Orthotics for Morton’s Neuroma


Do Orthotics help reduce Morton's Neuroma pain?


Our understanding of the answer to this question is based on two things.

  1. The findings of a 1994 Study
  2. Our own day to day clinical experiences of treating 1000s of Morton’s neuroma sufferers with modern orthotics.

1994, as well as being the year the Spice Girls got together and Oasis released their first album ‘Definitely maybe', was the year that the first and more or less only study into the benefit of orthotics for Morton's neuroma was published. It evaluated the effect of using foot orthotics, and particularly their effects on Morton’s neuroma sufferers pain levels.

It showed that depending on foot type, orthotics offered a 45% reduction for pronated (flatter) feet, and 50% reduction for supinated (high arch feet).

The study had a few weaknesses by modern standards. One, being participants had no prior ultrasound imaging to exclude the presence of co-existing problems that sometimes go hand in hand Morton’s neuroma such as arthritis, bursitis, capsulitis etc. Overall, the author did an excellent job with the limited resources available to a UK NHS Podiatry department in 1994. This research has not been significantly updated since 1994.


 


Why hasn't this work been updated?

One of the reasons that this research has not been updated is that it is difficult to find a group of Morton’s Neuroma sufferers who are happy to agree to have no treatment other than orthotics for their neuroma pain for a period of months. This agreement, to have no other treatment, is a requirement of modern study methodology. This is because the scientific validity of a study is undermined if participants use orthotics as well as other treatments, such as physio, stretching icing, anti-inflammatory medications etc. If patients simultaneously use other treatment options, the researchers find it very hard to determine the single effect of using orthotics.

So, to recap, according to the study, orthotics in the distant days of the Spice Girls had a pretty good success rates, a 45% reduction for pronated (flatter) feet, and 50 % reduction for supinated (high arch feet).


 


What about today?

Our understanding of biomechanics and orthotics have moved on a long way since 1994.

These days we are able help a lot more than 50% of patients. The figure in 2019 based on my own experience and based on discussions with colleagues, is a lot closer to the region of between 70-80%.

Approximately 70-80% of patients with established neuromas will see a reduction in their pain levels. It is also our experience that with smaller neuromas, the pain can often totally resolve (whilst the orthotics are being used).


 

What is responsible for the improvement?


There is no doubt that modern orthotic manufacturing, helped by computer aided design and 3D printing, has come on a long way since 1994. Such improvements have allowed Podiatrists to design and prescribe ever more complex devices, which have probably helped raise overall success rates.

However, it’s not just orthotic manufacturing that has evolved. Our understanding of biomechanics has altered significantly since 1994.

When I was a Podiatry undergraduate in the 1990’s a lot of emphasis was placed on ‘kinematics’ or the visual ‘alignment’ or appearance of joints and foot position. Subsequent studies have shown that Kinematics are far less important than we first thought.

In 2019 most podiatrists subscribe more to the tissue stress model, and attempt to alter and manipulate the 3 key variables that are involved in damaged overloaded tissues.

The 3 variables are:

  1. Magnitude of reaction forces.
  2. Vector of reaction forces.
  3. The temporal pattern of reaction forces.

Normally at this point in a blog, I generally attempt to simply and summarise scientific data. But when it comes to the 3 variables above, on this occasion you will simply have either complete a degree in biomechanics or take my word for the fact those 3 variables are not easily broken down into understandable bite sized pieces. Especially how they are applied to orthotics, it is complicated... very complicated!


 

So, is the improvement simply down to better quality orthotics and an improved understanding of biomechanics?


Possibly, but I doubt it is just down to those factors alone.

Our treatment planning involves a very detailed biomechanical assessment that involves ultrasound imaging and elastography imaging of the forefoot. This type of extra imaging data provides a wealth of knowledge.

For instance, a scan will alert us to the presence of co-existing issues that often go hand in hand with Morton’s neuroma, conditions such as arthritis, bursitis capsulitis plantar plate degeneration etc. When we see such issues, we can now alter the design of the orthotic accordingly, making a better outcome for the patient more likely.


 

So, how do orthotics reduce pain?


Orthotics are constructed using corrected 3d models of your own feet. The process of taking the casts of your feet is a highly skilled process that enables your clinician to realign your joints as they take the impressions. When the impressions are poured, orthotists generally make angular corrections to the models of your feet. After this process has been completed, the orthotics are then moulded over the corrected models of your feet.

We know from modern studies that orthotics can reduce abnormal overloading mechanical forces responsible for Morton’s neuroma formation. Some orthotics also have domes that lift and separate the metatarsal bones creating room for the neuroma to sit in.

