What you're feeling¶
The pain sits in the ball of your foot, usually in the space between your third and fourth toes. It happens when a nerve in that space becomes thickened and irritated. The nerve there is built differently from the nerves between your other toes. It is thicker and held more firmly in place, which means it can get pinched and stretched as you walk.
The pain is felt on the underside of your foot, at the base of your toes. You might describe it as a burning ache, or a feeling of something sharp in the ball of your foot. Standing and walking put pressure on the sore spot, so symptoms tend to build through a day on your feet. Pushing off the ground as you step can make it worse. Taking your weight off the foot usually eases it.
Some people notice the pain most when they are up and moving, rather than at night or first thing in the morning. The flare tends to come after activity, once the nerve has been squeezed repeatedly.
Day-to-day, the sore spot makes itself known in small ways. Walking around the supermarket, standing at the kitchen bench, or climbing stairs can all press on the nerve. Shoes matter too. Narrow or tight footwear squeezes the bones in the ball of your foot together and presses on that nerve, so many people find themselves loosening laces or slipping shoes off under the desk. Some people feel the need to stop mid-walk, sit down, and take the shoe off to rub the sore spot.
If this sounds like your foot, there are ways to settle it. Simple, non-surgical treatments are tried first. Surgery is only considered once those have not worked.
What's actually happening¶
Between the bones of your toes, deep in the ball of your foot, runs a small nerve. The one between your third and fourth toes is different from the others. It is thicker, and it is held more firmly in place. Two nerve branches join together right there before running out towards your toes. That meeting point sits just under a strong strap of tissue that holds the bones of your foot together.
As you walk, your body weight squeezes the bones in the ball of your foot together. The nerve gets pinched between them, over and over. Because it is held tight and cannot slide out of the way, it takes the strain instead of moving free. Think of a garden hose caught under a heavy doormat: every step presses it flat, and over time the hose itself changes. The nerve responds the same way. It becomes thickened and irritated, and that thickened nerve is the sore spot you can feel.
The symptoms you read about above follow directly from this. Pressure on the nerve causes the burning ache in the ball of your foot. Squeezing from tight shoes presses the bones together harder, which is why narrow footwear flares it up. Taking your weight off the foot releases the pinch, so the pain eases when you sit down or take the shoe off.
There is no grading system for this condition, and no test that sorts it into mild or severe. What matters is how much it interferes with your life. Simple, non-surgical treatments come first, and they work for many people. Surgery is considered when those treatments have not settled things. The usual operation removes the thickened nerve itself. Most people who need a second operation because pain came back get real relief from it, with 67% achieving complete relief or marked improvement.
What we can do about it¶
Weight-bearing X-rays can rule out other causes of pain in the ball of the foot, such as a stress fracture. An ultrasound scan is another option, and an MRI scan can help tell a neuroma apart from other causes of forefoot pain such as a cyst or an inflamed joint lining.
The first things we try are the ones you can do yourself. A soft pad placed under the ball of your foot takes pressure off the sore spot and eases symptoms. Choosing roomier footwear and easing back on long days on your feet helps too, for the same reason. Physiotherapy aims to settle the irritation and get the load spread more evenly through your foot. We usually ask you to give these simple measures a fair go before moving on.
If self-management has not settled things, we can offer an injection. Using ultrasound to guide the needle means the cortisone goes exactly where the nerve sits. Cortisone is a strong anti-inflammatory medicine that calms the irritation around the nerve. Injections of cortisone given this way have shown better results for pain and function than injections of hyaluronic acid, a lubricating substance sometimes used for foot problems. Some people get relief that lasts, while others find the pain creeps back over time.
Surgery comes into the picture when these treatments have not given you enough improvement. The usual operation removes the thickened nerve itself through a small cut on the top of your foot. Another option reshapes the bones in the ball of your foot so pressure is spread more evenly when you walk, and this can be done through small cuts with a low rate of complications. We will talk through which option suits your foot and your goals, and decide together what to do next.
What to expect¶
Morton's neuroma rarely goes away on its own, but it does not have to run your life. For most people the pattern is one of flare and settle: the pain builds through a day on your feet, then eases once you sit down or take your shoes off. Left alone, it tends to keep coming back, especially if the footwear and activity that squeeze the nerve stay the same.
