How Do You Treat Plantar Neuroma in Your Practice?

Plantar neuroma (PN), also known as Morton’s neuroma (MN), is a prevalent source of metatarsalgia, particularly affecting the interdigital spaces of the toes. Widely documented in medical literature, this condition primarily targets women aged 45–50. Initially described as neuralgic pain between the third and fourth metatarsal bones by Civinini and Lewis Durlacher, Thomas George Morton described it as “a peculiar and painful affection of the fourth metatarsophalangeal articulation” in 1876.¹ Characterized by a fusiform enlargement of the common plantar digital nerve owing to fibrosis, MN manifests as a burning pain in the plantar aspect of the foot, situated between the metatarsal heads, often radiating to the adjacent toes. In some cases, the pain may extend proximally along the plantar or dorsal surface of the foot, exacerbated by tight footwear or high heels, prompting patients to seek relief through shoe removal and foot massage.²

Clinically, the presence of a neuroma is not visually apparent. Foot deformities, particularly hallux valgus, can result in toe overcrowding and increased pressure on the lesser toes, predisposing individuals to this condition. Plantar callosities surrounding the metatarsal heads may suggest transfer metatarsalgia, synovitis, or subluxation/dislocation of the metatarsophalangeal joint of the second or third toe. Additional differentials include plantar plate tears, Freiberg’s disease, and stress fractures of the metatarsals. Diagnostics for MN include the thumb-index finger squeeze, involving pressure application in the intermetatarsal space, and Mulder’s click test, performed by dorsiflexing the foot and squeezing the metatarsals. Positive results, indicated by pain or an audible click, respectively, suggest the presence of MN.³

A systematic review study, which carried out a meta-analysis on the efficiency of nonsurgical interventions for MN, provides evidence of recommending conservative methods before surgical approaches, as many patients may refuse the procedure or do not have indication for this type of treatment, therefore, nonsurgical interventions include: (1) use of wide shoes with low heels and padding under the metatarsal region, (2) foot orthoses, (3) oral nonsteroid or steroid medications, (4) corticosteroid injections, (5) sclerosing injections, or (6) use of extracorporal shock wave therapies without local involvement. There is not enough evidence in the literature to define which is the best choice of treatment when the authors compare the evidence for surgical and nonsurgical approaches.^4,5 Our search on PubMed, Cochrane Library, and Lilacs (Latin America and Caribbean Literature on Health Sciences) found no references of use of Traditional Chinese Medicine or acupuncture for the treatment of PN or MN.

In our practice, the choice of treatment for PN is directed to pain control and the same is adopted for foot pain from other etiologies. We begin by choosing points of the meridians that cross the affected area. We prefer to start with points distant from the painful area: Xuanzhong (GB39), the great Luo point of the yang meridians of the foot, or Zusanli (ST36), the He point of the Stomach meridian, or Sanyinjiao (SP6), Hui point of the yin meridians of the foot. There are two useful extra points in the calf that are Jiu Wai Fan and Jiu Nei Fan. Those points are respectively medial and lateral to Chengshan (BL 57). Laogong (PC 8) may be a useful choice, even if it’s located on hand, as that point corresponds to a usually painful area of the foot in the PN. Closer to the painful area, we choose transfixation from Kunlun (BL60) to Taixi (KI3), or from Taichong (LR3) to Yongquan (KI1). Local points, usually the last ones to be inserted, are Xiangu (ST43) and Neiting (ST44).^6,7 Another very useful technique is Wen’s scalp acupuncture.⁶ In this technique, the needles are inserted in the subcutaneous layer of the scalp, in areas that correspond to the function of the brain cortex beneath it. For pain control, we use both sensory and motor areas, in the contralateral side of the head. Our treatment protocol is to maintain the drugs prescribed and add acupuncture to it. The frequency of the appointments may vary from daily to a maximum interval of once a week, depending on the intensity of the pain. The total number of visits will depend on the response of the patient. The choice of accupoints may also vary according to that response: if the point is effective, it will be used again in the next acupuncture session.