Morton's neuroma is a thickening of a nerve between the toes, usually between the third and fourth, causing burning, tingling or a sensation of standing on a pebble. It is not a tumour and is highly treatable. Most people improve with footwear changes and ultrasound-guided injections; surgery helps resistant cases.
Symptoms
- Burning, electric or tingling pain in the ball of the foot spreading into the toes
- A pebble-in-the-shoe feeling
- Sometimes numbness in adjacent toes
- Worse in narrow or high-heeled shoes; eases when the shoe is off and the foot is rubbed
Causes & risk factors
- Chronic compression of the nerve by the metatarsal heads
- A narrow toe box or raised heel
- More common in women 40–60
- Runners with high forefoot loading
Conservative treatment comes first
- Footwear changes — a wide toe box, heel under 4 cm, forefoot cushioning (50–60% improve)
- A metatarsal dome pad, correctly positioned
- An ultrasound-guided corticosteroid injection (60–70% relief from 1–3 injections)
- Alcohol sclerotherapy for relapse
- A same-day ultrasound at assessment confirms the diagnosis and measures the neuroma
When surgery is considered
Excision removes the neuroma and affected nerve, giving reliable lasting relief at the cost of a permanent numb patch in the web space — walking in a wide shoe within days, sport at 6–8 weeks. Decompression releases the ligament and preserves the nerve, avoiding numbness, but is less reliable for an established neuroma.
Questions & answers
Yes. Many early cases improve with footwear changes and reducing forefoot load, and most people avoid surgery altogether.
No. Metatarsalgia is overload under the metatarsal heads; Morton's neuroma is nerve compression with a distinct burning, electric quality.
Usually two to three steroid injections, after which alcohol sclerotherapy or surgery is considered.
Full specialist guide
Morton's neuroma is a painful condition affecting the ball of the foot, most commonly between the third and fourth toes, caused by chronic compression and irritation of the interdigital nerve as it passes between the metatarsal heads. It produces the characteristic burning, electric, or pebble-in-shoe sensation that is one of the most recognisable presentations in foot and ankle practice. Treatment progresses through footwear modification and metatarsal padding to ultrasound-guided injection and, in resistant cases, surgical excision or decompression. Most patients achieve excellent symptom control without surgery. Our specialist team in Milton Keynes, Northampton and Banbury offers rapid assessment, imaging, and the full treatment pathway.
Morton's Neuroma: The Pebble-in-Shoe Feeling and How to Treat It
Morton's neuroma is one of the most distinctive and recognisable presentations in foot and ankle practice. Despite its name, it is not a tumour — the word neuroma simply refers to a benign thickening of the tissue surrounding the affected nerve. It is a highly common and, importantly, highly treatable condition. Most patients achieve excellent symptom control with appropriate conservative management and guided injections, without the need for surgery.
At Mercury Foot and Ankle, our specialist team provides expert assessment, same-day ultrasound, and the full range of treatments for Morton's neuroma at The Saxon Clinic, Milton Keynes, Three Shires Hospital, Northampton, and The New Foscote Hospital, Banbury.
What Is Morton's Neuroma?
Morton's neuroma is a benign thickening of the tissue (perineural fibrosis) that surrounds the common digital nerve as it travels between the metatarsal heads and bifurcates to supply sensation to the adjacent sides of two toes. The condition occurs most frequently in the third interspace — between the third and fourth toes — and less commonly in the second interspace (between the second and third toes).
The nerve becomes compressed and irritated as the metatarsal heads squeeze together during weight-bearing, particularly in footwear with a narrow or pointed toe box, or with a raised heel that increases forefoot loading. Over time, this chronic compression produces structural changes in the nerve and surrounding tissue — the perineural fibrosis — that sustain the symptoms even when the provoking footwear is removed.
Symptoms: What Morton's Neuroma Feels Like
The symptom complex of Morton's neuroma is distinctive and once recognised is difficult to confuse with other conditions. Characteristic features include:
A burning, electric, or tingling sensation in the ball of the foot, typically between the third and fourth toes. The feeling of walking on a pebble, lump, or bunched-up sock that is not there. Symptoms that are significantly worse in narrow, pointed, or high-heeled footwear and that improve when the shoe is removed and the forefoot is massaged. Numbness or tingling extending into the adjacent toes. Pain that is worse with prolonged standing, walking, or running and eases with rest and removal of footwear.
The Mulder's click — a palpable and sometimes audible click produced by simultaneously squeezing the metatarsal heads laterally and pressing upward in the affected web space — is a classic clinical sign that, when present, strongly supports the diagnosis.
Who Gets Morton's Neuroma?