Simple, non-surgical treatments are tried first, and they work for many people. Changing your shoes, using a pad under the ball of your foot, easing back on long days standing, and physiotherapy all aim to take pressure off the nerve. If those have not settled things, a cortisone injection can calm the irritation. Some people get relief that lasts, while others find the pain creeps back over time. There is no fixed timeline for how long symptoms last; what matters is how much the sore spot interferes with your life.
Surgery is considered once these treatments have not given you enough improvement. The usual operation removes the thickened nerve itself, and most people who need a second operation because pain came back get real relief from it. Patient-reported outcomes after removal of a symptomatic neuroma are acceptable, though not always as strong as earlier reports suggested, so it is fair to go in with measured expectations rather than promises of a perfect foot.
A few things are worth knowing as you weigh it up. Removing the nerve can leave a numb patch between the affected toes, and in some people a tender spot can form where the nerve was cut. Operations that reshape the bones in the ball of your foot can shift extra load onto the neighbouring toes and cause aching there. These are the reasons your surgeon will be careful about matching the operation to your foot, and why surgery is held back until simpler treatments have had a fair go.
When to see someone¶
See your GP if you have a burning ache in the ball of your foot that keeps coming back, especially if it flares after walking or standing and eases when you sit down or take your shoes off. Ask for a specialist review if simple changes like roomier footwear, a pad under the ball of your foot, or physiotherapy have not settled things after a fair go, or if the pain is stopping you doing your normal work or daily activities. This condition is not dangerous, and there is no emergency attached to it. But the sooner the pressure on the nerve is eased, the better your chances of avoiding surgery later.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology¶
Plantar Nerve Anatomy¶
- The tibial nerve divides into three terminal branches before reaching the foot: the medial calcaneal nerve, lateral plantar nerve, and medial plantar nerve [3].
- The medial plantar nerve innervates the abductor hallucis and continues under the abductor and plantar fascia to form common digital nerves terminating in the first, second, and third web spaces [3].
- The medial plantar nerve provides motor branches to the interossei and lumbricals [3].
- The lateral plantar nerve passes deep to the abductor fascia and plantar fascia, over the quadratus plantae, and continues distally under the flexor digitorum brevis [3].
- The lateral plantar nerve terminates in the fourth web space and supplies a branch to the third web space [3].
- The lateral plantar nerve supplies motor branches to the intrinsic muscles of the foot [3].
- The medial calcaneal nerve branches first from the tibial nerve and travels posteriorly to the subcutaneous tissue [3].
- The plantar surface of the foot is innervated by the digital branches of the medial plantar nerve [4].
Forefoot Neurovascular Anatomy¶
- The dorsalis pedis artery is a continuation of the anterior tibial artery that passes deep under the inferior extensor retinaculum [4].
- The dorsalis pedis artery lies between the tendons of the extensor hallucis longus medially and the extensor digitorum longus laterally as it passes anterior to the ankle joint [4].
- The deep peroneal nerve lies immediately lateral to the dorsalis pedis artery [4].
- The arcuate artery arises in the region of the bases of the metatarsals and passes laterally [4].
- The second, third, and fourth dorsal metatarsal arteries arise from the arcuate artery and descend to the dorsal surfaces of the respective dorsal interosseous muscles [4].
- The first dorsal metatarsal artery is the continuation of the dorsalis pedis artery and runs distally on the dorsal surface of the first dorsal interosseous muscle [4].
- The first dorsal metatarsal artery supplies branches to the dorsal skin, the first and second metatarsals, and the interosseous muscles [4].
- The deep plantar artery leaves the dorsalis pedis at the base of the first metatarsal and passes toward the plantar surface of the foot between the heads of the first dorsal interosseous muscle [4].
- The deep plantar artery communicates with the lateral plantar artery to complete the plantar arterial arch [4].
- The first plantar metatarsal artery is the continuation of the deep plantar artery and passes distally in the first interosseous space [4].
- The first dorsal metatarsal artery may lie superficial to or within the substance of the first dorsal interosseous muscle in 78% to 88% of feet [4].
- The first dorsal metatarsal artery may lie plantar to the first metatarsal in 12% to 22% of feet [4].
