T h e R e c u r ren t M o r t o n

N e u ro m a : What Now?
a, b
David R. Richardson, MD *, Erin M. Dean, MD

KEYWORDS
 Interdigital neuroma  Recurrence  Surgical treatment  Surgical exposures
 Nerve transposition

KEY POINTS
 Symptoms may recur because of an incorrect initial diagnosis, inadequate resection, or
adherence of or pressure on a nerve stump neuroma. Double crush phenomena or
more proximal nerve compression should be suspected in patients with recurrent symp-
toms or multiple interspaces involved.
 When revision surgery is planned, the recurrent interdigital neuroma can be approached
through a dorsal, plantar longitudinal, or plantar transverse incision. The plantar longitudi-
nal incision provides optimal exposure along the proximal extent of the common digital
nerve.
 Transposition of the proximal nerve stump into bone or muscle should be considered to
avoid traction or pressure on the nerve ending that can result in a painful stump neuroma.
 A thorough preoperative discussion with the patient will help ensure a full understanding of
the limitations of neuroma surgery, including the possibility of continued pain and difficulty
with shoe wear.

INTRODUCTION

Interdigital neuromas are a common cause of forefoot pain. Initial treatment generally is
nonoperative, but approximately 80% of patients eventually require surgical resection
of the neuroma because of continued symptoms and intolerance of shoe wear modifi-
cations.1 Reported outcomes of surgical treatment of interdigital neuromas are vari-
able, but overall, 50% to 85% of patients obtain significant improvement after
surgery.1–8 Our experience with primary neuroma resections is somewhat less encour-
aging. A retrospective review of 120 patients treated at our institution found only 50%
good or excellent results at an average follow-up of 67 months.8 Although our study may
have more heavily weighted postoperative numbness in the outcomes scoring than pre-
vious studies, it does suggest that patient outcomes may not be as good as reported.

a
Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-
Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA; b Crystal Clinic
Orthopaedic Center, 1310 Corporate Drive, Hudson, OH 44236, USA
* Corresponding author.
E-mail address: [email protected]

Foot Ankle Clin N Am 19 (2014) 437–449

http://dx.doi.org/10.1016/j.fcl.2014.06.006 foot.theclinics.com
1083-7515/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
438 Richardson & Dean

Accurate diagnosis and recognition of concomitant diagnoses are essential to plan-

ning for neuroma surgery. At the time of surgery, care must be taken to adequately
identify and resect the neuroma proximally enough to allow retraction of the nerve
end. Even with accurate diagnosis and surgical resection, recurrent symptoms may
develop.

BIOLOGY OF NEUROMA FORMATION

A true neuroma forms at the transected end of a nerve and generally shows prolifer-
ative histologic changes. Histology shows dense fibrous tissue formation with irregular
nervous tissue proliferation.9 This is in contrast to the findings in a primary interdigital
neuroma, which, in fact, is not a true neuroma (Figs. 1–3). What is commonly referred
to as a primary interdigital neuroma usually histologically shows signs of nerve degen-
eration, including degeneration of myelinated fibers, thickening of the epineurium and
perineurium, thickening and hyalinization of the walls of the neural vessels, and
concentric edema within the nerve.5,9 Therefore, a primary interdigital neuroma is
not a true neuroma. A recurrent neuroma, however, often is a true neuroma that has
formed at the cut end of the common digital nerve.
Neuromas tend to form at the transected end of nerves, and proliferation is directed
toward the skin or distal portion of the transected nerve.10,11 This process generally is
termed a stump neuroma and often is the cause of recurrent symptoms after primary
interdigital neuroma resection.

