The surgical treatment of Morton’s

neuroma
Samrendu K. Singh, James P. Ioli, Christopher P. Chiodo
Brigham Foot and Ankle Service, Department of Orthopaedic Surgery, 1153 Centre Street, Suite 56,
Jamaica Plain, Boston, MA 02130, USA
Introduction

 1845
 Lewis Durlacher  form of neuralgic affection involving the plantar nerves
between the third and fourth metatarsal bones
 1876
 Thomas G. Morton  further localized the problem to the region of the fourth
metatarsophalangeal joint

 Morton’s Neuroma is a relatively common painful disorder of the forefoot

characterized by thickening and fibrosis of an interdigital nerve
Anatomy
 Etiology
 Peripheral entrapment
 Tethering
 Ischaemia
 Repetitive trauma
Clinical Presentation

Diagnosis of Morton’s neuroma is based primarily on history and physical

examination

History
 Sharp, burning pain localized to 2nd or 3rd web space or MT interspace
 The pain is usually at plantar (at the level of MT head)
 Radiates into toes and may be associated with distal numbness
 Px feels the need to remove the shoe and massage the area
Physical Exam
 Cutaneous sensation decreased
 Lateral Squeeze test (+)

Differential Diagnosis
 Metatarsalgia
 Metatarsophalangeal synovitis / instability
 Stress Fracture
 Frieberg’s Infarction
 Infection
 Tumor
Treatment

 Non operative therapy

 NSAID
 Shoe wear modification
 Metatarsal padding
 Orthotics
 Steroid injections

Non operative therapy should be attempted for 3 months before proceeding with
surgery
Surgical Treatment

Procedures
 Isolated Inter-digital nerve excision
 Isolated transverse metatarsal ligament division
 Inter-digital nerve excision combined with transverse metatarsal ligament
division

Approach
 Dorsal Approach
 Plantar Approach
 Dorsal Approach
 3 – 4 cm longitudinal incision in the midline of involved interspace
 The subcutaneous tissues are bluntly dissected (care should be taken to avoid
damaging the dorsal digital nerve)
 A small self retaining retractors / Lamina spreader is placed between metatarsal to
put the transverse MT ligament under tension  Release sharply
 The two distal branches of the common digital nerve are identified and isolated
transected
 The cut distal end of the nerve are grasped with hemostat, elevated and dissected
proximally
 Small plantar branches should be divided
 With traction to the nerve , the nerve is transected as proximal to MT head as
possible
Plantar Approach (recommended for recurrent stump neuroma)
 4 cm longitudinal incision in the midline of involved interspace
 Minimal deep dissection is needed as the neuroma is located subcutaneously
 Neuroma is dissected and freed from adjacent tissues  continued proximally
to a normal segment of the nerve trunk
 The nerve is transected sharply and the proximal stump buried into the
intrinsic musculature of the foot
Post Operative care and return to
activity
 Dorsal approach
 Immediate weight bearing
 10 – 14 days skin sutures are removed
 Plantar approach
 Weight bearing and skin sutures removal are delayed for 2 – 3 weeks
Conclusion

 Morton’s neuroma is a common cause of forefoot pain

 The diagnosis is based on history and physical examination
 Surgery should be considered only after 3 moths of non – operative therapies
have failed
 A dorsal approach with division of the transverse intermetatarsal ligament
and neuroma resection
 Reports after the procedures
 patient satisfaction 80 – 93 %
 Interdigital numbness 68 – 72 %
 Plantar numbness 50 – 65 %