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Morten’s neuroma Vs plantar plate
If you’ve ever suffered from pain in the ball of your foot you’ll know only too well how annoying and debilitating it can be. However, addressing the cause of the pain starts with the right diagnosis.
Two widespread causes of forefoot pain are Morten’s neuroma and plantar plate trauma. While plantar plate tears are less well known and identified, they are clinically prolific.
Morten’s neuroma
A Morten’s neuroma is a nerve injury. The joints around the metatarsal bones rub together causing irritation and swelling, which encroaches on the nerves. The nerves can become damaged and thickened resulting in the shooting, stabbing pain and burning sensation linked with a Morten’s neuroma.
The nerves in the intermetatarsal spaces (between the 2nd-3rd and 3rd-4th toes) are most commonly affected leading to pain in the ball of the foot.
Symptoms of Morten’s neuroma
- A sharp, shooting pain in the ball of the foot (usually between third and fourth toe)
- A burning pain in the ball of the foot that may spread or shoot down towards the toes
- Toes may feel numb or tingle
- Pain is intensified when wearing tight shoes or high heels
Podiatrist and founder of A Step Ahead Foot + Ankle Care Dr Brenden Brown explains, “Wearing high heels or tight fashion shoes compresses the nerve and creates that electric, shooting pain.
“People with foot deformities, such as hammertoes, bunions, flat feet or high arches, are at higher risk of a Morten’s neuroma because these defects generally cause the foot to widen, making it more difficult to find shoes that aren’t tight.”
Treatment for a Morten’s neuroma
Treatment will depend on the severity of symptoms but first-line treatment options include:
- Appropriate footwear—avoid shoes that are narrow in the forefoot or tight in general
- Soft tissue rehabilitation — Soft tissue massage to the Morten’s region can provide some relief from the associated pain
- Soft cushioned orthotics with a metatarsal dome may help reduce pressure on the nerve
- Injections to reduce inflammation, such as cortisone or Prolotherapy
- Surgical opinion is required if conservative measures are unsuccessful
Plantar plate tear
This is the very start of clawed or hammer toes! A plantar plate injury involves the ligament and cartilage attached to the base of and between our toe bones (phalanges). Injury can involve tears, ruptures or distensions. Conservative treatment for this condition is highly effective.
Symptoms of plantar plate tear
- Dull ache or sharp pain under the ball of the foot
- A “V” sign where the toes separate and form a V shape
- Toe lifts upwards (commonly the 2nd or 3rd toe) and may become swollen
- In acute cases the toe becomes thickened or enlarged. Often described as “sausage like”
- Feeling that you have a small stone in your shoe when walking
- The feeling that there’s insufficient cushioning between the toe bones and the ground
- Small amount of callous develops under the metatarsal heads
- Surgical opinion is required if conservative measures are unsuccessful
Treatment for plantar plate tear
- Conservative treatment for this condition is highly effective if caught within the first 6 – 12 months
- Wearing firm, stiff-soled shoe can help alleviate pressure on the joint and reduce the pain
- Cushioned orthotics with a metatarsal dome (often recommended by orthopaedic surgeons)
- Soft tissue rehabilitation, deep connective tissue therapies to the joint capsules and the spaces around this area.
- Deep connective tissue therapies to the extensor and flexor tendons and muscles of the foot
- Serial strapping or taping to prevent the toes popping up or hold them in alignment
Dr Brenden says, “For years Morten’s neuroma has widely been the most common diagnosis for forefoot pain. Yet I find that in many cases, where there is a dull ache type of pain in the ball of the foot, the cause is a plantar plate tear rather than Morten’s neuroma.”
Radiology
Morten’s neuroma and plantar plate trauma are difficult to distinguish between on diagnostic ultrasound.
“When viewed in ultrasound the two conditions without further discovery and without an experienced radiologist can appear the same. The two conditions will often return a hypoechoic mass finding, hence the need for more detailed clinical symptoms and signs accompanying the request.