PRESENTATION OF RECURRENT NEUROMAS

Primary interdigital neuromas frequently cause pain localized in the metatarsal head.
Pain is aggravated by ambulation and shoe wear but is relieved by rest.1,12–14 The
most common complaints tend to be pain in the front part of the foot, improvement
in pain with shoe removal, pain between the toes, and inability to wear fashionable
shoes.14 Patients with recurrent neuromas report symptoms similar to their original

Fig. 1. Normal nerve in cross section (hematoxylin-eosin, original magnification 40). The
entire nerve is surrounded by epineurium, and smaller nerve fascicles are encompassed by
perineurium. (From Weiss SW, Goldblum JR. Enzinger and Weiss’s soft tissue tumors. 4th
edition. St Louis (MO): Mosby; 2001. p. 1112–21.)
 The Recurrent Morton Neuroma 439

Fig. 2. Morton neuroma (hematoxylin-eosin, original magnification 200). Dense perineu-

ral (A) and perivascular (B) fibrosis characterize the lesion. (From Weiss SW, Goldblum JR. En-
zinger and Weiss’s soft tissue tumors. 4th edition. St Louis (MO): Mosby; 2001. p. 1112–21.)

Fig. 3. Traumatic (stump) neuroma composed of small proliferating fascicles of nerve envel-
oped in collagen (hematoxylin-eosin, original magnification 100). (From Weiss SW,
Goldblum JR. Enzinger and Weiss’s soft tissue tumors. 4th edition. St Louis (MO): Mosby;
2001. p. 1112–21.)
440 Richardson & Dean

neuroma symptoms.1,12 Most also describe a fullness or a lumplike sensation in the

symptomatic area of the forefoot.1,12

MAKING THE CORRECT DIAGNOSIS

Correct diagnosis is mandatory for successful treatment of the patient with a sus-
pected recurrent neuroma. A thorough history and physical examination are impera-
tive. If the examining physician is not the surgeon who performed the original
resection, clinical records, especially the operative report, should be obtained and
reviewed. Physical examination should include placing the patient prone and identi-
fying the point of maximal tenderness. Although a Mulder’s click may not be present,
palpation and axial compression often exacerbate the symptoms (Fig. 4).
Other causes of forefoot pain must be ruled out radiographically and clinically
(Box 1). These may be isolated conditions or may exist concomitantly with a recurrent
neuroma.2,12,13,15
Other areas of nerve compression, including a double-crush phenomenon, should
be considered in all patients with suspected recurrent neuromas.13,15,16 Tarsal tunnel
or more proximal compression of the tibial nerve may cause diffuse distal nerve irrita-
bility or tenderness in multiple web spaces that mimics multiple adjacent web-space
neuromas.13,15,16 Electromyography and nerve conduction testing allow evaluation of
more proximal areas of compression.13,16
Wolfort and Dellon16 reported that 7 of 13 patients presenting with recurrent neu-
romas also had proximal compression of the tibial nerve. They suggested that multiple
coexisting neuromas or neuromas of the first or fourth web space are rare and may
actually represent misdiagnosed tarsal tunnel syndrome. Electrodiagnostic testing
can help delineate these findings.
When the diagnosis remains in question despite thorough radiographic and phys-
ical examinations, sequential diagnostic injections of local anesthetics may be
helpful.3,7,12,15

IF THE DIAGNOSIS IS CORRECT, WHY DO SYMPTOMS RECUR AFTER SURGERY?

Anatomy of the Interdigital Nerve
Cadaver dissections to evaluate the anatomy and branching patterns of the common
digital nerves found plantarly directed nerve branches consistently present along the
course of the second and third common digital nerves.17 These plantarly directed

Fig. 4. Diagnosis of interdigital neuroma. Palpation (A) and axial compression (B) often
exacerbate symptoms.
 The Recurrent Morton Neuroma 441

Box 1
Conditions that must be ruled out in diagnosing interdigital neuroma or that may coexist with
interdigital neuroma

 Metatarsophalangeal joint derangement

Arthritis
Synovitis
Instability
 Osteonecrosis of the metatarsal head
 Transfer metatarsalgia from adjacent toe deformity
 Space-occupying lesions
Bursa in the plantar or web spaces
Synovial or ganglion cysts
Lipoma
 Plantar fat pad atrophy
 Plantar warts
 Painful surgical incisions
 Iatrogenic superficial neuromas

branches were more highly concentrated along the distal few centimeters of the nerve.
To avoid tethering of the nerve stump, the common digital nerve should be resected at
least 3 cm proximal to the proximal edge of the transverse metatarsal ligament.17 This
is thought to allow better proximal retraction of the nerve stump off the weight-bearing
surface of the foot by severing the tethering plantar branches. These branches also are
postulated to form painful postoperative traumatic neuromas when the nerve is not
excised more proximally.17 Similarly, when a neuroma is resected and the proximal
end of the resected nerve is left in an area of movement, tension, or pressure, a stump
neuroma may develop.16

