Why does it feel like I'm walking on a marble?

Seems pretty detailed of a complaint doesn't it? It might but if you've ever experienced Morton's Neuroma you would know this is the most accurate description of what it feels like.

What is it?

Morton’s neuroma is a perineural scar tissue swelling of a plantar nerve between the toes. Symptoms usually include burning pain or paresthesia at the base of the toes. The nerve supply to the sole of the foot begins, behind the medial malleolus ( the inside ankle bone), with the posterior tibial nerve.





Morton’s neuroma results from a combination of repetitive mechanical entrapment ischemic tethering. This condition most commonly occurs at the metatarsal heads (long bones in the foot that meet the toes). Dorsiflexion of the toes allows for the interdigital nerves to become compressed by the metatarsal heads which can cause the pain.


Morton’s neuroma occurs in the third web space (between the third and fourth toes) in about 80-85% of cases, and in the second web space in 10-15% of cases. This condition affects 10% of the overall population, with females being affected five times more frequently.


Known contributors of Morton’s neuroma include wearing shoes with a tight shoe box, wearing high heels, or participating in activities that require repetitive toe dorsiflexion. Patients with hyperpronated feet may compensate with excessive toe dorsiflexion and are affected more frequently.


Clinical Presentation

Symptoms of Morton’s neuroma are described as a sharp, burning sensation between the third and fourth toe. The pain usually begins on the sole of the foot at the metatarsal heads and radiates into the toes. Patients may report that they feel as though they are walking on a marble. Complaints of numbness, paresthesia, or cramping in the toes adjacent to the neuroma are common. Patients will often complain of episodic sharp pain lasting for a few minutes, transitioning into a dull ache that lasts for the next couple of hours. The pain is often precipitated by wearing constrictive or high-heeled shoes during physical activity and may be relieved by removing the shoe and gently massaging the affected area.


Clinical evaluation may demonstrate different characteristics of the condition such as tenderness within the affected interspace. Reproduction of localized pain in the affected plantar web space between the third and fourth toes suggests the presence of Morton’s neuroma.


Evaluation of the foot and ankle mechanics should include assessment for loss of the longitudinal arch of the foot, hyperpronation, gastroc hypertonicity, and foot/ ankle joint hypomobility.


Diagnosis

Studies have shown that the history and physical evaluation of Morton’s neuroma is more sensitive than advanced imaging. Plain films may be utilized to rule out any foot bony pathology. MRI can detect neuromas in 97% of symptomatic patients and 25% in asymptomatic patients. Diagnostic ultrasonography is a useful diagnostic tool as well.


Management

If left untreated, Morton’s neuroma can become disabling with some biomechanical consequences in the ankle, knee, hip and spine. The first stage of conservative care can include patient education, footwear modification, and the use of a metatarsal pad.


The implementation of a metatarsal pad may help distribute pressure away from the affected third or fourth metatarsal heads.


Nerve mobilization techniques or nerve flossing may help restore normal neurodynamics. Patients may benefit by strengthening the flexor hallucis longus (the muscle that attaches to the big toe at the bottom of the foot) as this acts to transfer stress away from the third and fourth metatarsal heads.


Patients may benefit from myofascial release and stretching of the gastroc and soleus. Since abnormal foot joint biomechanics may contribute to the problem, clinicians should assess and manipulate any restrictions, especially the MTP and calcaneocuboid joints.


Patients should avoid wearing high-heeled, narrow, or unpadded shoes. A good alternative would be shoes with a wide non-constrictive toe box and low heel.


Patients who fail conservative management may require an injection. Outcome studies of steroid injections show mixed results, varying between no lasting benefit and resolution.





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