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Morton's Neuroma is caused by an irritated nerve a common problem in runners, and there are a number of simple fixes you can try before resorting more drastic solutions like sclerosing or surgery. A Morton's Neuroma normally causes a burning pain in the forefoot, usually between just behind the 3rd and 4th metatarsal headstoes (sometimes behind the 2nd and 3rd toes). The pain can be felt near often radiates towards the toes, and sometimes there is numbness rather than pain. The underlying cause is inflammation of the nerve between the bones of the metatarsal headsforefoot, often triggered by narrow or it can radiatetight [[Shoes|shoes]]. I have had good results with the simple fixes described below, mostly towards the 3rd and 4th toesI have had reports of other runners with similar success. {{DISPLAYTITLE:Mortons Neuroma, symptoms and fixes}}==Symptoms=Causes of Morton's Neuroma =Below A Morton's Neuroma is not a true neuroma, which is a list tumor that is generally benign. Rather, it is an enlargement of possible symptoms with the percentage nerve where it goes between the metatarsal bones of the foot. Because the nerve no longer fits between the gap, the pressure causes pain and sometimes numbness. This enlargement of patients who reported them based on two studiesthe nerve is often an inflammation due to irritation. Where both studies included a response there If the forefoot becomes compressed due to shoes that are two percentagestoo narrow, the nerve becomes damaged and inflamed. This inflammation means the nerve no longer fits in the space between the bones, creating further irritation and more inflammation. If this vicious circle can be broken, the problem may be resolved. However, in some situations the nerve can have fibrous tissues formed around it, which may require the destruction of the nerve or surgical removal.=Morton's Neuroma Symptoms=* Pain increased with walking The classic symptoms of Morton's Neuroma are a pain on the lower (91%plantar)surface of the foot, located between the 3^rd and 4^th metatarsal heads, though it can happen less commonly between other metatarsal's. The picture below shows the location of the inflamed nerve. The pain can be dull or sharp, and is often burning, occasionally radiating to the toes. Sufferers often find that removing footwear or massaging the area helps relieve the pain. * Relief by rest (89%){| class="wikitable" |- valign="top"* Plantar (sole) |[[File:Mortons2.jpg|right|thumb|x250px|The pain is felt in the area highlighted in red. It is often a burning pain (77%)that radiates out towards the toes.]]* Pain |[[File:Mortonneuroma.jpg|none|thumb|x250px|The is the most common location for the inflamed nerve that causes a Morton's Neuroma. The nerve gets compressed between the bones in Forefoot (76%)the forefoot.]] |}* Relief by removing shoe =Alternative Explanations (70%Differential Diagnosis)=* Pain radiating There are other problems that can have similar symptoms to toes a Morton's Neuroma. The most likely problems are a stress fracture (62%or stress reaction)and intermetatarsal bursitis. * Burning Pain (54%)* Pain between toes (43%)* Numbness into toes or A stress fracture in the metatarsal bones of the foot (40%/23%)* Aching or sharp can produce similar pain (40%)* Inability to wear fashionable shoes (39%)a Morton's Neuroma. Stress fractures are hard to diagnose, and won't generally show up on an x-ray. An MRI may reveal a stress fracture, but if the fracture is at the metatarsal head it can be overlooked as these are relatively rare. * Pain A stress reaction is the changes in the bone that occur with excessive stress, but before a fracture occurs. These stress reactions may show up foot or leg (34%/11%)as an edema-like bone marrow abnormality on an MRI. * Cramping Sensation The bursitis is an inflammation of the small, fluid-filled sacs (34%bursae)that provide cushioning to the bones, tendons and muscles near joints. There are bursae between the metatarsals that can become inflamed and produce symptoms similar to Morton's Neuroma.* Pain at rest (19%)* History While rare, it's also possible for the symptoms to indicate a sesamoid fracture, nodules associated with rheumatoid arthritis, synovial cyst, soft tissue chondroma, and plantar fibromatosis. I talked to one runner who had symptoms of assocated injuries (15%)* Pain at night (10%)* Pain in entire foot (9%)a Morton's Neuroma which turned out to be caused by large calluses under the forefoot. {| class="wikitable" |- valign==Images=="top"|[[File:MortonneuromaThe intermetatarsophalangeal bursa.jpg|right|thumb|x250px|The location of the bursa between the metatarsals.]]  |[[File:NeuromaCrossSection.JPG|none|thumb|x250px|Here is a cross section of the foot showing the location of the nerve. [[File:NeuromaCrossSection.JPG]]|}==In depth information=Diagnosing Morton's Neuroma=The best in-depth information on Morton's Neuroma is from not easy to diagnose clearly, but these are the Google Bookprimary tests. * '''Mulder's copy of [http://booksTest'''.google.com/books?id=sG5uN6KaU-8C&lpg=PA231&ots=atnvfRpn5Q&dq=mortonWhile not the most accurate diagnosis, it's%20neuroma&pg=PA231#v=onepage&q&f=false|McGlamry's comprehensive textbook easy to perform. The test simply puts pressure on the neuroma to see if this elicits pain. One hand is used to squeeze the sides of foot the forefoot, pressing the metatarsal heads together, and ankle surgery, Volume 2] ==What worked for me==I found that using [http://www.amazon.com/Foot-Alignment-Socks-Small-Medium/dp/B001U5BGUC "Comfy Toes Foot Alignment Socks"] has provided me with more relief than any the fingers of the other treatments I tried. These socks hand are intended used to squeeze the area between the metatarsal heads (where the pain is located). The pain is sometimes accompanied by a click the can be felt, called Mulder's click, further suggesting a Morton's neuroma.* '''Digital Nerve Stretch Test'''. While not as commonly used so that they stretch as Mulder's, this is another simple test. Both ankles are held in full dorsiflexion (toes pulled towards the gap between each toeshins), as shown while the toes either side of the suspected Morton's Neuroma are manually extended on both feet (see picture below). I wore Pain in the socks like this overnight and found it helped quite suspected location indicates a bitMorton's Neuroma. * '''MRI'''. The best diagnostic tool is an MRI, but it did trigger quite where a Morton's Neuroma is indicated by a bit Neuroma of pain as 5mm or more. The MRI should be performed in the prone position with the foot plantar-flexed (toes were stretched in pointed) and without contrast enhancement. If the neuroma is smaller than 5mm then other conditions should be considered. On the other hand, a negative MRI result does not exclude the nightpossibility of a Morton's Neuroma as studies have shown false negative rates of 17% and studies suggest that 30-35% of subjects have a Morton Neuroma without any symptoms. * '''Ultrasound'''. (You Ultrasound can see be used to diagnose Morton's Neuroma, but one study found that Ultrasound only found 56% of cases and there are concerns of a high false positive rate, so MRI is preferred. Ultrasound imaging is quite dependent on the technique and interpretation of the scar tissue on my feet from [[Epidermolysis Bullosa]]operator.){| class="wikitable" |- valign="top"|[[File:ToeStretcherIntendedMulders Sign.jpg|none|thumb|x200px|Mulder's Test.]] I changed the usage so that all the |[[File:digital nerve stretch was between the toes that have the Mortons Neuroma, as shown belowtest. This increased the stretch quite a bit and relieved the Mortons Neuroma furtherjpg|none|thumb|x200px|The Digital Nerve Stretch Test. It also reduced the pain I experienced overnight from the stretch. ]]|[[File:ToeStretcherUnintendedMortons Neuroma MRI.jpg|none|thumb|300px|MRI showing a Morton's Neuroma.]]|}==Other Treatments=Fixing Morton's Neuroma=A Morton's neuroma can be a difficult thing to fix once it flares up. The following are a list of possible longer the symptoms persist, the harder it can be to fix the problem, so don't ignore it. I recommend starting with conservative approaches before resorting to treating surgical intervention.* Getting a clear diagnosis is important, as the treatment for a stress fracture and Morton's Neuromaneuroma are quite different. None Get an MRI from a practice that specializes in the foot problems of these worked very well for me, but Your Mileage May Varyathletes and has extensive experience with Morton's neuroma. * The most important approach is It's critical to avoid prevent the nerve being aggravated further. Avoid any footwear that squeezes compresses the forefootsides of your foot or is too narrow. This will aggravate Wearing the nervewrong shoes, so avoid any shoe that puts any pressure on the sides even for a short period of the forefoottime, can cause a Morton's neuroma to flare up for weeks. It Changing footwear may help in over 40% of cases. * I resorted to go up a shoe size, or cutting away the shoe where it touches the sides of my shoes at the forefootto prevent pressure aggravating my Morton's Neuroma. * Check See below for alternative causesdetails. One runner found their pain was caused by calluses! * Toe stretchers can I used the overnight toe spreading socks (see below) to help spread heal the Morton's Neuroma I had. This approach gently spreads the metatarsal heads. I've used [http://www.amazon.com/Telebrands-PC-PAMPEREDTOES-Deluxe-Pampered-Toes/dp/B002HMCIOK/ref=sr_1_1?ie=UTF8&qid=1295090906&sr=8-1&rps=1 Pampered Toes] to give the nerve room to recover and it seems to helpprevent irritation. * Many people find that a metatarsal pad in their shoes help relieve the problem. I know of runners who will not run without metatarsal pads.