All about Morton's neuroma and its operation
Want to know all about Morton's neuroma and its operation ? Dr Julien Lopez, foot surgeon and Morton specialist, explains everything there is to know about this pathology.
What is Morton's neuroma ?
The Morton's neuroma is the compression of a nerve in the forefoot, usually in women. For a long time, we considered Morton's neuroma as a pseudo-tumor hence its name. In reality, this suffering is due to the compression of the plantar interdigital nerve and its thickening. The nerve travels through a tunnel formed by bones and soft parts. The exact causes of Morton’s neuromaand its surgery are not known exactly, but it is believed that when walking, the nerve is repeatedly compressed causing inflammation. In the forefoot, the interdigital nerves ensure the sensitivity of the toes. They pass through a narrow fibrous canal just below the metatarsal heads. When they get stuck for various reasons (narrow shoes, anomaly in the foot), the nerve becomes irritated and swells : it is Morton's disease for an operation . Although we know that the nerve is compressed, the mechanisms of the formation of Morton's neuroma remain unclear. It is believed to be a ductal syndrome much like carpal tunnel syndrome in the hand.
How to recognize Morton's Neuroma ? What are the symptoms of Morton's neuroma ?
The main symptom is pain : it is violent and sometimes described as a sensation of stabbing or electric shock. Usually localized under the foot, the pain can diffuse in the toes, on the back of the foot or towards the ankle. Morton’s neuroma causes sharp pains such as electric shocks or burns when walking or standing for prolonged periods of time. Patients often describe the sensation of walking with a pebble in the shoe. Morton's pains are located on the plantar surface of the foot (metatarsalgia) at the base of the toes. Morton’s neuromais usually located in the 3 rd inter-metatarsal space (between the third and fourth toe). In 20% of cases, it develops bilaterally and affects both feet. Sometimes clinical signs are associated such as hypoaesthesia (decreased sensation) or paresthesias (tingling).
When walking, the pain can force the patient to take off their shoes, sometimes even in the street. During these painful periods, taking off your shoes and massaging your foot reduces the pain.
How to recognise the diagnosis of Morton’s neuroma?
If you think you have this condition, you will need to see a Morton’s neuromaspecialist. The diagnosis of Morton’s neuroma is clinical.
During the consultation, the Morton neuroma foot surgeon will examine the tenderness of the toes and seek to locate the pain. The surgeon will seek to assess the thickening of the nerve using the Mulder compression test. This test consists of pushing the nerve between the metatarsal heads and then with the other hand, a transverse compression maneuver of the forefoot is performed to obtain a reaction. Sometimes this reaction is audible in the form of a snap and reproduces the characteristic pains usually felt by the patient. Palpation of the base of the toes is often painful. The presence of these signs strongly suggests the diagnosis of Morton’s neuroma.
An x-ray assessment is carried out to look for contributing factors or to eliminate other causes of pain. The ultrasound is the examination of reference used to make this diagnosis which specifies the location, the thickening of the nerve and the size of the neuroma. You can also perform an MRI but it is a less reliable examination : sometimes this examination is negative but that does not rule out the diagnosis (false negatives).
How to treat Morton’s neuroma?
The initial treatment of Morton's neuroma is always medical with an adaptation of the footwear : it is necessary to favor flexible and wide shoes. Making insoles with retro-capital support can also provide relief. Physiotherapy sessions may be prescribed depending on the case. The corticosteroid injections sometimes provide relief with limited effectiveness over time.
When the medical treatment is not sufficient to relieve the pain, it is sometimes necessary to operate on a Morton’s neuroma.
How does Morton's neuroma evolve without treatment?
It is impossible to predict the course of pain without treatment. Morton's neuroma can heal on its own or worsen over time causing pain and making it more and more difficult to put shoes on.
To limit the risk of worsening symptoms, it is essential to treat as soon as the first symptoms appear and to consult a surgeon specializing in Morton’s neuroma.
Why do you need surgery for Morton's neuroma?
It is necessary to know whether an operation for Morton's neuroma is necessary.
Often, Morton's neuroma tends to worsen over time. When walking, each step taken represents an attack that irritates the interdigital nerve. Wearing narrow shoes and heels aggravates the symptoms. If your pain has persisted for several months and you think you are suffering from this pathology, it is necessary to consult a specialist in Morton's neuroma in order to offer appropriate treatment.
Everything you need to know about the operation for Morton’s neuroma: Morton's neuroma and its surgery
We will explain everything about the operation for Morton’s neuroma.
