1. Morton’s Neuroma

2. Normal Anatomy
Intermetatarsal plantar nerves are terminal branches of the medial and lateral plantar nerves
Run into the webspace plantar to the intermetatarsal ligaments
Each nerve passes within the plantar aponeurosis and splits into 2 branches supplying the skin
The 3rd common nerve receives a large communicating branch from the lateral plantar nerve which passes deep to the deep transverse metatarsal ligament at the 3rd web space

3. Pathology
Benign neuroma (a growth of neural tissue) or irritation of an intermetatarsal plantar nerve
Causes neuropathic pain most commonly the 2nd and 3rd metatarsal spaces

4. Mechanism of Injury Insidious Chronic Trauma Theory Ischemia Theory
Multiple different theories that may be occurring in isolation or concurrently
Chronic Trauma Theory
Repetitive trauma to the forefoot and plantar intermetatarsal structure
Dorsiflexion of the toes and contraction of the flexor digitorum brevis stretches intermetatarsal plantar nerves causing repeated traction
Ischemia Theory
Degenerative changes to the plantar digital arteries
Intermetatarsal Bursitis Theory
Inflammation of a bursa in the 2nd and 3rd webspace can cause fibrosis of the adjacent nerve
Entrapment Theory
Intermetatarsal nerve becomes trapped by the anterior edge of the deep transverse metatarsal ligament
Pronation Theory
During over-pronation the 3rd intermetatarsal space is reduced leading to neural compression

5. Subjective Examination
Pain, burning or tingling on the plantar aspect of the foot
Usually the 3rd webspace
Worse with wearing tight shoes
Relieved by rest or removing the shoe

6. Objective Examination
Tenderness direct palpation of the web space of the toes
Tenderness on stretching of the web space of the toes
Reduced sensation in between the affected toes

7. Special Tests Mulder’s Click Tinel- Hoffman sign
Audible or palpable ‘click’ with exacerbation of pain when side compression is applied to the metatarsal heads whilst isolating the painful web space using the other hand
Tinel- Hoffman sign
Pins and needles over a nerve trunk on tapping the suspected web space of the foot

8. Further Investigation
Ultrasound
MRI

9. Management
Aim is to reduce pressure, inflammation and nerve irritation
Surgery is often considered before conservative interventions

10. Conservative Reduce pain and inflammation
Massage
Ice
NSAID’s
Orthotics
Wide flat shoes
Restore Normal Range of Movement
Ankle and Foot
Soft tissue massage
Foam rolling
Stretching
Dry needling
Joint mobilisations
Joint manipulations
Neurodynamic mobilisations
Restore Normal Muscle Activation
Intrinsic foot muscles

11. Plan B
Corticosteroid injection
Decompression Surgery
Neurectomy

12. References
Jain, S. and K. Mannan (2013). "The diagnosis and management of Morton's neuroma: a literature review." Foot Ankle Spec 6(4):
Pastides, P., S. El-Sallakh and C. Charalambides (2012). "Morton's neuroma: A clinical versus radiological diagnosis." Foot Ankle Surg 18(1):
Sault, J. D., M. V. Morris, D. J. Jayaseelan and A. J. Emerson-Kavchak (2016). "Manual therapy in the management of a patient with a symptomatic Morton's Neuroma: A case report." Man Ther 21: