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Foot and Ankle Surgery xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Review

Morton’s interdigital neuroma of the foot

A literature review
Francesco Di Caprio, MD* , Renato Meringolo, MD, Marwan Shehab Eddine, MD,
Lorenzo Ponziani, MD
Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy

A R T I C L E I N F O A B S T R A C T

Article history:
Received 26 September 2016 Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains little
Received in revised form 15 November 2016 studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study may deal
Accepted 27 January 2017 with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The present literature
Available online xxx review crosses all key points, from diagnosis to surgical and nonoperative treatment, and recurrences.
Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in those
Keywords: who want to delay or avoid surgery. Dorsal or plantar approaches were described for surgical treatment,
Morton both with strengths and weaknesses that will be scanned.
Civinini
Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse metatarsal
Interdigital neuroma
ligament, too distal resection of common plantar digital nerve, an association of tarsal tunnel syndrome
Metatarsalgia
and incomplete removal. A deep knowledge of the causes and presentation of failures is needed to
surgically face recurrences.
© 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Conservative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Surgical treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Recurrent neuromas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction treatment. The third in conservative and infiltrative treatment.

The fourth in discussion and final supervision.
Morton's neuroma is a very common cause of metatarsalgia, Interdigital neuroma is a clinical syndrome of the forefoot
and consists in an interdigital nerve disease of the foot, classically which has often been described in the last two centuries. It was
located at the third intermetatarsal space. first reported by Civinini [1,2] in 1835 and later by Durlacher in
Despite its high incidence, Morton’s neuroma was little studied. 1845 [3], who described the clinical complex of symptoms. Thomas
For this reason we performed this literature review, with the first George Morton described “a peculiar and painful affection of the
author being involved in literature search, paper drawing up, fourth metatarsophalangeal articulation” in 1876 [4,5]. He
introduction and diagnostics. The second author in surgical attributed the pain to the fourth metatarsophalangeal joint. It
was Hoadley who first actually excised an interdigital neuroma
from the third webspace of a foot in 1883 [6].
* Corresponding author at: U.O. Ortopedia e Traumatologia, Ospedal Ceccarini,
Morton's neuroma prefers the female sex, with a female:male
Viale Frosinone, 47838, Riccione (RN), Italy. Fax: +39 0541 608837. ratio of 4:1 [7], with an average age of 50 years at surgery [8]. The
E-mail address: [email protected] (F. Di Caprio). neuroma is bilateral in 21% of cases, it affects third space in 66% of

http://dx.doi.org/10.1016/j.fas.2017.01.007
1268-7731/© 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

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cases, the second in 32%, and the fourth in 2% [8]. Multiple