In some cases the functional discomfort persists despite medical treatment : we can discuss a surgical intervention. To choose the operative technique, the surgeon will first have to specify certain elements in consultation. The choice of technique and the assessment of the actions to be performed is left to the surgeon depending on the severity of the damage and the complexity of the intervention.
The principle of surgical treatment is based either on the release of the nerve (neurolysis) or on the resection (neurectomy or neuromy) of the nerve. The choice of technique depends on the size of the Morton’s neuroma.
The operation usually takes place on an outpatient basis (hospital stay for one day). However, for various reasons, it is possible to plan a few days of hospitalization depending on your social situation and your associated illnesses.
You will have to carry out the obligatory pre-anesthetic consultation with the anesthesiologist. During this consultation, the anesthesiologist will explain the possible modes of anesthesia to you according to your associated pathologies and the planned operative procedure. If necessary, he will adapt your treatment before and after the operation and may prescribe anticoagulants, painkillers, anti-inflammatory drugs or others.
Several types of anesthesia are possible : you may benefit from local or regional anesthesia meaning that only your leg will be desensitized : this is the most common. General anesthesia is also a solution if you prefer to be asleep.
The choice of technique and the assessment of the actions to be performed is left to the surgeon depending on the severity of the damage and the complexity of the intervention.
- Before the operation for Morton’s neuroma: you will be installed on a stretcher and taken to the pre-anesthesia room. Local anesthesia will be performed before entering the operating room.
- Installation in the operating room : You will be installed in the supine position, that is to say on your back
- The tourniquet : Throughout the operation, a tourniquet is usually placed at the ankle to prevent bleeding.
- The incision : the incision measures from a few millimeters with the percutaneous technique (minimally invasive or micro-invasive surgery) up to 2 cm with the so-called “ open ” technique .
- The surgical gesture
- Neurolysis : Neurolysis is offered when Morton's neuroma is small in size. This minimally invasive surgical technique frees the nerve by severing the deep transverse inter-metatarsal ligament. It is performed with specific instruments through a short incision of a few millimeters between the toes). When the nerve is thick, the percutaneous technique to operate on a Morton’s neuroma has a high failure rate and it is preferable to perform a neurectomy.
- Neurectomy : Neurectomy involves the surgical removal of the nerve responsible for pain. It is performed by a short scar of 1 to 2 cm between the toes on the back of the foot. The consequence of this technique is often loss of sensitivity in the mirror toes, which will recover partially over time and not always completely. In the 2 months following the operation, it is common to have the sensation of having a lump under the foot (postoperative hematoma).
- Operative time : The duration of the surgical procedure is relatively short, generally 30 minutes. The intervention may be longer in the event of associated procedures or operating difficulties.
- The material : No material is necessary.
- At the end of the operation : The surgeon makes a dressing.
It is important to note that the surgeon may face an unforeseen or unusual situation requiring different acts than those initially planned. In this case, the surgeon will explain the difficulties encountered and the actions taken as soon as you wake up or return to your room.
What are the postoperative consequences?
WalkingThere is no immobility after a Morton’s neuroma operation, walking is authorized immediately. Your surgeon may have prescribed a therapeutic shoe for you to walk on. This shoe is not essential, it is only used to reduce pain and promote walking and comfort. You can put on your shoes classically as soon as you feel able. Crutches can be useful for the first few days to make walking easier.
Dressing and home careSome dressings care are needed for a fortnight. Remember to contact a nurse to organize the repair of the dressing within 2 days of the operation.
SwellingSwelling is not a complication and it is a frequent phenomenon after such an operation. To limit swelling of the foot, it is recommended that you limit your movements for the first few days, apply ice, and keep your leg elevated when you are at rest. Do not stand still, without walking.
Medicinal treatmentsDepending on your history, your existing medical illnesses and your mobility, the anesthesiologist may prescribe anticoagulant treatment by injection (subcutaneously) or systemically (per os). This treatment helps prevent the onset of phlebitis, i.e. the formation of a clot in the veins.
It is strongly recommended to take the painkillers prescribed systematically during the 2 days following the surgery.
PhysiotherapyPhysiotherapy is not systematic, its usefulness will be evaluated by the surgeon during your first postoperative consultation. In order to accelerate the functional recovery and the decrease of the swelling, self-rehabilitation is essential. If necessary, physiotherapy sessions will be prescribed to you during your first postoperative appointment.
Driving and stopping workDriving is prohibited for 3 weeks (unless you have had surgery on your left foot and you have an automatic car). The average time off work is 30 to 60 days depending on your professional activity.
Sport activitiesThe resumption of swimming and cycling is permitted from the first month and the resumption of other activities from the second postoperative month.