“Given that the difference in symptomatology between the two is often the key, clinical symptomatology should be included in the radiological request,” advises Dr Brenden.
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About us
A Step Ahead Foot + Ankle Care is one of Sydney’s leading foot and ankle clinics. Principal podiatrist and founder of A Step Ahead Dr Brenden Brown (AKA Dr Foot) has been taking care of people’s feet for more than 20 years.
With a background in sports medicine and having served as a former president of the Australasian Podiatry Council, Brenden is a wealth of information when it comes to foot and ankle care.
Blog
“I don’t think that space between my toes has always been there” is surprisingly a very common phrase to hear from our patients, especially when describing some pain at the front of the foot.
That’s exactly what Lydia came to us with yesterday, after having hoped the pain around the ball of her foot – that started for no particular reason that she can remember as is often the case – would go away on its own – but it keeps getting worse!
V sign of plantar plate disruption
I’m going to be very frank.
Nope, it’s likely NOT “just the structure of your feet now”, and if you’ve never noticed it before, it very likely “hasn’t just always been like that” – sadly far too many of my patients tell me that this is what they’ve been told by other health practitioners, GP’s and relatives alike, and it’s just not true.
The actual truth: It totally DOESN’T have to stay that way and you DON’T have to put up with frustrating pain that limits everything from general walking to exercise to social outings and everything else we love about life!
Hang on, what makes me so sure??
I couldn’t even tell you how many people I’ve diagnosed and treated with exactly these and other symptoms of a plantar plate injury, ranging from days after pain starting to unfortunately years down the track.
Injuries to your plantar plate are very commonly misdiagnosed and left untreated – you’re not alone there! But it can definitely be fixed – we do it every day! So we have a great, thorough treatment plan that has been tried and tested over many years and hundreds of patients with this exact problem.
The tools in our tool box range from a series of deep connective tissue massage, to 3D-designer laser-scanned custom orthotic insoles (super fancy I know!), to strapping and footwear changes and stretches and everything in between!
Do it – join our healthy, happy and active team of fully recovered patients – give our friendly team a call on – getting rid of pain like this is why we love what we do.
A Step Ahead Foot + Ankle care
Penrith, St Marys and soon to come to a suburb near you!
Blog
Standing occupations and what happens to feet!
Busy looking people!
Most of us stand or walk everyday but amongst us there is a proportion of our population that do it more than others. We are talking to you Nurses, Builders, Hairdressers, Concreter’s, Teachers, process line factory workers and Check out operators and, and, and and! You guys know more than anyone what a toll standing for hours can do to your feet. Below is a very quick description of some of the more common problems you may have suffered and things we as foot specialists see day in day out and help to treat.
Plantar plate tears / injuries / dysfunction
Is this you? (What it can look like)
• Do you have pain in the ball of your foot? Is it worsened when you stand or possibly wear shoes?
• Have you developed the feeling of a lump or a little pea under the ball of your foot?
• Is there dry hard skin (callus) developing under the ball of your foot?
• Have you noticed a small (or large) gap developing between your toes that resembles “V”? This is often the 2nd and 3rd toes, but it maybe any?
• How did it happen? Do you remember tripping falling and developing a pain in your forefoot (ball)? NO you DO NOT have to have had an accident!
• It may have developed slowly over time with no memory of a painful incident.
We see this many times a week and sadly we often see it misdiagnosed and therefore treated as the wrong problem. It can be misdiagnosed as a Mortons Neuroma or at times when people aren’t sure of things (and for many years) some practitioners diagnose Metatarsalgia .
Remember “Grandma’s feet? You know the ones where her big toe had formed a bunion and the next two toes popped up and crossed over each other? Yes those feet you wished you would never get, and swore you would never let it happen to you! Guess what without having it treated pronto –they soon may be yours!
Correct Diagnosis
A big part of this problem is misdiagnosis! You cant diagnose this if you don’t see a stack of it. As a clinic we will always send you for a Ultrasound BUT not just to anyone! Some radiologists commonly miss this and sadly are not familiar with the condition. Make sure when you are referred to get a diagnosis the radiologist knows and has diagnosed Plantar plate tears before!
