Morton's Neuroma

A runner comes in three weeks before her goal race with a story Dr. Alex Movshis hears often. Around mile 14 of her long run, a hot, electric burn starts between the third and fourth toes, and soon those toes feel like they belong to someone else. She stops, unlaces, squeezes the front of her foot, and it settles. She describes a pebble under the ball of the foot that is never there. Her doctor called it metatarsalgia. The X-ray was normal.

That pattern is Morton’s neuroma until proven otherwise, and it is quick to test. He pinches the third web space between thumb and index finger, from the top and bottom of the foot. If that reproduces her burn, the diagnosis is likely, and an ultrasound showing a dark, compressible oval between the metatarsal heads settles most doubtful cases. The harder part is treatment, where the evidence is thinner than most websites admit.

Morton’s neuroma is a scarred nerve, not a tumor

The name misleads. A true neuroma is a nerve tumor or the tangle of regrowing fibers that forms after a nerve is cut. Morton’s neuroma is neither. The tissue a surgeon removes shows benign perineural fibrosis: scar wrapped around a common plantar digital nerve, most often in the third intermetatarsal space between the third and fourth metatarsal heads (Mak 2021). The second web space is the next most common site. It does not spread and it is not cancer.

Anatomy explains the location. The nerve runs forward under the deep transverse metatarsal ligament, the band tying the metatarsal heads together, then splits to supply the facing sides of two toes. Every push-off bends the toes up and pulls the nerve against that ligament’s edge, while a tight shoe squeezes the heads together from the sides. Repeat that thousands of times a day and the nerve scars where it is pinned. That is why symptoms land on two adjacent toes, and why taking the shoe off helps.

So this is an entrapment neuropathy, the same family as carpal tunnel and tarsal tunnel, and Dr. Movshis treats it as a nerve problem first. The reasoning that applies to other peripheral nerve entrapments applies here: map where it burns, find the point that reproduces it, test it with ultrasound or a block. It skews heavily female: in the largest injection trial, 111 of the 131 patients were women (Thomson 2013).

Pain in the ball of the foot: Morton’s neuroma or metatarsalgia?

Metatarsalgia is a location, not a diagnosis. It means pain under the metatarsal heads, where Morton’s neuroma lives, but so do a torn plantar plate, an inflamed toe joint, and a metatarsal stress fracture. The label matters because the treatments diverge. Steroid beside a nerve is a reasonable step for a neuroma. Steroid into a toe joint whose plantar plate is already failing is a different decision. And a runner with a stress fracture who keeps training because “it’s just a neuroma” can turn a crack into a displaced break.

If the pain burns and the toes go numb, think nerve

Burning or shooting pain into the facing sides of the third and fourth toes (sometimes the second and third), numbness in those two toes, relief from taking the shoe off, and tenderness between the metatarsal heads rather than on them. That cluster is Morton’s neuroma.

If the pain sits under the second toe joint and the toe is drifting, think plantar plate

The plantar plate is the thick ligament under each lesser toe joint. When it degenerates or tears, usually at the second toe, the pain is under the joint itself, the top of the joint often swells, and over months the toe may drift toward the big toe or lift. It is frequently confused with a second web space neuroma, and on MRI the swelling around a torn plate can be misread as one (Linklater 2016). Pressing under the second metatarsal head hurts, and so does lifting the toe straight up while holding the metatarsal (the drawer test). Ultrasound shows the tear. Toe-joint synovitis behaves much the same way without a tear.

If one spot on the bone hurts after a mileage jump, stop and image

A metatarsal stress fracture hurts on the bone, usually the shaft of the second or third metatarsal, at a single fingertip-sized point. Hopping hurts. The top of the foot is often swollen, and the story is a recent jump in mileage, new speed work, or a new shoe. Numb toes are not part of it. Early X-rays are often normal. If this is your pattern, running stops today and the next step is imaging, with MRI when the X-ray is clean and suspicion stays high. This is the one ball-of-foot diagnosis where pushing through pain does real structural harm.