Orthotics also help reduce the hammering or retraction of the lesser toes. This is very helpful because hammered toes contribute to elevated pressures in the forefoot region.


 

Orthotics - Myth Buster


 

        1. Orthotics act as a brace and orthotics weaken the muscles of the feet.

          Electromyography (EMG) is a branch of medicine that for evaluates and records the electrical activity produced by skeletal muscles, it can be used to assess the muscles in the feet and legs during walking and running.
          A ground breaking 2009 paper entitled “Effect of foot posture (foot type), foot orthotics and footwear on lower limb muscle activity during walking and running: a systematic review, found the evidence does not support the idea that orthotics act as a foot brace or using orthotics causes muscle weakness. This paper was a quality study that collated the findings of 38 published studies.  It actually found the opposite.  It showed that the muscles of people who had certain foot types that included flat pronated feet only started working normally when the subject used orthotics. There is no evidence that using orthotics is detrimental, quite the opposite.

        2. Orthotics are uncomfortable.

          Custom made orthotics are orthotics made over models of your own feet. As such the vast majority of our patients find their orthotics comfortable to wear from day one.

        3. Orthotics are expensive

          High quality carbon fibre orthotics are very durable often lasting many years, and cost as little as £350. Which is approximately £29.17 a month through our 12 Month Interest free Credit Plan.

        4. All orthotics are the same.

          Orthotics purchased from a pharmacy or a trade fair are in no way comparable to quality prescription devices that are prescribed and fabricated to a prescription unique to your feet.  At The Barn Clinic treatment centres we have over 20 years of experience dispensing Morton’s neuroma.


 

The take home message


  • Custom made and even pre-made orthotics can be very helpful in managing Morton’s neuroma pain 
  • Modern manufacturing methods allow for smaller more user-friendly orthotics 
  • Ultrasound imaging when combined with a detailed biomechanical assessment can provide better outcomes for patients 
  • Orthotics are highly individual and totally dependent of the skill and experience of the clinician providing them

Will my Morton's Neuroma benefit from orthotics?

Well to quote my favourite album of 1994 in the words of Oasis…Definitely Maybe.

They don’t work for everyone but they certainly help the vast majority.


 

Elastography Imaging for Morton’s Neuroma


Elastography imaging of Morton’s neuroma represents possibly one of the greatest breakthroughs in the imaging of Morton’s neuroma in the last 30 years.

It provides a whole new level of detail, a level that until recently, we could have only dreamt of.


Elastography is a specialised form of Ultrasound imaging that can assesses the stiffness of certain tissues. It is commonly used to assess tumours in other areas of the body, such as the liver and breast. This is because tumours are known to be much stiffer than surrounding healthy tissue. A Morton’s neuroma is not cancerous, but like breast and liver tumours, they are known to be a lot stiffer than healthy nerves. The fact they are stiffer means they are perfectly suited to this new form of detection.

Elastography is the ultrasound equivalent of being able to feel a lump between your finger and thumb and instantly know how hard or soft the lump is. Standard black and white ultrasound only gives the user clues as to how hard or soft a tissue is, but no solid facts or data. Elastography Ultrasound on the other hand, utilises a range of measurements and colours that show the user instantly how hard or soft a tissue is. Different colour codes are superimposed over the 2-Dimensional images.

Stiff areas are marked with blue and soft/elastic tissues with various shades red or green.


 

Elastography for Morton's Neuroma


During Elastography imaging, a healthy nerve appears as a shade of green. However, a diseased Morton’s neuroma nerve will change colour and typically show as blue during the scan.

A 2016 study of 24 Morton’s neuroma evaluated the percentage of change in Elastography values between Morton’s neuroma and healthy nerves. The Elastography values of the Morton’s neuromas was 220% greater than healthy nerves in the same or opposite foot. 

Elastography now allows for increased accuracy in the mapping of the Morton’s neuroma. Small, but painful neuromas that could have previously been missed by Ultrasound and MRI can now be detected with Elastography. Elastography also allows us to more accurately assess and treat patients that have had failed alcohol injections, failed neuroma excision surgery and those suffering from a related condition called bursitis.


 

What Elastography means for our Patients


Using elastography will give us an additional level of knowledge and understanding of your condition. This means patients could benefit from a more specific diagnosis, improved insight with regards to recovery and treatment expectations & outcomes, and an even higher level of precision and accuracy in the treatment you receive.

Both conventional Ultrasound and Elastography scanning is provided to all of our patients as standard, and is included in the cost of the assessment consultation.