Clinically your podiatrist should be able to see this quickly but it can be tricky and some Pods are more equipped for general nail care. Choose someone who sees this regularly! ASK!
Treatment
Strong supportive footwear is a key here! Shoes should be solid on the base not bend or twist. Cushioning this condition with fancy air bubbles WILL NOT fix this!
Orthotics (Custom made) – Well-made and designed orthotics will assist poor foot posture and correct alignment. They cannot come out of a packet and fix this, they need to be designed to help address this.
Soft tissue therapy – This condition is often slated straight to surgery STOOOOOOOOP! Unequivocally this condition has a good prognosis with conservative therapy trail first! We see this condition many times a day and get great success. Now we realise not all Pods do soft tissue like we do (Come on pods get to it!) but this is really necessary to go hand in hand with your Orthoses. Orthoses alone WILL NOT fix this. If your Pod wont do soft tissue then find a physio who will!
Surgery. Yes if this condition progresses to an unresolvable tear there is a need for us to refer you to an orthopaedic surgeon for surgery. SURGERY is A LAST resort! On most occasions surgery can be avoided with early quality intervention. As a note we worry about the amount of these we see that have unnecessarily sent to a surgeon. Many times way too early and before conservative care I has been trailed correctly these patients (you) are sent to surgery!
Heel pain
Is this you? (What it can look like)
• Pain on the first few step in the morning or pain on rising after sitting (Or Both)
• Pain Located in the heel area, under the heel where the slightly fatty area is, or pain in the Achilles running up the back of the lower leg.
• Pain may initially subside in first stages after first few steps
• Pain worsened by long period on your feet may become painful after walking or activity for reasonable periods of time.
Correct Diagnosis
The first thing your friends will tell you is “It’s a Heel spur”. Sadly life is not that simple and where once medicos lumped this into one general diagnosis (Sadly some still do). We recognise that this set of symptoms may be one of many conditions. Plantar fasciitis, fatty pad syndrome, Achilles tendonitis, and even Abductor Hallucis tendonitis can contribute to this pain. Find a practitioner who knows the difference! Again not all practitioners see these things a lot.
At times simple clinical signs are enough, but diagnosis maybe needed via radiology such as diagnostic ultrasound. Xray will show you a spur (Yes I know) but the bony spur is NOT the problem.
Treatment
Strong supportive footwear is a key here yet again ! Shoes should be solid on the base not bend or twist. Cushioning this condition with fancy air bubbles WILL NOT fix this!
Orthotics (Custom made) – Well-made and designed orthotics will assist poor foot posture and correct alignment. They cannot come out of a packet and fix this; they need to be designed to help address this.
Soft tissue therapy – Deep connective tissue massage, will be useful in all the above conditions. Again be wary of people simply telling you that orthotics will get rid of this. They go hand in hand but are not the only answer.
Shockwave – As a clinic we have been using shockwave for about 3 and a half years. As we are “early adopters” of new therapies, this is not as common to other practitioners but the use of this therapy is very handy and growing in popularity. We find this takes half the time that Deep connective tissue does to relieve this in combination with the other therapies.
Stretching – there are some very specific stretches that can be used for this group on conditions and for a large group of individuals this will help. Don’t be discouraged if these don’t work. Look above there are more options and solutions.
Tibialis Posterior dysfunction.
(Super flat feet / Fallen arches)
Is this you? (What it can look like)
• Pain in and around the arch. May be worse after walking or standing
• Discovering you have a “Fallen arch”
• Noticing one arch is lower than the other.
• Pain fatigue during or after walking. Pain on standing on toes ,climbing ladders.
Correct Diagnosis
This should be fairly easy to diagnose. The lowering of one arch, as opposed to the other, in combination with pain located in the arch. Should lead to an easy diagnosis. Diagnostic Ultrasound maybe used and your Podiatrist (us) can refer you off for this.
