Bursitis and Morton’s Neuroma
Morton’s neuroma is a fairly common cause of foot pain that is reported far more frequently in females as compared to males (female to male ratio is 9:1). This high incidence is attributed mainly to the anatomy of female foot as well as lifestyle choices such as prolong use of narrow toe-box shoes or long hours of standing etc. Unfortunately, poorly managed foot pain can also aggravate the risk of developing other disorders such as bursitis.
Typical Presentation of Bursitis and Morton neuroma:
- Excruciating pain that is often especially pronounced in the region of third and/ or fourth metatarsal space.
- Aggravation of pain or discomfort upon weight bearing.
- Feeling of electrical jolt like sensation; especially on the movement of the involved toes
- Feeling of numbness radiating to the involved web-spaces
- Sensation of walking on a marble
- Progressive disability
However, in some cases the two conditions may coexist asymptomatically i.e. without any pain or noticeable symptoms.
Diagnosis of Bursitis and Morton’s neuroma
The diagnosis of Morton neuroma and bursitis is mostly clinical i.e. more than 85-90% cases can be identified on good history taking and clinical examination. For more complex or concealed cases, radiological tests like an ultrasound or magnetic resonance imaging (MRI) may be needed.
Bursitis can be differentiated from the Morton neuroma on scans via following features:
- Morton neuroma appears as patchy enhancement (which is actually perineural fibrosis). The lesion is characteristic for a tear-drop shaped mass of soft tissue; usually along the plantar aspect of metatarsal heads.
- Bursitis appears brighter and has signs of rim enhancement. Often times the bursitis may show signs of fluid accumulation around the tissues due to ongoing inflammation.
Management of Bursitis and Morton neuroma
Generally no management or clinical workup is necessary if Morton neuroma is pain free and identified accidentally on physical examination. For painful or disturbing neuromas, the choice of therapy depends on overall health and patient factors.
Most common management tools to control the symptoms of these two conditions primarily revolves around:
- Lifestyle modification and changes in the activity status
- Modification on the type of footwear
- Conservative options like pain remedies, massaging and application of compresses
In chronic cases:
- Steroid injections or analgesics injections may be used to resolve pain and active inflammation
- If these are not helpful, ultrasound guided neurolytic injections, ultrasound guided radiofrequency ablation, or ultrasound guided cryo-ablation are excellent treatment choices.
- Innovative therapies like platelet rich plasma injections, stem cell therapy are also often used especially in complex cases.
- Surgery is usually opted as a last resort after all other options have been tried.
- Bauer, T., Gaumetou, E., Klouche, S., Hardy, P., & Maffulli, N. (2015). Metatarsalgia and Morton’s Disease: Comparison of Outcomes Between Open Procedure and Neurectomy Versus Percutaneous Metatarsal Osteotomies and Ligament Release With a Minimum of 2 Years of Follow-Up. The Journal of Foot and Ankle Surgery, 54(3), 373-377.
- Zanetti, M., Strehle, J. K., Zollinger, H., & Hodler, J. (1997). Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers. Radiology, 203(2), 516-520.
Janet D. Pearl, MD, MSc is the Medical Director of The Center for Morton’s Neuroma and Complete Spine and Pain Care, an interventional and integrated Pain Management program located in Framingham, Massachusetts. Previously, Dr. Pearl was the Co-Director of the Pain Management Center at St. Elizabeth’s Medical Center, where she was also the Director of the Fellowship program. She is the former Director of a satellite pain center of the Brigham and Women’s Hospital, Pain Management Center, located at the HealthSouth Braintree Rehabilitation Hospital. Dr. Pearl held academic appointments at Harvard Medical School and Tufts Medical School. She serves on the Health Care Services Board of the Commonwealth of Massachusetts Department of Industrial Accidents since 2000 as one of its physician representatives and is Chair of the Committee on Pain Management.