Failure to Fully Resect

Johnson and colleagues9 analyzed 37 histologic specimens resected during reopera-
tions for recurrent neuromas and noted that 21% showed features of a primary inter-
digital neuroma, indicating residual unresected neuroma; 21% showed features of a
stump neuroma, indicating failure to resect proximal enough or continued pressure
on or tethering of the nerve; and 46% showed features of both primary neuroma
and stump neuroma, indicating incomplete resection at the index procedure. Interest-
ingly, 12% showed no neuromatous tissue and instead had features of fibrofatty tissue
or foreign body–reactive tissue. These patients actually were the most satisfied after
reoperation.

Adherence to Surrounding Structures

Distal nerve stumps also can adhere to surrounding tissues such as the adjacent
metatarsal, plantar fascia, tendons, muscle, or other surrounding structures. In the
experience of the senior author, the neuroma is most commonly adhered to the third
metatarsal. Some authors have recommended burying the nerve ending into a known
tissue to avoid adherence to a structure with excursion or extrinsic pressure. Tension
442 Richardson & Dean

or pressure on the nerve in this setting can irritate the nerve ending, leading to painful
stump neuroma formation.16,18
Nelms and colleagues18 described a technique for recurrent neuroma excision that
includes transfer of the nerve stump into a drill hole in the metatarsal shaft. They re-
ported 89% good or excellent results with this technique. Histologic evaluation found
that a nerve ending buried in a bone canal will form a neuroma with a more regular
structure but similar appearance to a nerve ending left outside of the bone canal.19
Therefore, although a neuroma will likely still form, it is protected from mechanical
stimulation and the generation of pain with this technique.
Wolfort and Dellon16 reported 80% excellent and 20% good results with implanta-
tion of the nerve stump into plantar intrinsic muscle belly. Because selected muscles
should have little excursion, the interosseous musculature is well suited for this pur-
pose. The idea of placing a nerve end into an innervated muscle has proven successful
in the upper extremity and appears to work well in the foot as well.16 Histologic eval-
uation found that a nerve stump buried in muscle will form little or no neuroma and re-
mains completely contained within the muscle.19,20
Colgrove and colleagues10 used a technique with a similar goal of burying the nerve
stump within the intrinsic muscles of the foot. Their technique involves transposing the
interdigital nerve between the transverse head of the adductor hallucis muscle and the
interossei muscles. The distal nerve stump is anchored in place with a suture that is
passed through the plantar foot and is removed 3 to 4 weeks after surgery. They
compared the results of transposition with those of standard resection and found
that although early results at 1-month and 6-month follow-up showed lower pain
scores for the resection group, at 1-year and 3- to 4-year follow-up, the transposition
group had significantly lower pain scores. At final follow-up, 96% of the transposition
group was completely pain free, whereas only 68% of the resection group was pain
free. The authors hypothesized that the excellent results obtained with transposition
of the nerve may be related to the formation of a smaller transaction neuroma that
is removed from the weight-bearing surface of the foot and cushioned by muscle.
These reports suggest that improved outcomes are possible with transposition tech-
niques, but more studies are needed to fully delineate the techniques that produce the
best long-term outcomes.

