Conservative Treatment Options for Morton’s neuroma
The first step in treating Morton’s neuroma is to use conservative or non-medical methods to attempt to relieve the pain. In many cases, conservative treatment may result in some pain relief in the early stages of Morton’s neuroma where the pain is mild but unfortunately this relief may only be temporary . In other words in most cases, these methods will provide some short term pain relief in the early stages of the condition, but they will become ineffective fairly soon.
To decrease inflammation, one should use ice on the painful area for 15-20 minutes, at least 2-3 times per day – especially in the evening. (Caution: avoid using ice if you suffer from circulation or sensation problems in the foot.) Applying ice then heat, known as contrast therapy, is another treatment for Morton’s neuroma. This treatment involves alternating between ice packs and heating pads. Typically, an ice pack will be placed on your foot for 15- 20 minutes. Next, the ice will be removed and a heating pad will be placed on your foot for another 15-20 minutes. The contrast between hot and cold will alleviate pressure due to swelling as well as increase blood flow to the affected tissues, which can speed up the healing process.
The effect of ice on Morton’s neuroma is debatable since Morton’s neuroma is not an inflammatory disease however, Morton’s neuroma often occurs in conjunction with bursitis or epicondylitis and these are inflammatory conditions in which case ice would be helpful. It may be very difficult even impossible to determine whether the pain that you are feeling is from a Morton’s neuroma or an adjacent bursitis or epicondylitis.
2. Physical Therapy
Physical therapy should not be glossed over as unimportant because often it is an important aid to treat pain, especially as part of more comprehensive plan. Even when other methods, such as medications and surgeries, are used, physical therapy is an important adjunct to help healing and reduction of pain.
The types of physical therapy that are used for Morton’s neuroma include:
- Stretching and Massage. This helps increase the flexibility of the affected area by loosening tight tendons and ligaments.
- Toe Exercises. Muscle strengthening through toe exercises is an important part of physical therapy to minimize the effect of Morton’s neuroma.
- Ankle Exercises. As a result of the pain from Morton’s neuroma, the muscles that support your ankle can become weak. Strengthen exercises can strengthen the ankle, providing more stability and lessen the chances of further injury.
Your physical therapist should do an evaluation of the way you walk and run (a gait analysis). They look for factors that might lead to or exacerbate Morton’s neuroma. The gait analysis helps tailor individualized physical therapy and helps with designing the correct custom orthotic. Some of the factors that should be looked for in a gait analysis of Morton’s neuroma include:
- Are your feet, shins and legs relaxed prior and during impact?
- Are any of the toes off the ground at impact and while transferring the weight across the planted foot?
- Does your calf shake when it hits the ground?
- Do you push or pull your body across the ground or spring your body off the ground?
- Does your foot point straight with the second toe being the pointer toe towards the direction you are going or do you point your toe outwards?
- Is your shin, ankle and foot in alignment or do you have a weak or weak ankles?
3. Orthotics and Shoes
Shoes are an important factor in determining how much pain a Morton’s neuroma causes. Research has shown that tight fitting shoes, such as high heels, can cause this condition to occur. Continuing to wear those types of shoes will only cause the pain to increase and may necessitate more aggressive treatment of the problem. Wearing wide shoes with a generous toe box is among the first treatments for Morton’s neuroma. In other words, do not wear high heeled, pointy toed or narrow toed shoes.
You may also try an off the shelf medical orthotic or have a custom orthotic created to help with the pain. Custom orthotics are generally the most effective non-surgical treatment, when dealing with the very early stages of Morton’s neuroma. Now you can get medical grade off the shelf orthotics or, if needed, custom orthotics. These are an affordable therapy for mild Morton’s neuroma. Make sure that your shoes have enough space, particularly in the toe box for the orthotic to fit comfortably.