If the pain is in the heel, it is a different problem

Heel pain that is worst on the first steps out of bed and eases after a few minutes of walking is plantar fasciitis, not a forefoot nerve problem. Some runners have both, and each gets treated on its own terms.

If the whole sole burns, or the burning starts higher up, look upstream

Burning and tingling across the whole sole and into several toes, worse after long standing, with a tender spot behind the inner ankle, is tarsal tunnel syndrome: the tibial nerve pinched at the ankle before it divides into the plantar nerves. Forefoot burning with low back or buttock pain, numbness on the top or outer edge of the foot, weakness lifting the big toe, or a reduced ankle reflex points to an L5 or S1 radiculopathy. Neither responds to a web-space injection, which is why the first visit includes a neurological exam of the leg. Numbness in both feet that starts at the toes and creeps upward is usually peripheral neuropathy, which needs blood work, not a needle.

How the diagnosis is made

History carries most of the weight: where it burns, which toes go numb, which shoes provoke it, what happens when they come off, and whether it started with a change in training.

Two exam tests matter. The first is the thumb and index finger squeeze described above, pinching the web space from top and bottom. Compared against ultrasound in patients with suspected neuroma, it was the most sensitive clinical test studied, at 96 percent, while compressing the forefoot from the sides was far less sensitive, at 41 percent (Mahadevan 2015). The second is Mulder’s click, a palpable clunk as the thickened nerve pops out between the metatarsal heads during a side squeeze. It was only 61 percent sensitive in the same series and was more likely with larger lesions (Mahadevan 2015), so a negative click rules nothing out. In a surgical series of excised neuromas, clinical assessment alone was 98 percent sensitive, and the authors concluded imaging is needed mainly when the picture is unclear or more than one web space is involved (Pastides 2012).

Ultrasound helps when the exam is not clear-cut. Pooled against surgical findings, ultrasound and MRI detect Morton’s neuroma about equally well, with sensitivity of 91 and 90 percent (Bignotti 2015). A second meta-analysis put ultrasound specificity at 88 percent against 68 percent for MRI (Xu 2015). Ultrasound also checks the neighboring plantar plate and guides the needle. MRI earns its place when exam and ultrasound disagree or a stress fracture is possible.

One caution. In 70 people with no foot pain at all, MRI showed a “Morton neuroma” in 30 percent (Zanetti 1997). The authors suggested the finding matters only when it is at least 5 mm across and matches the symptoms. A “neuroma” on a report, in a foot that hurts somewhere else, is a coincidence.

When the story is mixed, a diagnostic block settles it. Local anesthetic placed into the web space under ultrasound should switch the burning off while it works. If it does, the web space is the likely source. If the foot still burns, the next question is the tibial nerve at the ankle, tested with an ultrasound-guided nerve block at the tarsal tunnel, or the L5 and S1 roots. Diagnostic blocks are also the key test after failed surgery, when it is unclear whether the pain is a recurrent neuroma, a stump neuroma, or a different web space (Adams 2011).

The treatment ladder, and what is not on it

Step 1: Wider shoes, lower heels, and a pad in the right place

Conservative care comes first. It targets the mechanism: stop squeezing the metatarsal heads together and stop forcing the toes into extension under load.

• A toe box wide enough that the forefoot is not compressed from the sides when you stand. If the upper bulges at the little-toe joint, the shoe is too narrow.
• A lower heel. Forefoot pressure climbs as heel height goes up (Mandato 1999).
• A metatarsal pad just behind the metatarsal heads, not under them. It spreads the heads and offloads the web space, and placement matters. In a pressure-mapping study, pads slightly behind the line of the metatarsal heads reduced peak pressure, while a pad that crept too far forward raised it (Hastings 2007). That study was in people with diabetic neuropathy, but the mechanics carry over. We place the first pad in the office and mark the spot.
• Lacing that skips the eyelets over the forefoot, so the shoe stops clamping the metatarsals.