Morton's neuroma predominantly affects women, reflecting the footwear patterns that drive its development. The condition is most common between the ages of 40 and 60, though it affects a wide age range. Active runners who have a high forefoot loading pattern or who have recently increased their mileage are a second common presentation group. A splayed forefoot — where the metatarsal heads are more widely separated than normal and squeeze together more forcefully in shoes — is an anatomical predisposing factor.
Diagnosis
Diagnosis is primarily clinical, based on the characteristic history and the findings on examination including the Mulder's click and reproduction of symptoms with direct web-space pressure. Diagnostic ultrasound — available at our Milton Keynes, Northampton and Banbury clinics — confirms the neuroma, measures its size (an important factor in treatment decision-making), and guides injection treatment with precision. Neuromas measuring 5mm or less tend to respond better to conservative management; those above 8 to 10mm are more likely to require surgical intervention. MRI provides an alternative imaging modality and is useful in equivocal cases.
Conservative Treatment
Footwear modification is the most important first step and the one most likely to produce significant improvement without further intervention. The requirements are straightforward: a wide toe box that does not compress the forefoot; a heel height below 4 centimetres to reduce forefoot loading; and adequate cushioning under the forefoot. Many patients achieve 50 to 60% improvement in symptoms from footwear change alone within 4 to 6 weeks.
Metatarsal dome padding — a small raised pad placed just proximal (behind) the metatarsal heads inside the shoe — spreads the load across the forefoot and reduces compression of the nerve space. Positioning is critical: the dome must sit behind, not under, the painful area. When correctly positioned, this inexpensive intervention can provide significant additional relief.
Activity modification during an acute flare — temporarily reducing high-forefoot-loading activities such as running — reduces neural irritation and accelerates response to other conservative measures.
Ultrasound-Guided Injection Treatment
When footwear modification and padding are insufficient, ultrasound-guided injection is the next step. Corticosteroid injection into the perineural tissue of the neuroma delivers targeted anti-inflammatory and pain-relieving medication precisely where it is needed. Ultrasound guidance is strongly preferred over blind injection — it significantly increases accuracy, improves outcomes, and reduces the risk of injecting into the adjacent blood vessels or metatarsal heads.
Approximately 60 to 70% of patients achieve meaningful relief from one to three guided injections. In some patients, relief is long-lasting; in others, repeat injections at appropriate intervals maintain symptom control. Alcohol injection (sclerotherapy) is a specialist technique used for neuromas that have responded initially to steroid injection but relapsed — the dehydrated alcohol progressively destroys the perineural fibrotic tissue over a series of injections.
Surgical Treatment
Surgery is indicated for neuromas that have failed an adequate trial of conservative management including guided injection. The options are excision and decompression.
Excision — removing the neuroma and the affected portion of the nerve through a dorsal (top of foot) or plantar (sole) incision — is the most commonly performed procedure and produces reliable, durable symptom relief. The principal consequence is permanent numbness in the web space between the two toes involved — this is predictable and expected, and the vast majority of patients find it entirely preferable to the preoperative burning pain.
Decompression — releasing the deep transverse intermetatarsal ligament that compresses the nerve — is an alternative that preserves nerve continuity and avoids permanent numbness, though it has a somewhat lower success rate than excision for established neuromas with significant perineural fibrosis.
Recovery after excision involves a period in a wide surgical shoe, with return to comfortable walking typically within 2 to 4 weeks and return to sport at 6 to 8 weeks.
Frequently Asked Questions
Can Morton's neuroma resolve on its own?
Early-stage neuromas with minimal perineural fibrosis can improve significantly with footwear modification and reduced forefoot loading. Established neuromas with significant fibrosis are unlikely to fully resolve without injection or surgical treatment, though symptoms can be well-managed conservatively for extended periods.
Is it the same as metatarsalgia?
No, though both cause forefoot pain and can coexist. Metatarsalgia is pain under the metatarsal heads from overloading. Morton's neuroma is nerve compression between the metatarsals producing the characteristic burning, electric, or pebble-in-shoe quality. The location and character of symptoms differ.
How many injections can I have?
Corticosteroid injections can be repeated 2 to 3 times at appropriate intervals. Beyond this, alcohol sclerotherapy or surgical treatment is generally recommended for patients with persistent symptoms.
Book a Specialist Assessment
If you have the characteristic burning or numb sensation in the ball of your foot and want an accurate diagnosis and treatment plan, our specialist team at Mercury Foot and Ankle is ready to help. Call 01908 014 486 or book online. We see patients at The Saxon Clinic, Milton Keynes, Three Shires Hospital, Northampton, and The New Foscote Hospital, Banbury.
This article is for educational purposes only. Sudden severe forefoot pain with significant swelling requires prompt medical assessment.
Sources & further reading
- NHS — Morton's neuroma
- OrthoInfo (AAOS) — Morton's Neuroma