 

Our Commitment to Investment in new Treatments & Technology


We are proud to announce that as well as being the first to introduce cryosurgery for the treatment of Morton’s neuroma in to the UK over 12 years ago, we are the first and only clinic in the UK offering elastography as standard to all of our patients. We have been so impressed with the extra information that Elastography has provided in our Sheffield clinic we over the last 12 months, that we are pleased to announce we have recently taken delivery of a second brand-new Elastography scanner for our busy London clinic.


 

Our Story & Our Ethos

Our Story So Far | 1999 - 2019 | 20 Years of Excellence


Since 1999, Mr Weaver was has taken a keen interest in diagnostic medical ultrasound. This interest was sparked by a realisation that Ultrasound imaging could really remove a lot of the guesswork involved in assessing and treating common podiatric conditions, such as Morton’s neuroma. Mr Weaver realised from the moment he saw ultrasound imaging being used first-hand, that it had the potential to really improve and unlock better treatment outcomes for patients.

At that time in the UK, training in Ultrasound imaging for Podiatrists was pretty much non-existent. Furthermore, organising ultrasound scans to assess and plan treatment for conditions like Morton’s neuroma or bursitis was a painfully slow business, that was sometimes limited by the lack of detailed knowledge of the person performing the scan of what was going on with the patient. Mr Weaver really wanted to overcome these issues by being able to scan his own patients, rather than relying on third parties who don’t know the patient as well as he did.

With a lack of UK based Podiatry specific training, Mr Weaver embarked on Ultrasound training in the U.S.

It was at this time that Mr Weaver completed training in ultrasound-guided injection techniques, including cryosurgery for the treatment of Musculo-skeletal conditions, such as Morton’s neuroma.

Mr Weaver has also successfully completed a UK based Master’s degree in Medical Ultrasound, obtaining the highest possible award of distinction. Since introducing cryosurgery for Morton’s neuroma to the UK, Mr Weaver has continued to strongly advocate its use and has lectured and taught workshops in various settings.

Mr Weaver now regards the information obtained from ultrasound scanning a patient as invaluable. Mr Weaver is better now than ever, able to offer treatment programs that are tailored and individual to each patient’s unique needs and requirements, such complex assessments often involve performing scans immediately after activities like hiking or running that bring the patients symptoms on. This extra layer of attention to detail is often what makes the difference in patients obtaining the outcome they are looking for.

Moving into the future, Mr Weaver has continued to pioneer the treatment of Morton’s neuroma and has become the first Podiatrist in the UK to use a new form of ultrasound imaging called elastography. Elastography is used elsewhere in medicine to map the density of tissue. Morton’s neuroma tissue has been shown to have greater stiffness when compared to surrounding healthy nerves. As such the use of elastography allows Mr Weaver to see a new dimension of the neuroma that has been unavailable, enabling him to address areas of the neuroma that might have previously been missed. This greater appreciation allows for a more tailored cryosurgery treatment.


 

Our Ethos


There is no such thing as an average patient. We don’t do average, only excellent.

We place a large amount of emphasis treating you as an individual and making your Morton’s recovery journey as quick and as smooth possible. To us, you are foremost, a person and not just another number.


 

A little bit more about Robin

When not treating patients in clinic, Robin enjoys spending time with his wife, Claire, a former dance and fitness teacher and his young son, Monty. He is a keen skier, plays club level tennis and enjoys hiking & mountain biking in the Peak District. He also likes a wide range of music, particularly house music.

 


 

Can Morton’s Neuroma ever be cured?

The short answer is yes, with Cryosurgery. And here's why...

Broadly speaking, there are two routes that you can take when it comes to treating a Morton's Neuroma. Those 2 routes are:

Management of the Morton's Neuroma


 

  • Orthotics - Most orthotics issue is that they work best in enclosed winter footwear and unless you have very specialist low profile dress orthotic they don’t work in open summer footwear. This means that every summer the neuroma tends to enlarge little by little, to the point that orthotics will eventually stop working. 
  • Footwear Modification - Choosing 'Zero-Degree Heel' Footwear, such as the Altra Zero-Drop range of footwear, Hocker, or Birkenstocks can be beneficial for Morton's neuroma sufferers due to the reduction of the forces on forefoot caused by the heel of the foot being higher than the toes. You can read about our footwear advice here
  • Lifestyle Modification - includes a reduction of your normal day-to-day activities, such as driving to the shops rather than walking or avoiding events or parties at which you will likely be stood for a long length of time
  • Reducing or Ceasing Sport of Activity - Reducing or omitting your favourite sport or activity can reduce irritation of the Morton's Neuroma by limiting the activity you are carrying out, and reducing time spent on your feet. For so many patients, this simply isn't an option, due to the enjoyment they feel when engaging in their chosen sport or exercise. 
  • Wearing metatarsal domes or pads.

