A pebble in the shoe that isn’t there

Patients with a Morton’s neuroma often describe the same thing: a burning or electric pain in the ball of the foot, a feeling like walking on a marble or a bunched-up sock, and sometimes numbness or tingling that radiates into two neighboring toes. The pain is typically worse in tight or high-heeled shoes and eases when they stop, take the shoe off, and rub the foot.

Despite the name, a Morton’s neuroma is not a true tumor. It is a perineural fibrosis — a thickening of the tissue around one of the common digital nerves as it passes between the metatarsal heads, most often in the third web space (between the third and fourth toes) and less commonly the second. Repetitive compression and irritation of the nerve, aggravated by narrow toe-boxes and high heels, are thought to drive it.

How it’s diagnosed

The diagnosis is mainly clinical. Squeezing the web space reproduces the pain, and compressing the forefoot from side to side while pressing the space can produce a palpable, sometimes audible click — the Mulder’s sign. Tenderness is focused in the web space rather than on the metatarsal head itself, which helps distinguish it from other causes of forefoot pain such as metatarsalgia or a stress fracture. Ultrasound or MRI can confirm the neuroma and measure its size when the picture is unclear or more than one web space is involved.

Start with non-surgical treatment

Most patients improve without surgery, and conservative care is always the first step. The foundation is footwear modification — a wide, low-heeled shoe with a roomy toe-box — combined with a metatarsal pad or orthotic placed just behind the metatarsal heads to spread them apart and offload the nerve. A corticosteroid injection can settle inflammation and provide relief, and for smaller neuromas an alcohol (sclerosing) injection is sometimes used. These measures relieve symptoms in a large proportion of patients and are worth a fair trial of several months before considering surgery.

When surgery is considered

Surgery becomes an option when well-conducted conservative treatment has failed and the pain continues to limit daily walking and activity. The most established and reliable operation is excision of the neuroma (neurectomy) — removing the affected segment of the common digital nerve together with the thickened perineural tissue. In some cases, particularly smaller or first-time lesions, a surgeon may instead choose to simply release the tight transverse intermetatarsal ligament that compresses the nerve, preserving the nerve itself.

What excision involves

Neuroma excision is usually done through a small incision on the top of the foot (a dorsal approach) over the affected web space, less commonly from the sole. The surgeon divides the transverse intermetatarsal ligament, identifies the common digital nerve, and removes the neuroma along with a short segment of normal nerve proximal to it, so that the cut nerve end retracts away from the weight-bearing ball of the foot.

The trade-off patients should understand is that removing the nerve leaves a permanent patch of numbness between the two involved toes. Most people find this a very acceptable exchange for relief of the pain, and it rarely affects function. Excision has a high success rate, with the large majority of patients reporting good or excellent pain relief.

Recovery and things to know

Recovery after a dorsal excision is generally straightforward. Patients typically walk soon after surgery in a stiff-soled postoperative shoe, protecting the wound for the first couple of weeks until the stitches are removed, and gradually return to regular footwear and normal activity over the following weeks. Swelling in the forefoot can take a while longer to fully settle.

The main long-term consideration is the small possibility of a recurrent or “stump” neuroma — pain that returns when the cut nerve end forms a new sensitive bulb. This is uncommon but is the usual reason a small number of patients need further treatment. As always, recovery timelines vary from person to person, and your progress will be reviewed at each visit.

This article is for general education and is not a substitute for individual medical advice.