Check back here if you did not see the first part of this case earlier this week. Then, continue below!
If you guessed Morton’s Neuroma (intermetatarsal neuroma), you were right!
But, the main question I want to know is how do we treat this patient! Google search led me to a non-specific treatment approach (ROM, strengthening, ultrasound, iontophoresis, stretching the heel cord, arch supports, metatarsal pads from a conservative treatment approach) and PubMed search for “Morton’s Neuroma and Physical Therapy” and “Conservative Treatment for Morton’s Neuroma” led me nowhere.
Basically, this patient was getting pain from compression of the interdigital nerve between 4th and 5th interspace (note that most individuals get it between 2nd-3rd and 3rd-4th). From an assessment standpoint, she not only had pain upon provocation to this area, but I noted ~25% less mobility in a dorsal direction of the 5th ray. I postulated that the previous 5th ray fracture (not sure what type) without adequate rehabilitation led to hypomobility and as time progressed, compensated movement patterns and eventually increased pressure between the metatarsal heads.
What led to my treatment approach is that performing a dorsal glide of the 5th ray and then re-assessing the same painful location resulted in very little pain (barely noticeable)! I opted to perform this further by providing a plantar glide of the 4th ray passively, then getting the patient to splay her toes while I provided this treatment for a more active approach.
Just this mobilization reduced her symptoms while walking up to 75% after re-assessment in a weight-bearing position. I typically practice and also teach my interns the below “5 T’s to OMT care” that then led to next treatment approach.
I then taped the same area using a spiral technique shown below to facilitate this biomechanical hypothesis. Her symptoms were reduced by 90+%. (note in picture that the tape is more mid-ray than behind the metatarsal head. This was due to it improving her symptoms more after an initial trial of the tape more distally).
I also performed cold laser on this area for 5 minutes and prescribed AROM exercises for the foot (DF & EV), self-dorsal glide of 5th ray, as well as toe splaying in non-weight bearing. These were focusing on “opening up” the joint space. These to be performed several times a day. Education was to keep the tape on for another 24-36 hours as long as it is not causing any adverse effects and to avoid closed-toe shoes.
I saw this patient for a total of 3 visits (1x a week for 3 weeks) progressing her weight-bearing load with therapeutic exercise each treatment. At last treatment, she had no symptoms coming into treatment with walking and heel raises in standing. I discharged with encouragement to follow HEP for several more weeks while transitioning into more a walking/running program.
To my knowledge, this is the first case I could find through a search that implemented a specific, tailored treatment approach for this condition. She did not have to buy an insert for the foot as I feel is just a bandaid fix. I hope you learned from it as much as I did!