Morton's Neuroma Surgery

Click here for conservative treatment options for neuroma

We can usually relieve pain caused by neuromas without resorting to surgery, and in fact, we feel surgery should be only used as a last resort. We have other pages on this site dealing with best non-surgical treatments for neuroma and home treatment for neuroma.

When should you have neuroma surgery?
At the Foot and Ankle Center of Washington we use the following criteria as a guideline when determining if a neuroma operation is indicated:

• You have a neuroma confirmed by examination, diagnostic injections and possibly ultrasound or MRI
• You have exhausted all conservative care. Conservative therapy may include the following:
  • Custom orthotics, prescribed and cast by your doctor and designed to relieve pressure on the neuroma
  • Shoe Therapy, including proper shoes for your foot type and activities and possible modifications to your shoes.
  • Accommodative padding.
  • Injection therapy
• Your neuroma interferes with daily activities.

The Neuroma Surgical Procedure
There are several different surgeries currently being used regularly for either decreasing pressure on the nerve or completely removing the neuroma.¹

Incision Choices
The first consideration is where the incision should be placed. Neuroma surgery can be performed either from the bottom of the foot or from the top. Both methods have their advantages and disadvantages. Surgery from the bottom of the foot (plantar approach) offers the advantage of a more direct approach.² The downside to the plantar approach is the possible pain that can occur from having a scar on the bottom of your foot.

The other option is to use an incision on top of the foot. This technique is considered the better approach for most people because it avoids the problems associated with an incision on the bottom of the foot – such as a scar on the bottom of the foot. Our preference is usually to perform the dorsal (top of foot) procedure as it avoids the complications of a painful scar on the bottom of the foot The only time we usually recommend the plantar approach is for those people who have had return of a neuroma after a prior surgery.

Surgery Choices
The goal with neuroma surgery is to relieve the pressure caused by the enlarged nerve. There are a couple ways to accomplish this. One surgical option is simply to release the ligament between the metatarsal bones and thereby reduce the pressure that the metatarsal heads place on the neuroma. The advantage of this procedure is that the nerve is left intact and it eliminates the possibility of developing a new neuroma (called a “stump neuroma”) at the site where the nerve is removed. The disadvantage is that the neuroma is left in place and may continue to cause pain. .

The second option is to perform remove the neuroma completely (a neurectomy) The advantages of this procedure are that the enlarged portion of the nerve is completely removed leading to what we feel is a more predictable relief of pain. A disadvantage is that removing a portion of the nerve leaves a numb sensation on a small portion of the toe. ^3,4

To our knowledge, no good studies are available that compare these two primary surgical procedures for Morton’s neuroma. The most common surgery is removal of the nerve. We usually remove the neuroma as it seems to offer less chance pain will return later.

Postoperative Treatment
Many studies state that patients can walk on their foot immediately after a neuroma operation as long as they use a protective post-op shoe. We find, however, that patients have a much better recovery period with less pain and swelling if they give their foot more protection in the first weeks after surgery. For the best results and least pain we recommend being non-weightbearing (on crutches or a knee-walker) for about 1-2weeks after neuroma surgery. After that you will wear a walking boot for 2-4 more weeks. Most patients can then usually move into a regular shoe as tolerated. Patients may work into a shoe but may still have some discomfort until the area completely heals and tissues remodel.

We find that patients often do better long term if they wear total contact orthotics in shoes after recovery from neuroma surgery. The orthotics act to decrease pressure under the surgery site on the ball of the foot. This is particularly helpful during the first months after surgery when some healing is still taking place.

Complications
Every surgery has potential complications. Every effort is made to prevent them, but they can still occur. In fact, both the surgeon and the patient can do everything perfectly right, and a certain number of patients will still develop complications. These include pain, infection, stump neuroma and slow healing. Other complications, more specific to neuroma surgery, include:

• numbness - one complication will almost always occur after neuroma surgery – and that is numbness in the skin on the sides of the toes adjacent to where the neuroma was removed. For most patients, this is not a problem as they don’t notice it in day to day activity. Sometimes there is also some numbness on the bottom of the foot near the site where the neuroma was located.
• Callus - In rare cases patients can develop a callus under the ball of the foot. This is probably due to changes in weightbearing after the surgery.
• Continued or Return of Neuroma Pain after Surgery - There are a number of reasons that pain persists or returns after neuroma surgery. Patients who have had the decompression type of surgery may continue to have problems if the size of the neuroma is such that it still becomes irritated. Those patients who have had removal of the neuroma may develop a stump neuroma (a second neuroma that forms at the site that the nerve was cut during surgery) that may be even more painful than the original problem. These stump neuromas can be very difficult to treat and may require additional injections and possibly another surgery.
• Metatarsal pain from removal of fat in the area.
• Pain from an adjacent neuroma

There are a number of variables in selecting a neuroma surgery and the most important key to a successful outcome is finding an experienced surgeon who understands each variable and who has the skills to perform all types of procedures. On our Bunion Surgery page, we

How do you find the Best Neuroma Surgeon?
As in everything, some foot surgeons are exceptionally skilled at neuroma surgery; some are mediocre and most are somewhere in-between. To ensure the best possible outcome, it is critical that you find an experienced and skilled neuroma surgeon. On our page on bunion surgery, we outline a number of items to look for in identifying good surgeons and also how to identify surgeons you should avoid. You can find surgeon evaluation information here.

Click here for conservative treatment options for neuroma

References
1. Weinfeld SB, Myerson MS. Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg. Nov 1996;4(6):328-335. [Medline].
2. Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. Mosby-Year Book;1999.
3. Thompson FM, Deland JT. Occurrence of two interdigital neuromas in one foot. Foot Ankle. Jan 1993;14(1):15-7. [Medline].
4. Levitsky KA, Alman BA, Jevsevar DS. Digital nerves of the foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot Ankle. May 1993;14(4):208-14.[Medline].
5. Thomas JL, Blitch EL 4th, Chaney DM, Dinucci KA, Eickmeier K, Rubin LG, et al. Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. Mar-Apr 2009;48(2):251-6. [Medline].
6. Mulder J. The Causative Mechanism in Morton's Metatarsalgia. J Bone Joint Surg Br. 1951;33:94-95.
7. Rout R, Tedd H, Lloyd R, Ostlere S, Lavis GJ, Cooke PH, et al. Morton's neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians. Qual Prim Care. 2009;17(4):277-82. [Medline].

 

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Douglas Hale, DPM & Lawrence Huppin, DPM
Foot and Ankle Center of Washington, Seattle
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