Can I use Botox to treat Morton’s neuroma?
Morton’s neuroma is a chronic and progressive nerve entrapment syndrome that affects a fair percentage of the general population and causes neuropathic pain and discomfort along the second or third metatarsal space.
A 2013 study(1) reported that botulinum toxin A had been used successfully for the management of several conditions that are associated with neuropathic pain or loss of muscle tone. The study also suggested that the mechanism of action of botulinum toxin A makes it an ideal option for the management of neuropathic pain in Morton’s neuroma.
Can I receive Botox injections for the management of Morton’s neuroma?
Botulinum Toxin A (Botox) is made up of a simple peptide unit that constitutes one heavy and one light chain, attached via disulphide bridge(1). The mode of action of Botox injection is specific for blocking the release of acetylcholine at the motor endplate with its protease like action to result in:
- Substantial improvement in the spasticity of muscles or surrounding connective tissue elements (that are responsible for pain and discomfort)
- Analgesic effects can also be achieved due to improved spasticity of the connective tissue matrix. Additionally, several research studies suggest that Botox-induced analgesic effects are also attributed to selective inhibition of the release of pain or inflammatory mediators from the nerve terminals.
How effective is Botox for Morton’s neuroma?
A 2013 study by José M. Climent and associates(2) assessed the effectiveness of Botox for the management of Morton’s neuroma in 17 patients who had pain and discomfort which lasted for more than 3 months and had not responded to conventional therapies. After administration of Botox in the neuroma, investigators assessed the pain and mobility over the next three months and concluded that:
- Botox therapy is associated with a remarkable improvement in Morton’s neuroma pain within 3-4 weeks.
- The effects can last up to 3 months after a single injection and usually improves with time.
- The patient satisfaction was greater than 70%. However, investigators suggested that the quality of results and patient satisfaction scores could have been improved if the Botox injection was administered under ultrasound guidance.
- Most importantly, no patient reported any worsening of symptoms.
- Besides improvement in pain symptoms, Morton neuroma patients also reported a significant improvement in overall functioning.
The therapeutic effects of Botox therapy are largely dose-dependent and usually a small dose of just 50U is considered effective for optimal alleviation of symptoms. The effects of Botox therapy are usually evident within 2-3 days (48 to 72 hours) after the administration of injection. Typically, the peak clinical efficacy was achieved over the next 1-3 weeks. Based on several clinical studies, the effects can last up to 3 months, possibly longer(1,2).
Botox injection vs. Other therapeutic options for Morton’s neuroma treatment:
Although, currently Botox therapy is not considered the first-line of treatment for the management of Morton’s neuroma, it at least as effective and viable as corticosteroid injections in terms of therapeutic benefits (with minimal risk of adverse effects)(3) and it is comparable in effectiveness to alcohol injections(4). It is important to note that the quality of results of Botox may vary depending upon the technique, intensity of initial symptoms and related factors.
Should I have Botox to treat my Morton’s Neuroma?
We do not routinely use or recommend Botox to treat Morton’s neuroma for the following reasons:
- It is still considered highly experimental for Morton’s neuroma. There has been only one study(2) (that we could find) demonstrating the use of Botox form Morton’s neuroma and that study had only 17 patients, which is considered very small. The study did give us an indication that Botox is effective for Morton’s neuroma but because of the small study size and shortness of the study, we cannot draw any broad conclusions from it.
- The effects of Botox are only temporary in any circumstances and generally only last 3-4 months. The one study that used Botox for Morton’s neuroma(2) only followed 17 patients for 3 months.
- No insurance company will reimburse a Botox injection for Morton’s neuroma, so it will have to be paid by the patient out of pocket and Botox is quite expensive.
- We use other non-surgical procedures to treat Morton’s neuroma such as ultrasound guided radiofrequency ablation, ultrasound guided cryosurgery and ultrasound guided ablation injections. These procedures are more effective than Botox injections to ttreat Morton’s neuroma; they last longer and they are, for the most part, reimbursed by Insurance companies.
- Wu, H., Sultana, R., Taylor, K. B., & Szabo, A. (2012). A prospective randomized double-blinded pilot study to examine the effect of botulinum toxin type A injection versus Lidocaine/Depomedrol injection on residual and phantom limb pain: initial report. The Clinical journal of pain, 28(2)
- Climent, J. M., Mondéjar-Gómez, F., Rodríguez-Ruiz, C., Díaz-Llopis, I., Gómez-Gallego, D., & Martín-Medina, P. (2013). Treatment of Morton neuroma with botulinum toxin A: a pilot study. Clinical drug investigation, 33(7), 497-503.
- Markovic, M., Crichton, K., Read, J. W., Lam, P., & Slater, H. K. (2008). Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton’s neuroma. Foot & ankle international, 29(5), 483-487.
- Hughes, R. J., Ali, K., Jones, H., Kendall, S., & Connell, D. A. (2007). Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. American Journal of Roentgenology, 188(6), 1535-1539.
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.