* Orthotics may help, though I personally dislike orthotics and believe they are likely to cause other problems. * A simpler alternative to orthotics is to build This pad presses up the insole of your shoes under the first metatarsal and big toe area. This can reduce that hurts to spread the pressure on the nervemetatarsal heads. The insole can It may be possible to build up with the area using layers of duct tape rather than a pad, which may give more control over the shape and I know size of at least one runner who has benefited from this approachthe pressure. However, if the problem is a stress fracture rather than a Morton's Neuroma, a metatarsal pad will aggravate the problem.* Cortisone injections can help reduce the inflammation of the nerve, but often multiple injections are requiredand the relief may be temporary. ** Cortisone is a steroidal anti-inflammatory that may be able to break the vicious cycle of irritation and inflammation, and allow the nerve to heal. By temporarily shrinking the nerve, it is more likely to fit in between the metatarsals without irritation.** There suggestions that cortisone can help in about 40% of cases and that relief can last for three months. Typically injections are given 1-3 weeks apartand should be given from the top of the foot or between the toes, not through the sole of the foot. * Alcohol injections are generally considered a safe approach that can be effective. ** I could not find a clear explanation of the mechanism for the alcohol; but this technique is sometimes called "sclerosing" meaning to harden, or "[http://en.wikipedia.org/wiki/Neurolysis neurolysis]" meaning a temporary degeneration or blocking of the nerve. * Injections * One study showed that 3 to 7 injections of a 4% alcohol solution every 5–10 days helped ~90% of cases. A ten month follow up indicated a reduction in the size of the neuroma. ** The injections combine alcohol with an anesthetic to reduce the pain. The treatment can be used to kill off leave is some residual, transient pain in some cases (sclerosing~16%) . ** Note that the nervealcohol injection should be guided accurately using ultrasound, which requires a skilled technician and this may limit the effectiveness of the treatment. Without the ultrasound guidance, the treatment does not seem as effective.* If nothing else works, the nerve can be surgically removed, which is generally successful(~80%), though there are in some cases of (~5%) the end of the removed nerve becoming becomes inflamed and causing problemsrequires further surgery. If this approach is taken, it is recommended that the nerve is removed through the top of the foot to prevent problems with scaring of the sole of the foot and reduce recovery times. * X-Rays and a professional evaluation can be useful There is little evidence to rule out other possible problemssupport the use of orthotics in treating Morton's Neuroma. * Ice may help, but it does not seem as effective on this problem is it is on muscular problems. * Strengthening There are some recommendations for strengthening the [[Muscle|muscles ]] that flex the toes and support the arch of the foot may help, but I found no evidence to support this. Typical exercises would include scrunching up a towel with the toes, or picking up marbles with the toes.==Overnight Toe Spreading Sock==I found that using [http://www.amazon.com/Comfy-Alignment-Socks-Small-Medium/dp/B001RYWZN8 "Comfy Toes Foot Alignment Socks"] has provided me with more relief than any of the other treatments I tried. A similar product is [http://www.amazon.com/Happy-Feet-Womens-Original-Alignment/dp/B005GYVYQ4 Happy Feet]. These socks are intended to be used so that they stretch the gap between each toe, as shown below. I wore the socks like this overnight and found it helped quite a bit, but it did trigger quite a bit of pain as the toes were stretched in the night. (You can see the scar tissue on my feet from [[Epidermolysis Bullosa]].)[[File:ToeStretcherIntended.jpg|none|thumb|250px|This is how the socks are supposed to be used.]]I changed the usage so that all the stretch was between the toes that have the Morton's Neuroma, as shown below. This increased the stretch quite a bit and relieved the Morton's Neuroma further. It also reduced the pain I experienced overnight from the stretch. [[File:ToeStretcherUnintended.jpg|none|thumb|250px|This is the way that I found to be most effective.]]There are plastic toe spreaders such as [http://www.amazon.com/Telebrands-PC-PAMPEREDTOES-Deluxe-Pampered-Toes/dp/B002HMCIOK Pampered Toes], but I didn't find them as comfortable.==Shoe Modification==I routinely cut open the toe box of my shoes to allow my toes to spread while I run. This prevents blisters of the toes, and I believe it also increases my biomechanical efficiency. However, when I had a Morton's neuroma I cut far more of the shoe a way to prevent any pressure on the sides of my forefoot.[[File:Open Toe Box.jpg|none|thumb|200px|My Modified Nike Frees]]A friend did a rather more subtle change, opening up just the sides where the forefoot touches the shoe[[File:SarahsModSmall.jpg|none|thumb|200px|Minor modification, cutting open the side of the shoe]][[Category:Injury]]