- The dorsal surfaces of the toes and foot receive sensory innervation through the superficial peroneal nerve branches [4].
- The first web space is innervated by the deep peroneal nerve [4].
Foot Compartments¶
- The interosseous compartment of the foot lies dorsal to the medial, lateral, and central compartments between the metatarsals [9].
- The interosseous compartment contains digital nerves [9].
- Manoli and Weber demonstrated that each of the four interosseous muscles and the adductor hallucis lies in separate compartments [9].
- The barrier between the superficial and calcaneal compartments of the foot becomes incompetent at a pressure of 10 mm Hg [9].
Tarsal Tunnel Anatomy¶
- The tarsal tunnel is a fibroosseous tunnel within the posteromedial ankle and hindfoot [3].
- The tibial nerve, posterior tibial artery, accompanying veins, posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus tendons pass through the tarsal tunnel into the foot [3].
- The flexor retinaculum acts as the roof of the tarsal tunnel and extends from the medial malleolus to the medial side of the calcaneal tuberosity [3].
- The medial distal tibia, talus, and calcaneus make up the floor of the tarsal tunnel [3].
- Septa projecting from the fibrous roof to the calcaneus separate the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons [3].
- The tibial nerve, posterior tibial artery, and accompanying veins pass between the flexor digitorum longus and flexor hallucis longus tendons to enter the foot [3].
- The tibial nerve typically branches within the tarsal tunnel just proximal and deep to the upper edge of the abductor hallucis muscle [3].
Investigations¶
Clinical Examination¶
- The diagnosis of interdigital neuroma is usually made by conducting a careful history and physical examination [14].
- Plantar foot pain just distal to and between the metatarsal heads, often described as “burning,” is characteristic of interdigital neuroma [14].
- Patients with interdigital neuroma often feel as if they are walking on a marble [14].
- Symptoms of interdigital neuroma are typically aggravated by activity or by wearing shoes with high heels or a narrow toe box [14].
- Patients with interdigital neuroma often note that they feel better in their bare feet and get quick relief by removing their shoes [14].
- The Mulder sign is elicited by squeezing the foot while palpating the web space [14].
- A painful click during the Mulder sign is diagnostic of an interdigital neuroma [14].
- Neuromas rarely occur in the first and fourth web spaces, so for pain that occurs in these areas, other causes of forefoot pain should be considered [14].
- The involved ray should be evaluated for metatarsophalangeal (MTP) joint instability, especially if the second web space is symptomatic [14].
Imaging¶
- Weight-bearing radiographs are useful for excluding a stress fracture of the metatarsal neck in the evaluation of interdigital neuroma [14].
- Ultrasonography has been reported to be 85% accurate in diagnosing interdigital neuroma [14].
- MRI may be useful in the diagnosis of interdigital neuroma, and the administration of contrast medium may increase its accuracy [14].
- Interdigital or Morton neuroma is most frequently found in the distal third metatarsal interspace [20].
- Unlike most other tumors, interdigital or Morton neuroma lacks increased signal on T2-weighted MRI sequences [20].
- MRI can be useful in the diagnosis of metatarsalgia, such as distinguishing among a neuroma, cyst, bursa, or synovitis [18].
Diagnostic Injection¶
- Injection of the involved web space with local anesthetic that results in relief of the neuritic symptoms is diagnostic of interdigital neuroma [14].
- Injections performed under ultrasound guidance had higher short-term relief compared with blind injections for interdigital neuroma [14].
References¶
[3] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED HAMMER TOE AND MALLET TOE DEFORMITY WITH ASSOCIATED DOUBLE CORNS > TARSAL TUNNEL SYNDROME.
[4] Campbell S Operative Orthopaedics 4 Volume Set. RESULTS OF SUTURE OF THE SCIATIC NERVE > NEUROVASCULAR ANATOMY.
[9] Rockwood And Green S Fractures In Adults. Effect of Blast on the Musculoskeletal System > Foot.
[14] Aaos Comprehensive Orthopaedic Review 3. Neurologic Disorders of the Foot and Ankle > II. Interdigital Neuroma.
[18] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > METATARSALGIA.
[20] Campbell S Operative Orthopaedics 4 Volume Set. OTHER DISORDERS OF FOOT AND ANKLE.