One of the frequently misdiagnosed conditions effecting cyclists (and non cyclists) is the Morton’s Neuroma.  It would seem as though every incidence of forefoot pain is blamed upon this annoying condition.  In truth, the incidence of true Morton’s Neuroma is quite low across the population.  It’s prevalence in women is far higher then men with females 8-10 times for likely to suffer the condition, with the 45-55 year old age bracket the most common.  Morton’s Neuroma may also be asymptomatic with around 1/3 of clinically observed cases occurring without symptoms.

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The term Morton’s Neuroma when correctly applied relates to a benign enlargement of the neural sheath typically between the 3rd and 4th toes.  The term Neuroma is actually a misnomer as there is no evidence of a tumour or malignancy in the nerve.  The tissue surrounding the nerve is usually fibrotic and enlarged causing compression on the nerve root with subsequent neural symptoms including burning and numbness.

The location of the enlarged tissue mass sits slightly beneath the metatarsal heads suggesting the influence of compression on this condition is less then previously thought.  It is likely that the influence of the plantar structures including the transverse metatarsal ligament plays a role in the development of the condition in conjunction with tissue shearing stress.  Certainly compression of the foot exacerbates the condition.

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The typical presentation of Morton’s Neuroma in a cycling context begins with soreness and tightness across the forefoot that progresses to numbness in the toes. This may be paired with pain and clawing of the digits.  Normally removal of the shoe and massaging of the foot alleviates symptoms temporarily.  In more severe presentations, pain may persist after the shoes have been removed.  No sign of swelling or redness is usually noted.

Treatment depends largely on the causative factors.  Primarily, the first action is to address ill fitting or improperly set up cycling shoes.  The two most common shoe faults that contribute to development of this condition are shoes that are too tight, or too long.  Coincidentally, many will go into longer shoes to reduce tightness and still suffer pain due to the shoes being too long.

After footwear and cleat position has been addressed, treatment then focuses upon altering the repetitive mechanical stress displaced through the forefoot.  Changing the nature of the load through this region can be achieved in many ways.  The most common modification is the use of a metatarsal dome.  A domes lifts from behind the metatarsal region and alters loading through the nerve root.  The success of this intervention is varied and on occasion may actually worsen the condition.  I have seen a huge variety of domes used over the years and success is achieved via the most unlikely looking domes on occasion.  This demonstrates the subjective and finicky nature of this type of treatment.  Often many attempts are needed to get the dome feeling ‘just right’.  On many occasions, they simply don’t work and alternate treatment options need to be explored.  This may be altering the load pathway through the forefoot or adjusting the tilt of the footbed to displace the centre of load laterally or medially.

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Less conservative measures include cortisone injections and rarely, excision via a dorsal or plantar approach.  Surgery is indicated in recalcitrant cases where conservative measures are not successful.

We have treated hundreds of cases of Morton’s Neuroma at Cobra9 HQ.  We stress the importance of diagnosis and accurate clinical assessment before treatment.  If we use a dome or other surface addition, we often advise our clinicians to provide a temporary version initially prior to us making it ‘permanent’ on their orthotic. This makes the modification process simple and gets the best outcome for our riders and clients.

Note:  Many other foot based maladies are confused as Morton’s Neuroma including intermetatarsal bursitis and capsulitis and it is important that a correct diagnosis is made through your health specialist prior to commencing treatment.  

Nathan W.