By Thomas McMahon- Brindabella Podiatry
The psychological barrier to an active lifestyle is sufficiently overwhelming without neurological symptoms of a Mortons Neuroma complicating the issue. Responding to World Health Organisation (WHO) warnings that 25% of the world population is inactive, citizens of developed nations have embraced a modern, evidence-based approach to physical activity and cardiovascular health. Often organised and promoted by institutions of health – e.g. Heart Foundation and local community groups – social walking groups have been established to uniformly reduce the risk of mortality associated with low levels of physical activity. Despite reducing the likelihood for premature mortality, regular physical activity is naturally associated with an increased incidence of activity related pathology such as Mortons Neuroma.
Infamously debilitating, a Morton’s Neuroma is a common, neurological condition of the forefoot predominantly affecting middle-aged women. Characterised by sharp, burning, tingling sensations localised to the forefoot and adjacent toes, symptoms of a Morton’s Neuroma arise from the irritation of a branch of the common digital nerve. The affected nerve branch is subject to repetitive trauma secondary to problematic gait patterns, poor choice of footwear and/or the presence of concurrent forefoot pathology e.g. bursitis. First described in 1835 as “fusiform swelling of the common digital nerve of the third intermetatarsal space”, modern histological studies have confirmed the origin of symptoms to be an inflammatory reaction. Depending on the severity of the neuroma, the neurological pain can manifest after a arbitrary threshold of activity or it may be instantaneous. Less often, a sense of numbness consuming the forefoot can precede or succeed more painful symptoms.
Medical literature currently supports several competing theories to explain the eitiology of a Morton’s Neuroma. With evidence to support chronic repetitive trauma, ischaemia, entrapment, bursitis and excessive pronation, these theories represent the frontier of Morton’s Neuroma understanding. As each theory is valid but not consistently applicable, the true, underlying cause of a Morton’s Neuroma would most often involve a combination of these theories operating concurrently. Given that physiological changes to digital nerves and arteries (excluding nerve demyelination) are found in symptomatic and asymptomatic patients, the cornerstone of management is to treat the symptoms, with the intention to achieve pain free activity.
Diagnosis is a crucial first step in the management of Morton’s Neuroma. A comprehensive biomechanical assessment of the feet and lower legs will provide an accurate diagnosis with regard to physical ability, gait, footwear, compensatory mechanisms and soft-tissue abnormalities. Accurate diagnosis is paramount because treatment strategies are only effective if targeting the appropriate condition.
Unless carefully managed, the irritated nerve of a Morton’s Neuroma will insidiously grow in size and symptom intensity. The details of management are categorised as operative or non-operative i.e. surgical or conservative. Alike the majority of lower limb pathology, surgical intervention is typically reserved for extreme cases or as a last resort. Injections of steroids and/or local anaesthetic offer a less invasive alternative to surgical excision, however, these agents typically mask symptoms, meaning recurrence is likely. Non-operative management strategies are built on the principles of load management and directed towards reducing pressure, inflammation and irritation. Footwear modifications, custom made orthoses and gait alterations represent conservative treatment modalities that will address the root cause of the neuroma and thus provide indefinite, long-term symptom resolution.
The podiatrists at Brindabella Podiatry have decades of collective experience treating Morton’s Neuroma and alternative conditions of the forefoot. If you or anyone you know are burdened by pain similar to that described here, please don’t hesitate to call an book an appointment. The first step to pain relief is a phone call away.