Morton’s Neuroma

In this episode of PodMD, director and principal podiatrist of the Brimbank foot & ankle clinic Mr Tristan Fairbairn will be discussing the topic of morton’s neuroma, including what morton’s neuroma is, how a patient would typically present, the treatment options, the likelihood of recurrence, when to refer and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Mr Tristan Fairbairn

    Tristan is a podiatrist providing care in Melbourne’s northern and western suburbs, and is the director and principal podiatrist at the Brimbank foot & ankle clinic. He is currently undertaking extensive postgraduate training to become a podiatric surgeon, and is also endorsed by the Podiatry Board of Australia to prescribe scheduled medicines.
    Tristan has been working in private practice for 15 years and is skilled to treat/perform general podiatry issues, biomechanical and musculoskeletal injuries, minor soft tissue procedures, injection therapy, orthotic therapy, and fracture management.

    Today, we’ll be discussing the topic of Morton’s Neuroma.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Tristan, thanks for talking with us on Pod MD today.

    Tristan: Thanks for having me.

    Question 1
    The topic of today’s discussion is Morton’s neuroma. Can you describe for our listeners what Morton’s neuroma is?

    Tristan: Morton’s Neuroma, often referred to as interdigital neuroma, is a type of compressive neuropathy of the interdigital nerve as it supplies the 3rd and 4th digits of each toe.

    Question 2
    How would a patient with Morton’s neuroma typically present?

    Tristan: Typically, there’s a number of symptoms that patients will often present with. The most common though is focal pain in between the 3rd and 4th metatarsal heads. Sometimes there is a palpable mass in the region, and there’s often a variety of symptoms, such as burning, aching, and referral into the third and fourth toes itself.

    Question 3
    What are the risks of not treating the condition?

    Tristan: The main risk associated with this problem is that it will typically continue due to the nature of the pathology. The nerve will become fibrosed and quite thickened, so it’s unlikely that it will resolve on its own, so ongoing pain and deformity is expected.

    Question 4
    What are the treatment options?

    Tristan: Like most foot and ankle conditions, there’s a number of nonoperative and operative modalities available. In terms of nonoperative modalities, the main treatments will consist of appropriate shoe gear. So once again, wide, deep, capacious shoes with adequate width and depth, used in conjunction with offloading foot orthoses to reduce pressure under the third and fourth metatarsal heads has been shown to be effective.
    The use of non-steroidal anti-inflammatories in conjunction with corticosteroid injections are another useful modality that can help with symptom relief.
    In terms of surgical interventions, the most reliable approach is a neurectomy, which involves a dorsal incision over the intermetatarsal space and resection of the offending nerve.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Tristan: To the best of my knowledge, no, there doesn’t appear to be any trials at this stage. However, over the years there’s been a number of adjunctive procedures that have been suggested and trialled. These include release of the deep transverse metatarsal ligament, translocation of the common plantar digital nerve above this, as well as adjunctive procedures such as gastrocnemius recession in the presence of ankle equinus to reduce forefoot pressures.

    Question 6
    Are there any warning signs a GP, podiatrist or their patient can look out for?

    Tristan: Yes, there is. In terms of hammer toe, there’s a number of concerns. First of all, with respect to the patient, it’s important to establish if the patient has any underlying neurovascular compromise, because given the pressure lesions, this can result in further ulceration and deformity. Obviously, if that isn’t the case, ongoing pain and deformity is the main issue.

    Question 7
    What is the likelihood of recurrence of the condition?

    Tristan: In terms of non-surgical management, if effective, it’s important that underlying mechanical issues are addressed, so in the instance of an associated pes planus, or flat foot deformity. As long as that’s maintained, we tend to see good results. As for surgical, the only chance of recurrence is something called a stump neuroma, albeit a very rare chance of this occurring.

    Question 8
    When should a GP or podiatrist refer?

    Tristan: As with all musculoskeletal foot and ankle concerns, a patient should be referred if they have failed conservative treatment such as injections, foot orthoses and footwear changes.

    Question 9
    What role does the GP or podiatrist play in the treatment of the condition?

    Tristan: The podiatrist and the GP both play an important role in the management of Morton’s neuroma, not only in the diagnosis, but in the management.
    Most podiatrists will be able to prescribe orthoses and footwear advice, however, it may require an endorsed podiatrist to undertake injections such as corticosteroid injection into the area. Alternatively, GPs may refer independently to have these injections guided at, say, an interventional radiologist.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on morton’s neuroma?

    Tristan: Morton’s Neuroma is one of the most common types of forefoot pain that will present into general practice and podiatric clinics. It’s a type of compressive neuropathy, resulting in fibrotic changes to the common plantar digital nerve. There are a number of conservative treatments that should be explored before surgical excision is considered

    Thanks for your time and the insights you’ve provided.

    Tristan: Thanks very much.

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.