All of these options generally help to alleviate the symptoms of the neuroma, but the neuroma is always there in the background. Your neuroma will soon start to throb if you even look at high-heeled shoe, let alone wear one! And then, there are lot of practical problems with management options.

Interventional Treatment for Morton's Neuroma


 

  • Steroid injections are anti-inflammatories and cause atrophy (shrinkage of tissue). Many experts think it is the atrophy, both of the swollen nerve tissue and the tissue surrounding the nerve that helps relieve the neuroma pain. The ‘atrophy effect’ causes shrinkage of the tiny lumbrical muscles (that allow you to curl your toes) that surround the nerve. As the lumbrical muscles shrink due to the steroid, the neuroma is temporarily decompressed giving relief. However, after 3-4 months the lumbrical muscles recover and regain their bulk and the nerve is again compressed. Leaving you back where you began. In our experience steroid injections don’t seem to offer a long-term solution or cure for Morton’s neuroma.
  • Alcohol injections generally provide terrible outcomes, and can often make matters a lot worse.
  • Decompression surgery doesn’t cure a neuroma, it is simply an attempt to make room for the nerve, by cutting the transverse ligament (an important structure that stabilises the forefoot). The main issues with decompression are the risk of accidental injury to the nerve during the decompression surgery, and the amount of scar tissue that can form in the ligament and around the nerve after the decompression. Even when the symptoms are alleviated by decompression, the enlarged nerve (often measuring around a centimetre in diameter - normal diameter 2-3mm) will still be present in the forefoot and will often require a degree of ‘management’.
  • Excision surgery  - There is a little-known fact that every single person who has a neurectomy will develop a stump neuroma, because fusiform stump formation is the body’s normal physiological response of the body after a nerve has been cut.  Only a relatively small number of patients (around 35%) ever report being totally pain free after excision surgery and many are made a lot worse. Can excision surgery be a cure for Morton’s suffers? If a cure is based on having no symptoms then possibly, for some patients. If a cure is based on having a normal nerve in the foot, then no.

Cryosurgery for Morton's Neuroma

Cryosurgery does not kill or permanently destroy the nerve. The freezing of the nerve triggers a breakdown of the scar tissue that caused the nerve to be enlarged. Typically, after 16 weeks the nerve has totally recovered and reduced from 1cm in diameter to measuring a healthy 2-3mm again. Cryosurgery is the only intervention at this moment in time that leaves no trace behind. If you scan the foot of a patient that has had cryosurgery all that will be seen is a normal forefoot. On the other hand, if you scan patients that have had the other interventions listed above you can generally see varying degrees of scar tissue and damage.

Cryosurgery has been performed since 1960's on nerves, and it is regularly carried out on various part of the body to provide pain relief. It's been proven that freezing nerves causes no damage at all, and if anything, it actually has a rejuvenating effect. One of the features of Morton's neuroma, is the development of abnormal blood vessels around the nerve sheath. This is a process called angiogenesis. Angiogenesis helps drive the inflammation process. Cryosurgery has been shown to reverse angiogenesis. 

Being the first person in the UK to offer cryosurgery and having performed well over 3000 cases over the last 12 years, I now regard cryosurgery as the ‘Gold Standard’ for the treatment and cure of Morton’s neuroma.

If you are fed up of managing your neuroma and you are ready to choose an intervention, choose the right one, choose cryosurgery.

Get your foot and your life back. And let us help you.

Contact Us

Morton's neuroma advice for cyclists

Morton’s Neuroma Shoes – The Good, The Bad & The Terrible

 

 

 

 

 

Altra Zero-Drop Trainers can improve Morton's neuroma symptoms.

 

 

 

 

 

 

 

 

Avoid wearing thin soles flip-flops with Morton's neuroma

 

 

 

High Heels Morton's Neuroma

The Good

Zero degree shoes, such as the footwear brand 'Altra' are an excellent choice of shoe, especially if you are a runner suffering with a Morton’s neuroma.  Most running shoes lift the heel of the foot around 1-2 cm higher than the forefoot. The lift of the heel increases the forces on the forefoot that cause Morton’s neuroma by 3-4 times.

Running shoes such as Altra and Hocka have a ‘Zero drop’ or 'Zero-Degree Heel'. This means that the heel of the foot and the toes are literally on the same level. Zero-Drop shoes are beneficial for Morton's neuroma sufferers due to the reduction of the forces on forefoot caused by the heel of the foot being higher than the toes.

Shoes with a positive heel raise the heel above the forefoot and push the pad of fat tissue that protects the metatarsal heads and inter-metatarsal nerves forwards. This exposes the nerves to increased compressional forces making Morton’s neuroma more likely.

 

 

The Bad

If you are on a rocky beach this summer think twice about wearing flip flops.

Thin flip flops are often 'Zero-Drop', which as we know is beneficial for Morton's neuroma. However, the toe-post that slots between your toes can compress the 2nd and 3rd metatarsal together, making developing Morton’s neuroma in this region more likely.  Thin-soled flip flops also offer little protection from protruding objects underfoot, such as rocks and stones.

Try to remember, the nerves in the forefoot are actually very close to the ground. Sometimes the nerves in the forefoot can be injured by walking on sharp rocks or stones, and such injuries can progress in to Morton’s neuroma.

 

 

The Terrible!

Studies that measure peak pressures in the feet (plantar pressures) show that, in a flat shoe only 28% of the body’s weight runs through mid-foot region (where Morton’s neuroma form). However, this increases to a staggering 66% of body weight in a high heel.

Not only do the high heels increase plantar pressures they also are tight in the toe box, crushing the contents of your midfoot together, this crushing action is also responsible for Morton’s neuroma formation.

High heels can cause changes to the feet that can trigger Morton’s neuroma even when you aren’t wearing them. This is because regular use of high heels causes a shortening of your Achilles tendon and overtime time can alter the position of your lumbar spine (lumbar lordosis). Unfortunately, both of these issues also increase forefoot plantar pressures and can aggravate Morton’s neuroma.

Mortons Neuroma Festive Period Appointments

Festive Period Appointments

The Most Wonderful Time Of The Year… To Have Cryosurgery!

 

A lot of our patients find that Christmas and New Year is the ideal time to come for clinic for treatment. It’s a wonderful time to visit out London Clinic, and our Sheffield Clinic is very close to one of the UK’s best shopping Centre’s, Meadowhall. We have appointments available around the festive period, so it’s never been a better time to make use of your annual leave!

London Appointments:

Friday 8th December (~Fully Booked)

Sheffield Appointments:

Friday 1st December (Fully Booked)

Wednesday 6th December (Fully Booked)
Thursday 7th December  (Fully Booked)

Wednesday 13th December (Very Limited – 1 Appointment remaining)
Thursday 14th December (Fully Booked)
Friday 15th December (Fully Booked)

Wednesday 20th December (Fully Booked)
Thursday 21st December
Friday 22nd December (Limited Availability)

Mortons Neuroma International Patients

International Patients

The closest… or the best?

Map of The Barn Clinic - Cryosurgery Patients

We see patients from all corners of the globe, including:

  • Republic of Ireland
  • United States of America (CA, MN, NY, FL)
  • Canada
  • France
  • Spain
  • Germany
  • Belgium
  • Netherlands
  • Denmark
  • Switzerland
  • Finland
  • Sweden
  • Greece
  • Cyprus
  • Hungary
  • Latvia
  • Turkey
  • South Africa
  • Uganda
  • United Arab Emirates
  • China
  • Malaysia
  • Thailand
  • Australia (NSW, V, WA)

We are happy to assist with travel arrangements, hotel bookings, travel advice and medical terminology specific translators for your appointments.

All of our FAQ’s have been translated into our other languages, so you can get the information you need!

Christmas Availability Mortons Neuroma

Christmas Availabilty

Christmas is fast approaching, and for a lot of people, it’s a great time to relax and recharge! Many people take advantage of this break from work to arrange their Cryosurgery and allow for extra recovery time.

If this is something that you feel work  well for you, please see our availability below. (We will be updating this information daily – please book early to avoid disappointment)

Our remaining December availability is as follows:

  • Tuesday 20th December (FULLY BOOKED) – SHEFFIELD
  • Wednesday 21st December (FULLY BOOKED) – SHEFFIELD
  • Thursday 22nd December (Limited) – SHEFFIELD
Our clinic shutdown period is from the 23rd December – 3rd January. Appointments in the new year will commence from Tuesday 3rd January.
Merry Christmas, and Happy New Year from the entire Barn Clinic team.

 

Mortons Neuroma Footpain

Morton’s Neuroma and Other Causes of Cycling Foot Pain

With the rise in popularity of cycling since the success of British riders in the Tour de France and Rio Olympics, the number of cycling related forefoot problems we’ve seen at The Barn Clinic has increased.

This is no great surprising considering cycling requires the transfer of power from the legs in a ‘piston like’ motion through the pedals. The resultant compressional forces can detrimentally affect the delicate nerves in the forefoot resulting in burning, tingling and numbness in the forefoot.

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