Morton's neuroma is a thickening of one of the inter-metatarsal nerves in the forefoot, most commonly between the third and fourth toes.
The classic symptom is a sharp, burning, or electric-shock pain in the ball of the foot, often radiating into two adjacent toes.
Many patients describe the sensation of having "a pebble in the shoe" that can't be dislodged.
Relief often comes from removing the shoe and rubbing the foot.
In Johor we see this most in women over 40 who habitually wear narrow or high-heeled shoes, runners whose training volume increased recently, and people working long hours on hard floors with tight-fitting footwear.
Conservative management resolves around 60–70% of cases without injection or surgery.
Confirming the diagnosis
Clinical diagnosis is usually straightforward:
- Mulder's click - squeezing the forefoot across the metatarsal heads while pressing between the affected toes often reproduces the pain with a palpable click.
- Thumb index web-space test - localised tenderness between the specific metatarsal heads.
- Imaging - ultrasound is the first-line imaging if confirmation is needed. MRI is rarely required unless something atypical is suspected.
Most Morton's neuromas are between the 3rd-4th metatarsals, some between the 2nd-3rd. Bilateral presentations do occur.
The conservative pathway - 8 to 12 weeks
Step 1: footwear
Most Morton's neuroma patients can trace the onset to their footwear. The single biggest intervention:
- Wide toe-box shoes - the toe region must be wide enough to let the forefoot splay naturally. Most pointed-toe dress shoes and narrow trainers are the direct cause.
- Zero or low heel drop - heel lift shifts forefoot load forward, onto exactly the area that's already irritated.
- Firm, stable sole - reduces forefoot bending stress.
For women in Johor corporate roles, this may require a footwear wardrobe change. It's usually worth it.
Step 2: metatarsal pads
A metatarsal pad - a small dome placed proximal to (before) the metatarsal heads - lifts the tissue just before the affected nerve, widening the space the nerve passes through.
Fitted correctly, these can provide immediate symptom relief.
Off-the-shelf versions are RM 20–50. Custom-fitted orthotic versions (by podiatrist) run RM 350–700 and are more durable.
Step 3: load management
Reduce aggravating activities temporarily:
- Running volume reduced by 30–50% for 4 weeks.
- Substitute lower-impact cardio (swim, cycle) during flares.
- Avoid extended standing in hard shoes.
- High-heel days minimised during the conservative trial.
Step 4: foot strengthening
- Intrinsic foot muscle work - short-foot exercises, toe spreads, marble pickups. 5 minutes daily.
- Calf and foot mobility work - calf stretch wall lean, ankle mobility drills.
- Hip and glute work - cascade effect up the kinetic chain matters; a weak hip increases forefoot loading on running.
Step 5: manual therapy and soft tissue work
Physiotherapist-delivered mobilisation of the metatarsals, soft tissue work to the plantar fascia and intrinsics, and specific release of the affected intermetatarsal space.
Can provide useful symptom relief alongside the other measures.
When conservative care fails
Around 30–40% of patients don't resolve with the above and need escalation. Options:
- Corticosteroid injection - image-guided (ultrasound), around 50–60% success rate. Can be repeated once. Diabetic patients have lower success.
- Radiofrequency ablation - newer option, good results in small trials.
- Surgical neurectomy - removal of the affected nerve. Good outcomes for refractory cases; trade-off is permanent numbness in the affected toes (usually well-tolerated).
- Alcohol sclerosing injections - less common now.
Most Johor surgical Morton's cases go through orthopaedic foot-and-ankle specialists at KPJ, Gleneagles, or Regency.
Why the surgery timing matters
Delaying surgical removal for years of conservative struggle often produces worse long-term outcomes - the nerve can become chronically sensitised.
If 3 months of good-quality conservative care plus one injection hasn't worked, further time rarely helps.
Move to surgical discussion.
Typical Johor costs
- Physio course: 4–8 sessions at RM120-250.
- Metatarsal pads: RM 20–700 depending on off-the-shelf vs custom.
- Wider shoe wardrobe replacement: variable.
- Ultrasound-guided injection: RM 800–1,500 per injection.
- Surgical neurectomy: RM 5,000–12,000 (private day surgery).
How PhysioJohor matches Morton's neuroma patients
WhatsApp us with: typical daily footwear (especially any high-heeled or narrow shoes), location of pain between which toes, duration of symptoms, any ultrasound or injection history, and your JB location.
We match to a physio with foot-and-ankle specific experience - getting the metatarsal pad placement right and the footwear advice specific takes experience.
Related guide: Physiotherapy in Johor - complete guide