Post operative follow-upTwo appointments are necessary postoperative : 21st day and then 60 days after the operation. No x-ray is necessary.
ComplicationsThe following list of complications is not exhaustive, but the most frequent complications are mentioned.
Any surgery of the foot for Morton's neuroma can create some complications that are both common and specific to the type of intervention performed. This risk varies from one individual to another depending on their age, existing medical illnesses (hypertension, diabetes, poor skin condition, etc.) as well as depending on their lifestyle (tobacco, alcohol, practice of an activity. athletic).
Some complications can be prevented by simple measures such as:
- Compliance with postoperative instructions.
- Stopping smoking.
Contact a surgeon for an operation for Morton’s neuroma in the foot in order to make the diagnosis as soon as possible.
If you wish to learn more about the anomalies of the forefoot we invite you to click here.
In case of questionsFor any additional questions or in the event of a problem, you can contact him or call his secretariat.
In conclusionThe Morton’s neuroma operation is an effective outpatient surgical procedure. Walking is authorized immediately.
The surgery gives 90% good results. However, residual pain persists in rare cases : they remain discreet and not disabling.
FAQ
What is Morton’s neuroma?
Morton’s neuroma is nerve compression of the foot that often affects women. It causes pain like electric shocks or burns when walking or prolonged standing. Morton’s neuroma is usually located in the 3rd inter-metatarsal space (between the third and fourth toe). In 20% of cases, it develops bilaterally and affects both feet. Sometimes clinical signs are associated such as hypoaesthesia (decreased sensation) or paresthesias (tingling).
Which specialist to treat Morton's syndrome?
If you have neuromatous pain, you can consult your doctor, a podiatrist or surgeon specializing in Morton’s neuroma. Whichever specialist you consult, medical and non-surgical treatment is always indicated as the first response. In case of failure, you can consult Dr Lopez, a morton’s neuroma surgeon, who will suggest a Morton’s neuroma operation in Nice. (Since 2021, Doctor Lopez no longer practices Morton’s neuroma operations in Monaco, he now operates exclusively at Saint George’s Clinic in Nice) For patients who live on the island of beauty, it is sometimes difficult to find a Morton’s neuroma specialist in Corsica. If you cannot get an appointment, Dr Lopez can see you in Nice.
How to treat Morton's neuroma?
The initial treatment is always medical: insoles, physiotherapy, adaptation of the footwear and corticosteroid infiltrations.
Morton’s neuroma operation?
The decision to operate on a Morton’s neuroma is performed on an outpatient basis under local anesthesia (LRA). The surgery is done using a minimally invasive or percutaneous technique through small incisions. The objective is the release of the nerve or its complete excision (neurectomy). After the operation, walking is allowed immediately.
How long does the operation take for Morton’s neuroma?
On average, an operation for Morton’s neuroma lasts 30 to 60 minutes.
How much pain is felt during the operation for Morton's neuroma?
Surgery for Morton’s neuroma is painless. Immediately after the operation, the pain is not felt because the foot remains asleep for several hours. Then the painkillers prescribed by the anesthetist provide adequate relief.
What anesthesia is used during the operation of a morton’s neuroma?
You will have to carry out the obligatory pre-anesthetic consultation with the anesthesiologist. During this consultation, the anesthesiologist will explain the possible modes of anesthesia to you according to your associated pathologies and the planned operative procedure. If necessary, he will adapt your treatment before and after the operation and may prescribe anticoagulants, painkillers, anti-inflammatory drugs or others.
Several types of anesthesia are possible : you may benefit from local or regional anesthesia meaning that only your leg will be desensitized : this is the most common. General anesthesia is also a solution if you prefer to sleep.
What is the period of immobility after surgery for Morton’s neuroma?
There is no immobility after surgery. Driving and resuming professional activity are possible after a few days.
Am I allowed to drive after surgery for Morton’s neuroma?
No surgical contraindication stands in the way of driving. If you are allowed to walk, you can press a pedal safely. You have the right to drive a motor vehicle as soon as you feel able to do so. Remember to check with your insurance that you are covered after an operation.
Can we operate on both feet at the same time?
No, it is not possible to operate both feet at the same time. However, two Morton neuroma can be operated on a single foot and by a single incision. On the other hand, it is possible to operate on both feet 15 days apart.
What is the cost of an operation for Morton’s neuroma?
The price of an intervention varies depending on the clinical condition of the patient and the procedures to be performed. Social security covers the costs of the operation. The reimbursement of additional fees depends on your insurance contract. The average remaining charge after reimbursement by your insurance company is € 300.
If you would like to learn more about forefoot anomalies, click here for all the information you need.