Off the shelf orthotics may be a good way to test the effectiveness of orthotics, without buying custom orthotics. If you have some relief with off the shelf orthotics, you may decide to have a custom orthotic made for your foot. You can usually get a custom orthotic at a podiatrist or an orthotics specialist. Your foot will be casted to create an orthotic that spreads apart the bones of the ball of your foot (metatarsal heads). Spreading the metatarsal heads may reduce the pressure on the nerve in the web space and may prevent the neuroma from worsening.
In more persistent cases, custom shoes may be necessary to relieve pain. These shoes will be made to your specifications and include a wide toe box and built-in metatarsal roll. If you play sports, it is often necessary to have custom shoes to allow you to continue with the activity. Sports such as running, walking, tennis, golf, skiing, and bicycling will require shoes or insoles that are specifically designed to reduce Morton’s neuroma symptoms.
A simple way to treat the pain of Morton’s neuroma is through the use of medications. Mortons neuroma pain is primarily a pain that arises from the nerve, and this means that many medications are available to treat the pain. Although pain medications on their own are not often as effective as combination treatments, they can help to reduce pain enough to facilitate physical therapy and exercise.
- Tylenol / Acetaminophen
Acetaminophen is often used for the relief of mild to moderate pain associated with many conditions, including Morton’s neuroma. Unless directed by a physician, acetaminophen should not be used for longer than 10 days. When used appropriately, side effects with acetaminophen are not common. The most serious side effect is liver damage due to large doses, chronic use or taking Tylenol with alcohol or other drugs that also damage the liver. You should keep your dose below 3000 mg per day. If you drink alcohol regularly do not take Acetaminophen. In any event, you should consult your physician. For more information on Acetaminophen (Tylenol) click here.
Like Tylenol, non-steroidal anti-inflammatory drugs, or NSAID are recommended early in the presentation because they are effective with relatively few side effects. The most common NSAIDs are the over the counter pain medications Advil and Aleve. However, they are not the only NSAIDs available to a practitioner. Certain advanced NSAIDs called COX-2 inhibitors, such as Celebrex, can be prescribed. They are less likely to cause stomach side effects, such as bleeding ulcers, but medications in this class have been linked to cardiac side effects. For this reason, they are used with caution. In addition, long term use of NSAIDs can use kidney damage and bleeds in the gastrointestinal track and should be avoided. Follow these links for more information about the NSAIDs Ibuprofen (Advil) and Naproxen (Naprosyn/Aleve).
- Other Medications
In some cases the addition of other medications may be helpful in controlling pain due to Morton’s neuroma.Besides Tylenol and NSAID’s, tricyclic antidepressants such as amitriptyline, can be used to control nerve pain. Recent studies have found that these older style antidepressants are very effective in treating any nerve pain, and they can relieve some of the discomfort of Morton’s neuroma. A low dose can help with the burning in the toes.The antidepressant Duloxetine or Cymbalta is another of the antidepressants that has proven useful in the treatment of nerve pain. In fact, the FDA recently approved it as a treatment for chronic pain, and it can help with Morton’s neuroma if other medications are ineffective.
Some anticonvulsant medications such as Gabapentin or Lyrica, can help with the nerve pain from Morton’s neuroma. While the exact mechanism of action is unknown these medication are effective. Recently, the FDA approved Lyrica for use in diabetic peripheral neuropathy and post-herpetic neuralgia, but Lyrica can also help with the nerve pain associated with Morton’s neuroma.
Finally, opioid pain medications can be used in extreme cases of Morton’s neuroma. For pain that is not responsive to other methods or that is intermittent but extremely painful, narcotic pain medications, such as Tramadol or morphine related medications can help you to find relief. However, these are used rarely, only when other medications and multiple other treatments have failed due to a relatively high risk of dependency, and the presence of other side effects, such as nausea, constipation and sedation, and in excess amounts, respiratory failure and death.
If medications combined with other conservative treatments such as physical therapy are not effective, patients should generally go on to have interventional treatments, such as temporary corticosteroid injections or more permanent interventional treatments.
We strongly urge patients to avoid Morton’s neuroma surgery except as a last resort when other measures have failed.