locations are rare [9].
The most common symptom is a burning pain in the plantar
aspect of the foot, located between the metatarsal heads, often
radiating to the two corresponding toes. Sometimes the patient
reports a shooting sensation on the plantar side, associated with
sharp pain. Occasionally the pain radiates proximally along the
plantar or dorsal surface of the foot. The pain is exacerbated when
the patient is wearing a tight shoe or a heel, which is why the
patient is forced to remove the shoe and massaging the foot. The
patient may report a sensation of numbness in the toes or shock
sensation.
Below the medial malleolus the tibial nerve divides into two
plantar branches, medial and lateral. These are distributed to the
sole up to the intermetatarsal spaces. In particular, the medial
plantar nerve is divided into the own digital hallux nerve and the
common digital nerves for first, second and third interspace, while
the lateral plantar nerve form the own digital nerve for the fifth toe
and the common digital nerve for the fourth interspace. An
anastomotic branch, present in 66.2% of cases, arises from the
common digital nerve for the fourth interspace, passing below the
fourth metatarsal, in communication with the common digital
nerve to the third interspace, whereby the latter is formed by an
anastomosis between branches from both nerve trunks [10]. Each
interdigital nerve passes below the corresponding distal metatar-
sal transverse ligament (DMTL), which is just proximal to the
metatarsal heads, and then divides into the two digital nerves.
Morton's neuroma [11] consists of a bulge in the interdigital
nerve just distal to the DMTL, and before the bifurcation in the
digital nerves (Fig. 1). Macroscopically it has a typically fusiform
configuration, a glistening and white to yellowish appearance and
a relatively soft consistency. Histological findings include neural
degeneration, epineural and endovascular hyalinization, and
perineural fibrosis [12–14].
It was suggested that the common digital nerve to the third
interspace is thicker than the others, as it results from an
anastomosis between branches from the two nerve trunks [15–
17]. Another anatomical factor is the increased mobility of the
fourth radius (moving on the cuboid), compared to the third (fixed
to the cuneiform). Some believe that taut DMTL play a critical role
in compressing the interdigital nerve [12]. In this sense, the use of
high heels is another predisposing factor since the extension of the
metatarsophalangeal forces the digital nerve just beneath the
DMTL [1,17,18]. This latter theory was debated on the basis of
anatomical studies [19] and imaging [20]. Fig. 1. Subdivision of plantar nerves.
Illustration showing the anastomotic branch from the common digital nerve for the
Some studies described the relationship with trauma [21,22].
fourth interspace (branch from the lateral plantar nerve), to the common digital
nerve to the third interspace (branch from the medial plantar nerve). The
2. Diagnosis interdigital nerve passes below the corresponding intermetatarsal ligament, which
is just proximal to the metatarsal heads, and then divides into the two digital
The diagnosis of Morton’s neuroma is eminently clinical [23– nerves. Morton's neuroma consists of a fusiform bulge in the interdigital nerve just
distal to the intermetatarsal ligament, and before the bifurcation in the digital
25]. It’s important to accurately locate the pain. In fact, patients
nerves.
with Morton's neuroma do not experience pain on the metatarsal
heads. In the latter case it will be important to highlight the
forefoot deformities, instability or arthritis in the metatarsopha- Ultrasound and MRI have always been considered not reliable
langeal joint, Frieberg’s disease. in the diagnosis of Morton's neuroma [13,26,31–34]. The MRI
Clinically there may be tenderness and a dorsal bulging may be recently showed a sensitivity 93% with specificity 68%, while the
found. It may also be present an enlargement of the interdigital ultrasound sensitivity was 90% and specificity 88% [35]. Ultra-
space. When pressure is applied axially to the intermetatarsal sound, even in highly skilled hands, has a high rate of incidental
space acute pain is induced. The pressure can be exerted while finding of an asymptomatic interdigital nerve enlargement,
tightening the metatarsals with the other hand, and this may be which can lead to a false diagnosis of a Morton’s neuroma.
associated with a painful and palpable clicking sensation (Mulder’s Moreover small lesions are difficult to diagnose by imaging, but
sign) [25]. This test demonstrated a 94–98% sensitivity [26–28]. are still able to cause symptoms as larger lesions [32,33]. Clinical
X-rays are essential to investigate other causes of metatarsalgia examination is still the gold standard for the diagnosis of a
[29,30] (metatarsal hypermetria, tarsal–metatarsal joint stiffness, Morton’s neuroma [32,33].
Frieberg's disease, toe deformities, metatarsal–phalangeal insta- There is no absolute requirement for imaging patients who
bilities). clinically have a Morton’s neuroma. The two main indications for