Treatment
Strong supportive footwear is a key here yet again and now again ! Shoes should be solid on the base not bend or twist. Cushioning this condition with fancy air bubbles WILL NOT fix this! (Can you see a pattern)
Orthotics (Custom made) – Well-made and designed orthotics will assist poor foot posture and correct alignment. They cannot come out of a packet and fix this; they need to be designed to help address this. IN particular without orthoses this condition WILL NOT get better! Get them and GET THEM QUICKLY!
Soft tissue therapy – Deep connective tissue massage, will be useful in all the above conditions. Again be wary of people simply telling you that orthotics will get rid of this. They go hand in hand but are not the only answer.
Braces – In the initial stages having braces specifically designed to support the arch will support and make steady the arch. It works well at first but is really a short term solution. Look towards orthoses and soft tissue.
Surgery. Yes if this condition progresses to a tear there is a need for us to refer you to an orthopaedic surgeon for surgery. On most occasions surgery can be avoided with early quality intervention.
Bunions
Is this you? (What it can look like)
• Your big toe starts to point out towards the smaller toes and is no longer straight
• Pain may develop around the big toe joint. Making it difficult to walk or stand
• Many people can have a bunion and not have any pain.
• The toe may begin to twist as well
Correct Diagnosis
On most occasion a qualified health practitioner should be able to diagnose this simply by looking at the clinical signs, however you may require a xray if you are considering surgical intervention.
Treatment
Strong supportive footwear. (Wow we just wont stop talking about this supportive footwear will we!!!) Shoes should be solid on the base not bend or twist. Cushioning this condition with fancy air bubbles WILL NOT fix this! (Can you see a pattern)
Orthotics (Custom made) – Well-made and designed orthotics will assist poor foot posture and correct alignment. This problem is often a result of a variance in the structure of your feet Yet again these cannot come out of a packet and fix this; they need to be designed to help address this.
Soft tissue therapy – Deep connective tissue massage, will be useful in all the above conditions. There is a problem with the balance of two muscle in your feet. This can also lead to another condition that may damage other muscles and soft tissue structure, the plantar plate rupture or dysfunction. Again be wary of people simply telling you that orthotics will get rid of this. They go hand in hand but are not the only answer.
Braces – Often called night splints there is some research that suggests these can be really helpful. I (Brenden) am a little dubious! This relies on you being super diligent on putting the splint on night after night. I always argue that on a Friday night after a busy week and a catch up with the girls after work it’s not likely you’ll want to pop this on before heading to bed. This is where the success of these will fall down BUT if you are super diligent, give them a try.
Surgery. Yes if this condition progresses there is often a need or want for us to refer you to an orthopaedic surgeon for surgery. This surgery over years has increased in its success. See a orthopod who does this all the time. Why ? Because ensuring that the person does this and other foot surgeries often increases the chance of success. If they are also doing shoulders knees hips wrists etc etc they simply cant be as use to doing this surgery as someone who does this every day.
The HARD sell !
At A Step Ahead foot + Ankle care we see several patients a day with this condition. We have patients that travel literally hundreds of kilometers to seek our help –which is really lovely! Our clinics are set up quite specifically to treat patients with muscle injuries and mechanical problems with their feet. We have invested hundreds of thousands of dollars into equipment and the latest technology to help us, help you- beat your pain.
Our principal Podiatrist Brenden Brown is recognized as one of Australia’s leading experts in Podiatry (No really). A past President of the Australasian Podiatry council he is regularly asked for his opinion in the media, appearing regularly on television shows like the Today Show and Magazines like Men’s Health.
It would be a pleasure to help you beat your foot pain.
We are located in Penrith and St Marys in Sydney’s Western suburbs. You can contact us on 47322007 or 96732987 we hope you will……. See that wasn’t so bad was it!
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Dr Brenden’s White paper report on the “6 Reasons You Won’t Beat Heal Pain” outlines what’s stopping you from beating this and tips on how to stop it in its tracks!