Technique varies considerably among surgeons.12 A Cochrane systematic review of 3 randomized controlled trials comprising 121 patients concluded that, at most, very limited evidence exists that transposition of the transected plantar digital nerve may yield better long-term results than standard resection.3
In a retrospective case series, 82 patients with primary Morton’s neuroma were treated by a single surgeon and a single technique (dorsal incision and nerve transection).13 All patients had failed conservative management with orthotics, shoe modification, and NSAIDs (lidocaine injections were used only to pinpoint neuroma location). Sixty-six (81%) returned for follow-up.
Average follow-up evaluation was 5.8 years. Of the patients who were followed, 85% rated overall satisfaction as excellent or good.
Stepped care gets results
A prospective case series enrolled 115 subjects out of 340 consecutive patients who presented to a private orthopedic clinic with a diagnosis of Morton’s neuroma.1 The authors assessed a 3-stage protocol of stepped care, progressing to the next stage if improvement was inadequate after 3 months: Stage I comprised patient education, footwear modifications, and a metatarsal pad placed proximal to the involved nerve; stage II, injection of steroids with local anesthetic or local anesthetic alone; and stage III, surgery.
Of 57 patients treated only with footwear modifications, 47 (41%) improved and required no further treatment. Twenty-seven (47%) of the 58 patients who received injections improved and required no further treatment. Of the 24 patients who advanced to stage III, 96% improved with surgery.
Recommendations
No consensus exists regarding definitive treatment of Morton’s neuroma. The American College of Occupational and Environmental Medicine recommends excision of the neuroma if nonsurgical treatment fails.14
A 2003 Cochrane systematic review of 107 studies found insufficient evidence to assess efficacy of surgical and nonsurgical interventions.3 Stepped care has been adopted by many third-party payers who require conservative care before reimbursing for injections, and treatment with injections before reimbursing for surgery.