In a randomized comparison, 63 percent of patients treated with footwear changes and orthoses had complete or partial relief at 12 months, against 82 percent given a steroid injection (Saygi 2005). The injection group was more satisfied, though by the authors’ own account the gap at one year was not statistically significant. That makes footwear a fair first trial.

Step 2: Ultrasound-guided corticosteroid injection

If shoes and a pad have not settled it, the next step is a corticosteroid with local anesthetic placed into the intermetatarsal space next to the nerve, under ultrasound. This is the injection Modal offers for Morton’s neuroma, as one of our joint and soft tissue injections.

The evidence is real but more modest than most clinic websites suggest.

The best single trial comes from Edinburgh, where 131 patients were randomized to ultrasound-guided methylprednisolone 40 mg with lidocaine, or lidocaine alone, without knowing which they got. At three months the steroid group rated their foot health 14 points better on a 100-point scale, and the gap was already present at one month (Thomson 2013). Meaningful, but modest. A Cochrane review that pooled this trial with a second found the steroid’s added effect on pain itself was small and uncertain at three to six months, on low-certainty evidence (Matthews 2024). The same review found moderate-certainty evidence that ultrasound-guided injections beat unguided ones on pain and function. Not every trial agrees: one double-blind trial of 45 feet found no difference with guidance, and about half of the injections in each group had failed within a year (Mahadevan 2016). A systematic review of single injections put it fairly: better than usual care, questionably better than anesthetic alone, inferior to surgical excision, on low-quality evidence (Edwards 2021).

When it works, it can last. In follow-up of that guided-versus-unguided trial, the original injection was still working in 36 percent of feet nearly five years later, and 44 percent had gone on to surgery (Hau 2021). A good result at one year predicted a durable one.

Dr. Movshis’s approach follows from that. Every injection is done under ultrasound, so the needle tip sits beside the nerve and away from the plantar fat pad. If the first injection gives months of relief and then fades, a second is reasonable. If it does little, he does not keep repeating it, and the conversation turns to surgery. Side effects are local and uncommon: skin thinning or lightening and plantar fat pad atrophy, each reported in a few percent of steroid-treated patients (Matthews 2024).

Physical therapy alongside the ladder

Physical therapy will not dissolve a scarred nerve, but it handles pad and footwear fitting, mobilizes a stiff forefoot, and retrains how a runner loads the front of the foot. In one meta-analysis, forefoot manipulation and mobilization reduced pain compared with control, and alongside steroid injection it had the strongest evidence of any non-surgical option, though no single best treatment emerged (Matthews 2019). Modal’s in-house physical therapy team, on the same floor, takes this on when it fits the plan.

Treatments offered elsewhere that we do not perform

Modal does not offer alcohol sclerosing injections, radiofrequency ablation, or cryoneurolysis of the interdigital nerve. If you are weighing them elsewhere, here is the evidence.

Alcohol sclerosing injections had encouraging early numbers that did not hold. At five years, only 29 percent of patients in one prospective series remained symptom-free, and 16 of 45 had needed surgery (Gurdezi 2013). Another clinic abandoned unguided alcohol injections after 7 of 32 patients improved (Espinosa 2011).

Radiofrequency ablation looks better on paper. A meta-analysis of eight studies reported complete pain relief in about 48 percent at final follow-up (Llombart-Blanco 2025), pooling prospective trials, cohorts, and case series. An earlier meta-analysis judged the radiofrequency and cryoneurolysis literature alike as case series of limited quality (Matthews 2019). Dr. Movshis would want to see a sham-controlled trial before steering patients toward either.

Referral for neurectomy when the foot has not settled

For a confirmed neuroma that has failed shoes, a pad, and a well-placed injection, removing the nerve segment (neurectomy) offers the best odds of a complete result, and we refer to a foot-and-ankle surgeon for it. In a meta-analysis of 35 studies and almost 3,000 patients, complete pain relief was reported in 74 percent after neurectomy against 43 percent after injection (Lu 2021). Most of those studies were observational, and “complete” is a high bar. Some surgeons release the ligament and leave the nerve in place (neurolysis) instead.

