. 98-B, No. 10, OCTOBER 2016
1379
Number of patients responses
1 2 3 4 5
49 29 11 8 2
34 29 15 11 10
29 34 11 13 12
26 29 18 11 15
42 22 6 19 10
62 21 6 6 4
59 23 7 4 6
Discussion
This is the largest known study to assess the pre- and post-
operative patient reported outcomes of Morton’s neuroma
prospectively using validated scoring tools. Other studies have
attempted to quantify outcome, but these have been retrospec-
tive in design, involved few patients or have relied on the find-
ings of clinical examination to quantify improvement.1,19
We found that statistically significant benefit can be
expected from the excision of a Morton’s neuroma. The
MOXFQ and the physical component of the SF-12 both
showed significant improvements post-operatively. How-
ever, this is the first study to highlight that mental improve-
ment may trail physical recovery, as the mental component
of the SF-12 did not achieve statistical significance.
In this study, there was a predilection for Morton’s neu-
roma to affect the interdigital nerve of the third web space.
This has previously been reported.1,19,20 It has been sug-
gested that this is due to greater mobility between the third
and fourth metatarsals, causing local injury to the third
interdigital nerve which, being formed by the branches of
the medial and lateral plantar nerves, is larger and therefore
more susceptible to such injury.20 However, contrary to the
findings of Womack et al,21 we found no statistically signif-
icant difference when comparing the outcome of excision of
neuroma from the second and third webspaces.10
We also found that the outcome of resecting Morton’s
neuromas from adjacent web spaces can be expected to be
as good as that of resecting a single neuroma. This is con-
sistent with the findings of Benedetti, Baxter and Davis.22
However, it is contrary to the findings of others.23 Further-
more, concomitant ipsilateral forefoot surgery undertaken
at the time of excision of a neuroma does not statistically
worsen the outcome. The presence of concurrent foot
pathology in this study accords with the findings of Mor-
ris,6 who suggests that the mechanics of the foot are rele-
vant in the development of Morton’s neuroma. Diez and
Mas24 have also suggested that Morton’s neuroma can be
associated with other forefoot pathology in up to 80% of
patients. In our study, 12 patients underwent ipsilateral
forefoot procedures at the same time as excision of a Mor-
ton’s neuroma – their outcome was not statistically worse.
This is consistent with findings reported by Kasparek and
Schneider.10
1380 V. BUCKNALL, D. RUTHERFORD, D. MACDONALD, H. SHALABY, J. MCKINLEY, S. J. BREUSCH
The rate of failure after revision surgery ranges from
14% to 21%. The most common causes of recurrent symp-
toms are inadequate resection, friction, pressure or forma-
tion of a terminal neuroma.23,25,26 We found statistically
worse outcomes in those who underwent revision surgery:
five of seven patients who had further surgery did so for re-
revision. Some studies have recommended methods of
reducing this incidence, including implanting the stump of
the nerve into muscle.23
The satisfaction scores described in this study are in line
with those reported by Friscia et al27 who found that in the
long term (mean 5.9 years, 2.8 to 13), of the 313 patients
studied, 45.2% of patients were completely satisfied and
33.8% were satisfied. Kasparek and Schneider10 also found
similar results. However, Akermark, Saartok and Zuber28
reported much higher scores where 86% of the 55 patient
cohort expressed excellent or good results following sur-
gery with a mean follow-up of 29 months.
Excision of a Morton’s neuroma is not always success-
ful. In this study, only 63 patients (64%) were pain-free at
follow-up and eight (8%) were worse. Other studies have
also reported persistent pain in the affected foot after exci-
sion of a Morton’s neuroma.23 The presence of unrecog-
nised pathology may, however, account for the persistent
pain.
In this study, 100 out of 129 specimens (78%) had histo-
logical evidence of neuroma. These findings are similar to
those of Pace, Scammell and Dhar2 and Vachon, Lemay and
Bouchard,29 who reported that up to a third of operation
specimens were histologically normal. Histological confir-
mation of the diagnosis has little bearing on patient-
reported outcome measures as nine patients (90%) in this
study who were reported to be dissatisfied post-operatively
had a Morton’s neuroma confirmed on histological exami-
nation. This would suggest that outcomes are not solely
dependent on complete excision.
The patients in this study were reviewed at six months
post-operatively. This is a limitation of the study as a longer
period of follow-up may have revealed changing results
with time. However, many of the outcomes shown in this
study are comparable to those reported in current literature
where longer periods of follow-up have been used. Further-
more, this is the largest study to record and compare pre-
and post-operative outcomes using standardised validation
tools, thus making this study highly important in our mod-
ern understanding of surgical resection of Morton’s
neuroma.
In conclusion, patient-reported outcomes after resection
of a symptomatic Morton’s neuroma are acceptable, but
may not be as favourable as earlier studies have suggested.
Excision of neuromas from several sites give comparable
results, but caution should be exercised when considering
revision surgery, which has been shown to be a poor prog-
nostic indicator.
Surgical excision of a Morton’s neuroma does not
improve the mental component of SF-12.
Take home message:
Revision surgery for Morton’s neuroma should be undertaken
with caution as less favourable outcomes in this cohort are
demonstrated.
Author contributions:
V. Bucknall: Data collection, Drafting, writing and editing the paper.
D. Rutherford: Data collection, Data analysis, Editing the paper.
D. MacDonald: Editing the paper, Data collection.
H. Shalaby: Performed surgery, Editing the paper.
J. McKinley: Performed surgery, Editing the paper.
S. J. Breusch: Study concept, Performed surgery, Editing the paper.
The authors would like to acknowledge G. Keenan who carried out some of the
surgery included in the study.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by A. C. Ross and first proof edited by J. Scott.
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