Treatment Hierarchy
What Works + Exercise Prescription
Conservative management succeeds in 68-80% of cases when properly executed. The most common reason it fails isn't the wrong injection — it's wrong pad placement or continuing to wear the wrong shoes.
1. Wide Toe-Box Footwear
HIGH
Minimum 1cm clearance beyond the longest toe. Heel height ≤2cm. This is the foundation — every other treatment is an adjunct to it. Narrow shoes neutralise everything else. Occupational footwear assessment is as important as the clinical prescription.
Expected improvement: 1-4 weeks of strict compliance. ~50% of patients respond to footwear alone.
2. Metatarsal Pad Orthotic — Proximal Placement
HIGH
4-6mm firm pad (Poron, cork, or high-density foam). Orthotic shell trimmed to sulcus length. The pad must be placed proximal (behind) the metatarsal heads — 1-2cm behind the head line. The goal is to splay the metatarsals apart and lift them, decompressing the nerve tunnel.
Self-Check — Pad Placement
Press the pad to your foot. The leading edge of the pad should sit about 1-2cm BEHIND where it hurts. If the pad is directly under the pain site — it's in the wrong place. Move it back.
3. US-Guided Corticosteroid Injection
MODERATE
Methylprednisolone 40mg or Triamcinolone + 1% Lidocaine. 1.0-1.5mL. Maximum 2 injections, 4-6 week interval. Ultrasound guidance is required — blind injections have 16% lower response rate and risk plantar plate rupture.
6.3mm
The critical size threshold — lesions larger than this have poor corticosteroid response. US sizing before injection changes the decision.
Response rate: 50-80% at 3 months for lesions <6.3mm. Effect wanes at 12 months. CSI buys time — it doesn't cure. Permanent footwear change is required to prevent recurrence.
Tier 2 — Moderate Evidence (Alcohol Sclerotherapy + Active Rehab)
Alcohol Sclerotherapy (US-Guided)
MODERATE
4-20% dehydrated ethanol, 0.3-1.2mL per injection. 3-7 injection series, 1-2 week intervals. Achieves chemical neurolysis — permanent effect rather than temporary steroid relief. Response rate 68-80%. Preferred when CSI has failed or lesion is larger.
Recent evidence supports 4% concentration as effective as higher doses with less risk of adjacent tissue necrosis.
Intrinsic Foot Loading Programme
LOW — No Direct RCTs
No Morton's neuroma-specific exercise RCTs exist. Extrapolated from forefoot biomechanics and adjacent pathology evidence. Goal: improve transverse arch mechanics and reduce dynamic metatarsal compression.
Short Foot Exercise
3 × 10 holds
5 sec hold
Daily
Sit with foot flat. Draw the ball of your foot toward your heel — creating an arch — without curling toes. Hold 5 seconds, release.
Effort in foot arch muscles. Stop if sharp forefoot nerve pain.
Toe Splay and Spread
3 × 10
5 sec hold
Daily
Barefoot. Spread all toes as wide as possible. Hold 5 seconds. Trains forefoot splay mechanics — the same movement the orthotic should be facilitating passively.
Gentle stretch between toes. Stop if burning occurs.
Slow Calf Raises — Single Leg (Subacute)
3 × 12
3s down / 3s up
3× per week
When acute nerve pain has settled. Single-leg slow calf raise — 3 sec eccentric down, 3 sec concentric up. Progressive loading of foot intrinsics and calf-foot kinetic chain.
VAS ≤3/10. Zero shooting or burning pain during or after.
Pain Neuroscience Education (PNE)
MODERATE
1-2 sessions with a physical therapist addressing the neurological pain mechanism, kinesiophobia, and activity guidance. Important when fear of movement has developed secondary to chronic nerve pain. Reduces kinesiophobia and improves function in neuropathic pain presentations. (Evidence extrapolated from PNE literature; no direct Morton's RCTs.)
Tier 3 — Emerging Evidence (HA Injection, ESWT)
Hyaluronic Acid Injection EMERGING
Sodium hyaluronate, 3-injection series, US-guided. Lower short-term efficacy than CSI but similar outcomes at 12 months. Option when steroids are contraindicated (e.g., uncontrolled diabetes). 1 RCT (2024).
ESWT EMERGING
Extracorporeal shockwave therapy. Limited retrospective data only. May be trialled when injections are contraindicated. Effect size small.
What Doesn't Work
- Pad placed directly on the neuroma — increases compression. Must be proximal. This is the most common clinical error.
- Unguided (blind) injections — 16% lower response rate; risk plantar plate rupture from steroid leaching outside the target space.
- Serial CSI on large neuromas (>6.3mm) — delays appropriate escalation, causes fat pad atrophy, no meaningful neuroma reduction.
- Passive modalities alone (untargeted ultrasound, generic TENS, massage) without mechanical change — no tissue remodeling effect; neurophysiological/contextual mechanism only.
- High-concentration alcohol (>20%) as default — adjacent tissue necrosis risk without superior outcomes over 4% concentration.