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imaging are (a) an unclear clinical assessment and (b) cases when The surgical approach may be dorsal [66–69] or plantar
more than one web space is affected. Ultrasonography should be [23,70,71].
the investigation of choice [28]. A longitudinal dorsal approach centered on the interspace
On the contrary, The MR imaging diagnosis of Morton’s (Fig. 2) is the preferred by most surgeons, and it was first described
neuroma does not imply symptomatology. Careful correlation by McElvenny in 1943 [72]. The advantages of a dorsal approach as
between clinical and MR imaging findings is mandatory before compared to plantar approach are claimed to be as follows [12,73]:
Morton's neuroma is considered clinically relevant [30]. (1) The ability to release the DMTL; (2) The dorsal incision being in
The use of local infiltration with 2 ml of lidocaine below the the non-weight bearing surface of the foot, allows for early
intermetatarsal ligament instead has a high diagnostic value rehabilitation; (3) It provides a good overview interspace and
because it causes temporary pain relief. allows to follow the nerve proximally; (4) The plantar cutaneous
nerves are easier to find and excise through dorsal approach as
3. Conservative treatment compared to plantar approach where dissecting the nerves in
plantar fatty tissue can be difficult.
Conservative treatment consists in the use plantar orthosis with A longitudinal plantar approach (Fig. 3) must be performed
metatarsal unloading. The use of steroid infiltrations provides a exactly below the intermetatarsal space to avoid the scar to affect
long-term resolution of symptoms in a small percentage of cases the loading portion. In addition, the incision must be thorough
(30%) [36–38]. Some authors reported that injections provided with resolution through the fat pad to prevent the dissection
complete pain relief in approximately 30% of patients, and partial [74,75]. It’s possible to perform a transverse plantar approach
relief in 30–50% [36,39]. After two years nearly 95% of those (Fig. 4) just proximal to the flexion skin fold [70,76]. This prevents
patients with initial complete pain relief remained asymptomatic approach to the load portion, but it must be extended to the
[36]. Better long-term results were demonstrated for smaller adjacent spaces, with significant dissection, possible atrophy of the
neuromas [40]. fat pad, and difficulty following the nerve proximally [12].
Steroid infiltrations are repeatable only in a limited way as they The advocates of plantar approach believe that this approach is
can lead to atrophy of the plantar fat pad, skin discoloration at the safe, they do not believe that there is need to release the DMTL;
injection site [41], rupture of the metatarsophalangeal joint they believe that the DMTL is not contributing to neuroma
capsules with deviation of adjacent toes. In 60–70% of cases the formation and that its release predisposes to metatarsalgia by
patients still decide to undergo surgical treatment. One study metatarsal splaying [20,73].
compared the results of conservative and surgical treatment of Nevertheless one study revealed that DMTL transection does
Morton’s neuroma and as the result the authors recommended not increase the intermetatarsal angle or the risk of splayfoot
surgical treatment as initial treatment [42]. However, the development. Moreover, transection is recommended due to an
infiltrative treatment is believed to be indicated in those who enhanced overview during surgery and better clinical outcome
want to try to avoid surgery, or to delay surgery due to business or [77].
sporting engagement. An endoscopic decompression of the interdigital nerve through
In the recent years, new treatment strategies were studied. DMTL release was also described, with overall good results, low
Botulinum toxin A already demonstrated analgesic effects in rate of complications, and no loss of sensitivity [78–82]. One study
epicondilitis, low back pain, piriformis syndrome [43] and plantar indicated neurolysis by DMTL release in the cases of compression
fascitis [44], and also in neuropathic pain [45]. The analgesic symptoms without macroscopic changes in the nerve, with results
effects of the toxin may be related to inhibition on neuropeptide similar to neurectomy [83]. But no comparative studies between
release in nociceptive terminals [46]. A recent study about neurectomy and decompression exist.
Botulinum toxin A in the treatment of Morton’s neuroma
demonstrated improvements in 70.6% of patients 3 months after
a single injection, with no adverse effects [47]. Long-term results
are lacking.
Alcohol injections also demonstrated improvements in 69–90%
of cases [47–49], and a 30% decrease in the size of the neuroma
[48,50]. This treatment is repeatable, but a transitory increase in
pain occurred in 15% of patients [48]. Long-term results however
demonstrated a deterioration, with approximately one third of
patients undergoing surgery, one third with pain recurrence, and
only one third remaining pain free at five years follow-up [51].
Infiltrative treatment can also use ultrasound guidance [47,52–
55], even if this strategy failed to demonstrate better results
compared with non-guided injections [56].
Other conservative treatment methods include radiofrequen-
cies [57–60], extracorporeal shockwave therapy [61,62], laser
therapy [63,64], homeopathic injections [65].

