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Surgical treatment is only initiated if there is severe pain, as the available operations can be difficult. Otherwise, high arches may be handled with care and proper treatment.
Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute plantar pressure loading with the use of foot orthoses and specialised cushioned footwear. Other non-surgical rehabilitation approaches include stretching and strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization, massage, chiropractic manipulation of the foot and ankle, and strategies to improve balance. There are also numerous surgical approaches described in the literature that are aimed at correcting the deformity and rebalancing the foot. Surgical procedures fall into three main groups:
1. soft-tissue procedures (e.g. plantar fascia release, Achilles tendon lengthening, tendon transfer);
2. osteotomy (e.g. metatarsal, midfoot or calcaneal);
3. bone-stabilising procedures (e.g. triple arthrodesis).
Asymptomatic anatomical variations in feet generally do not need treatment.
Conservative treatment for foot pain with Morton's toe may involve exercises or placing a flexible pad under the first toe and metatarsal; an early version of the latter treatment was once patented by Dudley Joy Morton. Restoring the Morton’s toe to normal function with proprioceptive orthotics can help alleviate numerous problems of the feet such as metatarsalgia, hammer toes, bunions, Morton's neuroma, plantar fasciitis, and general fatigue of the feet. Rare cases of disabling pain are sometimes treated surgically.
Orthotics and corticosteroid injections are widely used conservative treatments for Morton’s neuroma. In addition to traditional orthotic arch supports, a small foam or fabric pad may be positioned under the space between the two affected metatarsals, immediately behind the bone ends. This pad helps to splay the metatarsal bones and create more space for the nerve so as to relieve pressure and irritation. It may however also elicit mild uncomfortable sensations of its own, such as the feeling of having an awkward object under one's foot. Corticosteroid injections can relieve inflammation in some patients and help to end the symptoms. For some patients, however, the inflammation and pain recur after some weeks or months, and corticosteroids can only be used a limited number of times because they cause progressive degeneration of ligamentous and tendinous tissues.
Sclerosing alcohol injections are an increasingly available treatment alternative if the above management approaches fail. Dilute alcohol (4%) is injected directly into the area of the neuroma, causing toxicity to the fibrous nerve tissue. Frequently, treatment must be performed 2–4 times, with 1–3 weeks between interventions. A 60–80% success rate has been achieved in clinical studies, equal to or exceeding the success rate for surgical neurectomy with fewer risks and less significant recovery. If done with more concentrated alcohol under ultrasound guidance, the success rate is considerably higher and fewer repeat procedures are needed.
Radio Frequency Ablation is also used in the treatment of Morton's Neuroma The outcomes appear to be equally or more reliable than alcohol injections especially if the procedure is done under ultrasound guidance.
If such interventions fail, patients are commonly offered surgery known as neurectomy, which involves removing the affected piece of nerve tissue. Postoperative scar tissue formation (known as stump neuroma) can occur in approximately 20%-30% of cases, causing a return of neuroma symptoms. Neurectomy can be performed using one of two general methods. Making the incision from the dorsal side (the top of the foot) is the more common method but requires cutting the deep transverse metatarsal ligament that connects the 3rd and 4th metatarsals in order to access the nerve beneath it. This results in exaggerated postoperative splaying of the 3rd and 4th digits (toes) due to the loss of the supporting ligamentous structure. This has aesthetic concerns for some patients and possible though unquantified long-term implications for foot structure and health. Alternatively, making the incision from the ventral side (the sole of the foot) allows more direct access to the affected nerve without cutting other structures. However, this approach requires a greater post-operative recovery time where the patient must avoid weight bearing on the affected foot because the ventral aspect of the foot is more highly enervated and impacted by pressure when standing. It also has an increased risk that scar tissue will form in a location that causes ongoing pain.
Cryogenic neuroablation is a lesser known alternative to neurectomy surgery. Cryogenic neuroablation (also known as cryo injection therapy, cryoneurolysis, cryosurgery or cryoablation) is a term that is used to describe the destruction of axons to prevent them from carrying painful impulses. This is accomplished by making a small incision (~3 mm) and inserting a cryoneedle that applies extremely low temperatures of between −50 °C to −70 °C to the nerve/neuroma. This results in degeneration of the intracellular elements, axons, and myelin sheath (which houses the neuroma) with wallerian degeneration. The epineurium and perineurium remain intact, thus preventing the formation of stump neuroma. The preservation of these structures differentiates cryogenic neuroablation from surgical excision and neurolytic agents such as alcohol. An initial study showed that cryo neuroablation is initially equal in effectiveness to surgery but does not have the risk of stump neuroma formation.
