Morton’s neuroma and stress fractures of the toes
These are two very different pathologies that we have chosen to group together because they affect similar regions of the foot and the physiotherapy management of each has some similarities.
What is a Morton’s Neuroma
Morton’s neuroma is an entrapment of one of the small nerves in the foot as it passes between the third and fourth toes. This region is particularly vulnerable to nerve impingement because it is where the lateral and medial plantar nerves join and typically the nerve is slightly thicker at this junction. The condition is more common in women than in men and poorly fitting or high heeled shoes may play a role in the development of a neuroma. Pain (and even numbness or tingling) is felt on the sole of the foot in the region of the neuroma (pictured left) or may extend towards the end of the third and fourth toes. Patients will occasionally experience pain on the top side of their foot in the same region.
How does physiotherapy treat Morton’s Neuroma?
Thankfully this is a very easy condition to treat and usually requires little more than some local massage to the sole of the foot (at the site of the nerve entrapment) and the addition of a small piece of foam (metatarsal dome)in the shoe to support the transverse arch of the foot (pictured opposite right). Note: this is different to the large longitudinal arch of the foot and using orthotics or foam supports on this arch will do nothing to relieve the symptoms of Morton’s neuroma. The physiotherapist may also tape the foot to relieve pressure on the nerve. This taping technique (‘transverse arch taping’) is very simple and can be taught to the patient. It is then a matter of reapplying this tape each morning for between 7 to 10 days or until the pain has fully resolved.
The patient can also be taught the massage techniques that are used on their foot. They are simple and relatively painless techniques that, when performed each day at home, will reduce the cost of physiotherapy considerably – often patients only need one consultation with a physiotherapist and they can be instructed how to treat the problem themselves at home.
For persistent or chronic cases, the metatarsal dome should be worn in all footwear (and can easily be swapped from shoe to shoe with a small piece of adhesive tape to keep it in place) until such times as the symptoms have completely resolved (usually 1 to 2 weeks). If pain recurs, a small ‘platform’ orthotic can be fitted with a permanent metatarsal dome and this is then worn continuously in the shoe. (Platform orthotics are a thin foam insert upon which small modifications to support various regions of the foot can be attached. They are inexpensive and can be accommodated in almost any footwear including high heeled shoes)
Stress fractures of the toes
Stress fractures may occur in almost any bone but are most commonly seen in weight bearing bones including the metatarsals of the foot (see picture right). Stress fractures of the metatarsals are most commonly seen in runners or people who walk a lot. The fracture results from the repetitive stress placed through the foot. Small cracks in the outer cortex of the bone begin to develop and pain is felt locally on the dorsum (top) of the foot. Unlike Morton’s neuroma, which symptomatically eases very quickly once weight is taken off the foot, the pain of a stress fracture can persist for many hours or even days after the activity (walking or running) is ceased. Sometimes it is possible to confirm the presence of stress fracture with a plain film x-ray (left) though this is not always the case. In situations where there is a strong clinical suspicion of a stress fracture and where x-rays are normal, a bone scan may be recommended to confirm the diagnosis.
Treating metatarsal stress fractures
The management of metatarsal stress fractures is relatively straight forward. Unlike Morton’s neuromas however, there is often the need to rest the affected foot for a considerable time – this may mean avoiding sport altogether for 6 to 8 weeks whilst the fracture heals. The key to managing these stress fractures is to ensure the problem does not reoccur once the patient returns to their regular activities. This boils down to two things:
- Supporting the transverse arch of the foot with an appropriate orthotic (often support of the longitudinal arch and heel is also required to correct any foot pronation) and
- Assessing and correcting running techniques to reduce pressure through the forefoot. This is not an easy task and requires dedication from the patient (essentially they have to relearn a new running technique). The physiotherapist should also be well trained in the assessment of lower limb biomechanics and should be familiar with the stresses placed on the foot by the unique demands of each sport.
In severe cases of metatarsal stress fractures, the foot and ankle must be maintained in a sold plaster cast or splint to ensure adequate bone healing.
© Andrew Thompson