4. Surgical treatment

Surgical excision of Morton’s neuroma must provide for the

common digital nerve resection as proximal as possible, with the
proximal stump embedded in the context of the intrinsic muscles,
to avoid an eventual amputation neuroma placed below the
metatarsal heads. It is necessary to avoid removing large amounts
of fat tissue to prevent the scarring and then the atrophy of the Fig. 2. Dorsal approach.
plantar pad. Illustration of longitudinal dorsal approach centered on the third interspace.

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Percutaneous treatment methods include metatarsal osteoto-

mies associated with DMTL release. One recent study [84]
demonstrated short-term results comparable with neurectomy,
but with better long-term results.
Another study demonstrated better results with metatarsal
shortening osteotomy associated with DMTL release, compared
with ligament release alone in the treatment of Morton’s Neuroma
[85].
The success rate for neurectomy ranges from 51% to 85% in long-
term follow-up studies [8,23,66,67,70,73,86,87].
Postoperative wound infection, hematoma and scar problems
were significantly higher in patients having plantar approach as
compared to those having dorsal approach [73]. Disorders related
to plantar scarring in the case of plantar longitudinal approach are
reported in 5.2% of cases, including delayed wound healing,
hypertrophic scar formation, and inclusion cyst [74].
The delay to full weight bearing was significantly better for the
dorsal approach [73]. No significant differences were demonstrat-
ed in overall long-term results between dorsal and plantar
approaches [88].
Scoring results were significantly better in cases of single
neuroma surgery, compared to multiple neuroma excisions [8]. It
remains unclear if the presentation of multiple neuromas itself is
the reason for a lower level of satisfaction, if multiple neuromas
correlate with other underlying forefoot pathologies, or if
diagnosis of these multiple neuromas was correct at all. Previous
reports have cautioned against simultaneous exploration of
adjacent interspaces, stating that the occurrence of two neuromas
in the same foot is rare and that the expected outcome is worse
Fig. 3. Plantar longitudinal approach. than that after the exploration of one interspace [7,9,66,89].
Illustration of longitudinal plantar approach centered on the third interspace. Nevertheless other reports did not confirm this hypothesis
[87,90,91].
No difference was found comparing scoring results between
patients who underwent neuroma excision in second and third
webspaces [8].
Comparing results of patients with or without transection of
the deep intermetatarsal transverse ligament showed slightly, but
not significantly, better results for cases with transection of the
deep transverse ligament. Poor results were observed more often
in cases without transection of the deep transverse ligament [8].
A reduction of sensation or numbness in the supplying area of
the resected nerve was detected in 72% of the feet [8,92]. The
clinical outcome was not influenced by the level of sensibility [8].
The pattern of numbness was quite variable and it was bothersome
a limited percentage of cases (17%) [73,92]. Sometimes the residual
discomfort is described as the feeling of walking on cotton, or to
have the jammed sock under the foot. Only 63% of the patients are
completely pain free at follow-up [87].
The common digital artery accompanies the nerve, and it is
resected along with the neuroma in 39% of cases. However this
does not create disorders due to the presence of anastomotic
networks [93].