Recently, an increasing number of procedures are being performed at specialist centers which offer a range of procedures to treat Morton's neuroma under ultrasound guidance. Recent studies have shown excellent results for the treatment of Morton's neuroma with ultrasound guided sclerosing alcohol injections, ultrasound guided radiofrequency ablation, and ultrasound guided cryo-ablation.
Metatarsalgia, literally metatarsal pain and colloquially known as a stone bruise, is any painful foot condition affecting the metatarsal region of the foot. This is a common problem that can affect the joints and bones of the metatarsals.
Metatarsalgia is most often localized to the first metatarsal head – the ball of the foot just behind the big toe. There are two small sesamoid bones under the first metatarsal head. The next most frequent site of metatarsal head pain is under the second metatarsal. This can be due to either too short a first metatarsal bone or to "hypermobility of the first ray" – metatarsal bone and medial cuneiform bone behind it – both of which result in excess pressure being transmitted into the second metatarsal head.
The most common symptom experienced due to Morton's toe is callusing and/or discomfort of the ball of the foot at the base of the second toe. The first metatarsal head would normally bear the majority of a person's body weight during the propulsive phases of gait, but because the second metatarsal head is farthest forward, the force is transferred there. Pain may also be felt in the arch of the foot, at the ankleward end of the first and second metatarsals.
In shoe-wearing cultures, Morton's toe can be problematic. For instance, wearing shoes with a profile that does not accommodate a longer second toe may cause foot pain. A small (80-person) study found no statistically significant difference in the frequency of longer second toes between people with and without ingrown toenails, but tight and ill-fitting shoes are generally considered to increase the risk of ingrown toenails, and shoes are often too tight on the toes.
Pes cavus (in medical terminology, also high instep, high arch, talipes cavus, cavoid foot, and supinated foot type) is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat less common.
Morton's neuroma (also known as Morton neuroma, Morton's metatarsalgia, Intermetatarsal neuroma and Intermetatarsal space neuroma.) is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces (between 2nd−3rd and 3rd−4th metatarsal heads), which results in the entrapment of the affected nerve. The main symptoms are pain and/or numbness, sometimes relieved by removing narrow or high-heeled footwear. Sometimes symptoms are relieved by wearing non-constricting footwear.
Some sources claim that entrapment of the plantar nerve because of compression between the metatarsal heads, as originally proposed by Morton, is highly unlikely, because the plantar nerve is on the plantar side of the transverse metatarsal ligament and thus does not come in contact with the metatarsal heads. It is more likely that the transverse metatarsal ligament is the cause of the entrapment.
Despite the name, the condition was first correctly described by a chiropodist named Durlacher, and although it is labeled a "neuroma", many sources do not consider it a true tumor, but rather a perineural fibroma (fibrous tissue formation around nerve tissue).
A neuroma (plural: neuromata or neuromas) is a growth or tumor of nerve tissue. Neuromas tend to be benign (i.e. not cancerous); many nerve tumors, including those that are commonly malignant, are nowadays referred to by other terms.
Neuromas can arise from different types of nervous tissue, including the nerve fibers and their myelin sheath, as in the case of genuine neoplasms (growths) like ganglioneuromas and neurinomas.
The term is also used to refer to any swelling of a nerve, even in the absence of abnormal cell growth. In particular, traumatic neuroma results from trauma to a nerve, often during a surgical procedure. Morton's neuroma affects the foot.
Neuromas can be painful, or sometimes, as in the case of acoustic neuromas, can give rise to other symptoms.
Some of the benign varieties of neuroma, in the broadest sense of the term, are not neoplasms.
- Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. Synonyms include scar neuroma, amputation neuroma, or pseudoneuroma.
- Morton's neuroma (a mononeuropathy of the foot) is another example of the more general usage of the term "neuroma". Some prefer the term "Morton's metatarsalgia", thus avoiding the term "neuroma" and its association with tumors.