Clinical Inquiries

What is the best way to treat Morton’s neuroma?

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References

EVIDENCE-BASED ANSWER

NO SINGLE TREATMENT HAS BEEN IDENTIFIED in the literature. That said, a protocol of stepped care that showed good results in an uncontrolled trial seems reasonable: patient education and foot-wear or insole changes, followed by corticosteroid injections and, finally, surgery (strength of recommendation [SOR]: C, case series).

Injecting sclerosing alcohol depends on the provider’s access to and comfort with ultrasound, but the evidence is insufficient to recommend it routinely (SOR: C, case series).

Evidence summary

Options for treating Morton’s neuroma include changing shoe type, using insoles or metatarsal pads, taking nonsteroidal anti-inflammatory drugs (NSAIDs), giving corticosteroid or sclerosing alcohol injections, and surgically excising or transposing the offending nerve.1-3

Different conservative measures produce similar results
A small randomized prospective study of 23 patients compared reduction in neuroma pain using supinatory or pronatory insoles.4 No explicit inclusion or exclusion criteria other than clinical diagnosis were mentioned. Neither participants nor evaluators were blind to intervention allocations.

Two patients (13%) dropped out at 1 month. At 12 months, pain reduction in the supination and pronation insole groups was 50% and 45%, respectively (not significant).

Injections improve symptoms with minimal adverse effects

A prospective randomized study of 82 patients compared steroid injections alone with shoe modifications.5 Primary outcomes were patient satisfaction (presence or absence of pain), amount of pain, and return of pain.

Steroid injections yielded better patient satisfaction compared with shoe modifications alone at 1 and 6 months. Twenty-three percent of shoe-modification patients achieved complete satisfaction at 1 month, compared with 50% of injection patients (P<.01; number needed to treat [NNT]=3.7). At 6 months, the results were 28.6% satisfaction with shoe modification and 73.5% satisfaction with injection (P<.001; NNT=2.3).

The difference disappeared at 1 year (63% satisfaction with shoe modification compared with 82% satisfaction with injection; P>.05), although patients were allowed to cross over at 6 months. No complications occurred. The study was limited by a high rate of crossover from the shoe modification to the injection group at 6 months, elimination of dropouts from the final analysis, and lack of intent-to-treat analysis.

Another technique uses the sclerosing effects of alcohol6 delivered by multiple ultrasound-guided injections over time.7,8 Improvement of symptoms with no long-term adverse events were reported in several case series, although in each study a small number of patients reported localized pain at the site of injection.6-10 The TABLE summarizes injection studies.5-11

TABLE
How injection therapies for Morton’s neuroma compare

StudyInjection materialsType of studyNumber of casesAverage follow-up, (mo)Average number of injectionsResults
Greenfield 19849SteroidRetrospective case series6724380% complete relief
Saygi 20055SteroidProspective quasirandomized injection vs footwear modification82122-382% vs 63% complete or partial pain relief in 2 groups, respectively
Markovic 200811Steroid*Prospective case series399138% complete satisfaction and 28% satisfaction with minor reservations
Dockery 19996AlcoholProspective case series100135.589% resolution or improved symptoms
Fanucci 20048Alcohol*Prospective case series4010490% resolution or improved symptoms
Hughes 20077Alcohol*Prospective case series10121.14.194% resolution or improved symptoms
Mozena 200710AlcoholRetrospective case series42113-761% resolution or improved symptoms. Patients with ≥5 injections (74%) were more likely to respond (P=.0072)
*Ultrasound guided.

Surgery: Consider cost and risk of complications
Most surgical studies enrolled patients who had initially failed conservative treatments. Costs and risks of complications must be weighed, including infection, scar sensitivity, residual pain, sensory deficits, and other wound-related morbidities.

Evidence-based answers from the Family Physicians Inquiries Network

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