5. Recurrent neuromas

The failure rate of neurectomy was reported to be as high as

14%–21% [73].
Recurrence of symptoms following interdigital neurectomy is
believed to be due to wrong diagnosis, wrong interspace, failure to
divide the transverse metatarsal ligament, too distal resection of
common plantar digital nerve, an association of tarsal tunnel
syndrome and incomplete removal [66,72,75,94,95].
The review of recurrences [96–98] have shown that two thirds
Fig. 4. Plantar transverse approach.
Illustration of transverse plantar approach just proximal to the distal flexion skin
of patients showed symptoms within 12 months from the first
fold, and extended from fourth to second webspaces. surgery. In these cases it is likely that the problem had never been
solved. A third of the patients developed an amputation neuroma,

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which needs at least 12 months to generate. In these cases it is purposes of this paper, which was conducted in order to provide a
likely that the cause is due to a resection not enough proximal. comprehensive and updated overview of the present literature for
The plantar branches prevents the nerve stump to retract clinical guidance.
proximally. They are concentrated in the 4 cm proximal to the When approaching a suspect of Morton’s neuroma (Fig. 5),
intermetatarsal ligament. So a resection at that level, or more medical history and physical examination play a decisive role. It’s
proximal, ensures that the nerve can withdraw proximally [99]. important to let the patient talk, which often describes the
Surgically facing a recurrent neuroma via dorsal approach symptoms in a very suggestive way of Morton’s neuroma. The foot
needs expanding the incision of about 1 cm proximal to adequately examination should search for the exact trigger point, distinguish-
expose the intermetatarsal space. ing between metatarsal and intermetatarsal pain. In the latter case
Plantar approach for recurrent neuroma showed better results it is essential to search the Mulder’s sign.
in various studies [12,20,72,90,94,96,97,100]. Other surgical When we have a clinical certainty of neuroma, it is not
improvements include release of the transverse metatarsal necessary to make use of any instrumental examination. In fact
ligament alone or in combination with neurolysis, and intermus- ultrasound and MRI, even if with high sensitivity [35], are not fully
cular transposition of the transected nerve [94]. reliable for the diagnosis [32,33]. If in doubt about the diagnosis,
The results of surgical treatment of recurrent neuroma are not use of imaging techniques may raise further doubts, both in the
satisfactory in 20–40% of patients [97]. Intra-operative findings, surgeon and in the patient, which in case of negative test will find it
simultaneous surgery to adjacent interspaces, concomitant fore- hard to believe the doctor’s diagnosis and seek a second opinion.
foot surgery and previous re-explorations did not significantly The most reliable method to clarify the diagnosis is a local
influence the outcome. Persistent or recurrent symptoms after anesthetic injection. Unfortunately it is common for patients to
transection of a nerve present a challenging problem for both the come to visit with these exams already available. There is often a
surgeon and patient. It is essential that there is a thorough pre- discrepancy between the physical findings and imaging, and in
operative discussion with the patient, providing the rates of failure these cases the surgeon needs to explain to patients that these tests
and the increased likelihood of restriction of footwear and activity are often misleading and that we must trust in the clinical
after revision surgery [91]. examination giving indication for surgery.
In case of metatarsal pain instead is necessary to examine other
6. Discussion possible causes of metatarsalgia, such as forefoot deformities,
alterations in the metatarsal formula, tarsal–metatarsal stiffness,
Morton’s neuroma is a very common cause of metatarsalgia, metatarsal–phalangeal instabilities, Frieberg’s disease.
and consists in an interdigital nerve disease of the foot, classically It is not impossible that the two issues are related, and for these
located at the third intermetatarsal space. cases combined techniques exist.
The weakness of this study is that a quality analysis of the Plantar orthosis can be useful for conservative treatment. The
papers was not performed, nor a comparison of the results from use of steroid infiltrations provides a long-term resolution of
the various studies in terms of AOFAS score or Foot Health Status symptoms in 30% of cases, and it’s indicated in those who want to
Questionnaire. A meta-analysis of the results was not in the try to avoid surgery, or to delay surgery due to business or sporting

Fig. 5. Algorithm for clinical practice.

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Please cite this article in press as: F. Di Caprio, et al., Morton’s interdigital neuroma of the foot, Foot Ankle Surg (2017), http://dx.doi.org/
10.1016/j.fas.2017.01.007