APPROACH FOR REVISION SURGERY: PLANTAR OR DORSAL

Several surgical approaches to the neuroma exist. Those most commonly used
include longitudinal dorsal, longitudinal plantar, and transverse plantar.9,12,15,18,21
Although the dorsal approach usually is used for primary neuroma resection, its use
in recurrent resections can be more difficult because of scar tissue and limited access
to the more proximal extent of the nerve.12 The dorsal incision allows better exposure
of the distal extent of the nerve for excision of primary neuromas and bursal tissue. The
plantar incision offers better exposure proximally along the common digital nerve
where stump neuromas tend to form. The dorsal incision has been used successfully,
however, for excision of recurrent neuromas. Stamatis and Myerson15 used a dorsal
approach in 47 of 49 patients with recurrent neuromas with only 22% of patients
dissatisfied with their results.
Plantar incisions are more commonly used for reoperation of the web space. One
concern with use of a plantar incision is hypertrophic or sensitive scar formation along
the weight-bearing surface of the foot. Faraj and Hosur21 compared outcomes in
patients who had excision of interdigital neuromas through dorsal and plantar ap-
proaches. They found that the plantar approach was associated with a significant
 The Recurrent Morton Neuroma 443

increase in postoperative wound infection, hematoma, and scar problems. Full weight
bearing and return to work and recreational activities were earlier in those with a dorsal
incision. Several reports, however, show few or no issues with scar sensitivity or other
complications with plantar approaches.9,12,15,18 Johnson and colleagues9 used a lon-
gitudinal plantar incision in 33 of 37 patients and achieved cosmetic and functionally
satisfactory incisional scars in all but 1 patient in whom mild thickening and callus of
the proximal extent of the incision developed. This patient’s original resection was also
through a plantar approach.
Beskin and Baxter12 used a dorsal incision in 12 patients and a transverse plantar
incision in 18 patients for recurrent neuroma resection and found no difference in out-
comes between the 2 approaches. No patients complained of painful scars. In fact,
most patients reported that their plantar scar healed faster and less painfully than their
original dorsal incision. Caution is advised in the use of the plantar incision, however, in
patients who are known to form keloid scars and in those with thick callosities because
their risk of scar sensitivity is higher.12
The largest series of plantar incisions is that of Richardson and colleagues22 who
reported outcomes of 150 plantar incisions for various forefoot procedures. They
found a 96% satisfaction rate; only 9 (6%) of 150 feet had an incisional keratosis, of
which 3 were symptomatic enough to require excision of the keratosis, and 4 patients
had delayed wound healing. Overall, outcomes were good or excellent in 84% of
patients with plantar incisions.

AUTHORS’ PREFERRED APPROACH FOR TREATMENT OF RECURRENT INTERDIGITAL

NEUROMA

Nonoperative options are discussed at length with the patient. Shoe modifications are
recommended, including properly sized shoes with a wide toe box. A metatarsal pad
is positioned just proximal to the metatarsal heads of the involved interspace to offload
the inflamed nerve (Fig. 5). If satisfactory symptom relief is not achieved with these
modifications, an injection of 1 mL of Bupivacaine and 1 mL of corticosteroid
(Fig. 6) into the involved interspace is recommended. We do not recommend injection
of an alcohol solution. In our experience, this has been associated with poor results
and at times resulted in worsening pain. If the diagnosis is in question, serial injections
of lidocaine are used instead to delineate the location of pathology. If temporary relief
is achieved with injection into the interspace, surgical resection is considered.

Fig. 5. Nonoperative treatment may include use of a gel cushion insert or metatarsal pad to
offload the inflamed nerve.
444 Richardson & Dean

Fig. 6. Injection of corticosteroid into affected web space may relieve symptoms, but relief
may be temporary.

Generally, we prefer a dorsal incision for primary neuroma resections and a plantar
longitudinal incision for recurrent neuromas. In our experience, recurrent symptoms
often are related to adherence of the nerve stump to adjacent structures, such as
the plantar fascia or metatarsal head, or to stump neuroma formation with scar or
bursal tissue at the site of previous resection. Adherence to the plantar fascia should
be suspected if a Tinel sign is positive plantarly along the course of the common digital
nerve.
The plantar longitudinal incision provides better exposure of the more proximal
aspect of the common digital nerve, allowing a more proximal resection or excursion
length for transposition into intrinsic muscle. A plantar transverse incision can be used,
especially in the rare situation in which multiple interspaces are to be explored.
Although it does not provide the same proximal exposure of the common digital nerve
as the longitudinal incision, the incision and subsequent scar are kept off the weight-
bearing aspect of the forefoot. The dorsal approach can be used for revision surgery if
an inadequate primary resection is suspected.