Go in knowing the trade-offs. Removing the nerve leaves the facing sides of two toes numb by design. Reduced sensation was reported in about half of feet operated through a plantar incision and 62 percent through a dorsal one, with more scar tenderness after plantar incisions and reoperation rates near 5 to 6 percent either way (Lee 2024). A review of recurrent neuromas puts relief after a first excision at 50 to 85 percent and names the failure modes: the wrong diagnosis, an incomplete resection, or a painful stump neuroma where the cut nerve end sits under load. Surgeons lower that last risk by moving the cut nerve end into muscle or bone, away from traction and pressure (Richardson 2014). Recurrent symptoms usually show up within the first year (Adams 2011).

Morton’s neuroma in runners

Runners get a version of this that behaves differently. Many are fine early in a run, and then the toes go. That timing makes mechanical sense. Runners who land on the midfoot or forefoot put more load through the front of the foot than heel strikers (Wei 2019), and in a lab study of fatigue, forefoot strikers shifted even more load onto the first through third metatarsals as they tired (Hamzavi 2021). Feet also swell over a long run, so the shoe is narrower at the end than at the start.

What actually changes symptoms:

Toe box and lacing. Most running-shoe fixes for a neuroma come down to forefoot width. The wide version of a shoe you already like usually beats a new model, and a thinner sock helps. Lace the forefoot loosely and take up tension at the top so the heel stays locked.

Strike and cadence. Raising cadence is standard advice for many running injuries, but it is not a forefoot fix. In a treadmill study, a 10 percent increase in step rate reduced pressure under the heel and midfoot and did nothing for forefoot pressure (Gerrard 2018). If the burning started after a switch to a forefoot strike or a lower-drop shoe, that change is the likelier culprit. A metatarsal pad works in a running shoe too, tested on short runs first.

Running a race on a neuroma

Often you can. A Morton’s neuroma is painful but not structurally dangerous, the opposite of a stress fracture. With a marathon or half marathon a few weeks away, do not change shoe models in the final weeks. Make the width and lacing changes now and test them on a long run. If you want an injection before the race, have it early enough to see how the foot responds over a few runs, and never in race week. The anesthetic leaves the forefoot numb for a while, and a start corral is a bad place to learn how a freshly injected foot feels.

Return to full training goes by symptoms, not the calendar:

1. Walking a full day in your normal shoes without burning.
2. The web-space squeeze no longer reproducing the burn.
3. Easy runs on flat ground without numb toes during or after.
4. Then long runs and speed work again, stepping back if the toes go numb and stay numb after the shoes come off.

If the pain moves onto the bone or makes hopping painful, treat it as a stress fracture until imaging says otherwise, and do not race on it.

When ball-of-foot pain needs urgent care

Most forefoot pain can wait for an appointment. These cannot:

• A red, hot, swollen forefoot, especially with fever, or any open wound on the foot of someone with diabetes.
• Sudden inability to bear weight, or an obvious deformity after a fall or twist.
• Numbness that is spreading quickly, a foot that slaps or drags, or new weakness in the leg.
• Back pain with numbness in the groin or saddle area, or new trouble controlling the bladder or bowels.

For any of these, call 911 or go to the nearest emergency room.

Morton’s neuroma care with Dr. Movshis in Midtown

Modal Pain Management is a single-physician practice at 369 Lexington Avenue, Floor 25, and every physician visit is with Dr. Movshis. He is dual board-certified in Anesthesiology and Pain Medicine and completed an ACGME-accredited interventional pain medicine fellowship at the Icahn School of Medicine at Mount Sinai (NPI 1942741160).

A first visit for ball-of-foot pain covers the history and the forefoot and neurological exam. Ultrasound of the web spaces and plantar plates is added when the exam leaves doubt, and a guided injection is scheduled when it is the right call. If the problem is a stress fracture, a plantar plate tear that needs repair, or a neuroma headed for surgery, he says so and refers you directly to a foot-and-ankle surgeon with the findings in hand.

Same-week appointments are available. Book online or call (646) 290-6660.

References

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