Morton’s Neuroma: Pain Between the Toes That Can Make Walking Difficult

Morton’s neuroma generally affects one of the nerves that run between the toes, most commonly in the space between the third and fourth toes. The term “neuroma” can be misleading: it does not refer to a tumor, but to a thickening of the tissue surrounding the nerve associated with chronic irritation.

The forefoot is subjected to considerable stress with every step. When the nerve is repeatedly compressed, it can become more sensitive, causing pain, burning, or changes in sensation.

“Several factors can contribute to the development of Morton’s neuroma, often occurring together. Certain foot structures, for example, can lead to increased pressure in the forefoot, increasing compression around the interdigital nerves. An altered distribution of weight during walking can also place greater stress on this area,” explains the orthopedic specialist.

Conditions that may be associated with Morton’s neuroma include:

• bunions (hallux valgus);
• certain toe deformities, such as hammertoes;
• high arches;
• particular characteristics of how the foot bears weight.

Prolonged use of shoes that are narrow in the toe box or have high heels can also increase pressure on the forefoot, contributing to nerve irritation over time.

“Not all patients describe Morton’s neuroma in the same way. In some cases, the discomfort presents as a sudden sharp pain, while in others it feels like constant burning or tingling involving the toes,” explains the doctor.

A recurring feature is the relationship between pain and weight-bearing: pain tends to appear or worsen while walking, particularly when wearing tight shoes or after standing for a long time. Relief often comes from removing the shoe or stopping the activity.

Because these symptoms can also occur with other forefoot conditions, such as metatarsalgia, it is not uncommon for patients to receive a diagnosis only after a relatively long period.

There is no single test for Morton’s neuroma that can replace an assessment by an orthopedic specialist. The orthopedic examination makes it possible to:

• review the history of the pain;
• identify the affected area;
• assess how the foot functions as a whole.

“The clinical examination remains essential,” explains Dr. Marcellini. “Diagnostic imaging helps complete the picture, but the findings must be interpreted alongside the patient’s symptoms and individual characteristics.”

When necessary, the diagnostic process may include ultrasound, X-rays, or magnetic resonance imaging (MRI), also to rule out other conditions that may cause similar symptoms.

Once Morton’s neuroma has been identified, the specialist works with the patient to determine the most appropriate treatment plan, taking into account the severity of the symptoms and the extent to which the pain affects daily activities.

Appropriate Footwear, Orthotics, Physical Therapy, and Injections for Morton’s Neuroma

“In less advanced cases, we generally try conservative treatments first, with the aim of reducing pressure on the nerve and limiting the irritation that triggers symptoms,” the specialist explains.

An initial step may involve choosing more appropriate footwear and, when indicated, using custom-molded offloading orthotics, made from soft materials to reduce pressure on the affected area.

Depending on the clinical findings, the specialist may also recommend:

• medication;
• physical therapy;
• local injections of anesthetics and corticosteroids.

Injections should always be used judiciously and assessed on a case-by-case basis, because repeated cortisone injections may, in some situations, be associated with changes in the fatty tissue of the sole of the foot or in skin pigmentation.

Surgery for Morton’s Neuroma

If these measures do not provide sufficient improvement and pain continues to affect the patient’s quality of life, surgery may be considered.

“The decision to operate is always made in consultation with the patient. We assess how much the pain affects their life and what their functional expectations are, rather than looking only at test results,” Dr. Marcellini explains.

The Minimally Invasive Foot Surgery Center at IRCCS Policlinico San Donato specializes in the diagnosis and treatment of the main conditions affecting the forefoot, supporting patients throughout every stage of care: from the initial assessment and selection of the most appropriate treatment to recovery.

For Morton’s neuroma, when conservative treatments are not sufficient, the Center uses minimally invasive surgery, a technique that relieves compression of the nerve through a very small incision while preserving the nerve itself.

Nerve decompression is performed through a small incision and increases the available space between the metatarsal bones, eliminating the mechanical cause of the pain. Compared with traditional techniques, this approach helps limit tissue trauma and promote a faster recovery.

The Center’s experience in treating conditions such as Morton’s neuroma, bunions, hallux rigidus, metatarsalgia, and hammertoes makes it possible to develop the most appropriate care pathway for each patient, taking into account not only clinical factors but also individual needs.