Plantar Surgical Approach

Before anesthesia, the patient is reexamined and the point of maximal tenderness is
marked (Fig. 7A). With the patient supine, intravenous anesthesia is administered,
and a forefoot block is placed with a combination of lidocaine and Marcaine without
epinephrine. An ankle Esmarch tourniquet is placed. A plantar longitudinal incision
is made centered over the involved interspace, with care to ensure that the incision
is not placed directly over the metatarsal head (Fig. 7B). Blunt dissection is carried
down through the subcutaneous tissues. The plantar fascia is incised longitudinally
in line with the incision, and the common digital nerve is identified (Fig. 7C). The nerve
 The Recurrent Morton Neuroma 445

Fig. 7. Surgical technique, plantar approach. (A) Before induction of anesthesia, point of
maximal tenderness is marked. (B) Plantar longitudinal incision. (C) Common digital nerve
is identified through longitudinal incision in plantar fascia. (D) Nerve is inspected for stump
neuroma, accessory branches, or adherence to surrounding structures, (E) dissected as far
proximally as possible, and (F) resected or transposed. (G) Plantar incision is closed carefully
to avoid excessive inversion or eversion of skin edges.

is inspected for stump neuroma, accessory branches, or adherence to surrounding

structures (Fig. 7D) and then is dissected as far proximally as possible (Fig. 7E) and
is resected or transposed into muscle as needed (Fig. 7F). The skin is closed with
3–0 nonabsorbable suture with care taken to avoid excessive inversion or eversion
of the skin edges (Fig. 7G). Non–weight bearing is suggested until the incision is
healed, usually at 2 weeks. Then full weight bearing is allowed in a stiff soled postop-
erative shoe for 2 more weeks.

Dorsal Surgical Approach

Patient preparation and anesthesia are as described for the plantar approach. A dorsal
longitudinal approach is centered over the involved interspace (Fig. 8A). Blunt
446 Richardson & Dean

Fig. 8. Surgical technique, dorsal approach. (A) Dorsal longitudinal incision. (B) Reformed
transverse metatarsal ligament after previous dorsal approach. (C) Normal interdigital nerve
is identified proximal to the stump neuroma. (D) Hemostat is placed as far proximally on
the nerve as possible to apply gentle traction before (E) transection of the nerve. (F, G)
The neuroma and surrounding bursa are dissected free from the interspace.

dissection is carried down through the subcutaneous layer, and a lamina spreader is
placed between the metatarsal necks allowing distraction through the interspace for
improved exposure. The transverse metatarsal ligament usually has reformed after
surgery through a previous dorsal approach to the interdigital neuroma (Fig. 8B). A
 The Recurrent Morton Neuroma 447

Freer elevator is placed just deep to the transverse metatarsal ligament, and the liga-
ment is incised longitudinally. The stump neuroma and occasional associated bursa
are visible directly below the incised ligament. The stump neuroma usually is found
on the tibial (medial) side of the interspace and often is adherent to the lumbrical mus-
cle or flexor tendon in this area. Proximally in the interspace the normal interdigital
nerve is identified proximal to the stump neuroma (Fig. 8C). A hemostat is placed
on the nerve as far proximally as possible (Fig. 8D). Gentle traction is placed on the
nerve, and it is transected as far proximally as possible (Fig. 8E). Alternatively, the
nerve can be transected slightly more distally and the nerve end transposed into mus-
cle as needed. The neuroma and surrounding bursa are then dissected free from the
interspace, with care to transect any plantarly directed branches or communicating
branches to surrounding interspaces (Fig. 8F, G). The skin is closed with 5–0 nonab-
sorbable suture, and a lightly compressive forefoot bandage is applied. The patient will
not bear weight until the incision is healed, usually at 2 weeks. Then full weight bearing
is allowed in a stiff-soled postoperative shoe for 2 more weeks.

OUTCOMES AFTER REOPERATION FOR RECURRENT INTERDIGITAL NEUROMA

Most patients with reoperation for recurrent neuromas have improvement in symp-
toms. Mann and Reynolds1 reported that 9 of 11 patients who had excision of a recur-
rent neuroma had at least 50% improvement in their symptoms. Beskin and Baxter12
reported that 86% of 30 patients (39 neuromas) had at least 50% improvement in
symptoms, although fewer than half of patients were completely symptom free.
Twenty-four (80%) reported no limitations in postoperative activities, whereas 6 had
mild restrictions, mostly relating to shoe wear and long distance ambulation.
Johnson and colleagues9 reported that 23 (70%) of 33 patients were satisfied after
reoperation for recurrent neuroma, and 75% would have the surgery again; 11 (31%)
of 36 feet were pain free, 17 (47%) had only mild residual pain, and 8 (22%) had no
improvement or were made worse by the surgery. Stamatis and Myerson15 reported
similar findings in 49 patients, with approximately 31% completely satisfied, 27%
satisfied with minor reservations, 20% satisfied with major reservations, and 22%
dissatisfied.
Shoe wear restriction is a common complaint after reoperation for recurrent neu-
romas, with only about 15% of patients able to wear any type of shoe.9,12,15 Discom-
fort is most commonly related to high-heeled shoes.12

Effect of Multiple Interdigital Neuromas on Outcome

The best treatment for patients with suspected multiple interdigital neuromas in adja-
cent web spaces remains a matter of controversy. Because of the low frequency of
adjacent interspace neuromas, reported to be 2% to 3%, more proximal nerve
compression or other diagnoses must be ruled out before treatment of suspected
adjacent interspace neuromas.4,23 Thompson and Deland23 suggested that it is
exceedingly rare to find 2 neuromas present simultaneously in the same foot that
are symptomatic enough to warrant surgical resection of both. In fact, they
cautioned against operating in 2 adjacent web spaces at the same setting because
of the risk of damage to the vascular supply of the toe. They recommended selective
xylocaine injection testing to find the more symptomatic web space followed by sur-
gical excision of the more symptomatic interdigital neuroma. Friscia and colleagues4
reported a dissatisfaction rate of 42% after resection of both adjacent neuromas, a
significant increase over the dissatisfaction rate of 8% to 11% after single interspace
surgery.
448 Richardson & Dean

Other authors, however, have reported no difference in outcomes when 1 or 2 adja-

cent web spaces were explored. Benedetti and colleagues13 reported their experience
with primary neuroma resection in simultaneous adjacent web spaces and found re-
sults similar to those after excision of a single interdigital neuroma: 10 (53%) of 19
feet had complete relief of symptoms, 6 (31%) had mild residual discomfort, and 3
(16%) had continued severe pain. Recurrent neuromas were suspected in patients
with continued pain. All patients had dense sensory loss along the plantar third toe,
with variable loss along the plantar second and fourth toes; however, only 9 of the
15 patients reported subjective residual numbness when asked. Stamatis and Myer-
son15 reported similar findings after excision of recurrent neuromas; no significant
difference in outcomes were found after exploration of an isolated or 2 adjacent inter-
spaces at a single surgical setting.
Effect of Concomitant Forefoot Surgeries on Outcome
Reports in the literature suggest that the addition of other forefoot procedures does
not adversely affect the outcome of neuroma excision.3,8,15

PATIENT EXPECTATIONS AND PREOPERATIVE COUNSELING

Although good or excellent results are expected after excision of a recurrent neuroma,
this result should not be promised or assumed. The patient must be fully counseled on
the limits of the procedure. Noting that despite an 80% satisfaction rate almost two-
thirds of patients experience some tenderness over the cut end of the common digital
nerve, Mann and Reynolds1 emphasized the importance of preoperative counseling.
Shoe wear restrictions also are a common complaint after primary or recurrent inter-
digital neuroma surgery, and patients should be informed that up to 85% of patients
have restrictions in shoe wear. A full disclosure of expected outcomes will allow a bet-
ter educated patient decision on whether to proceed and a more satisfied patient after
surgery when patient expectations are better aligned with the potential outcomes.

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