Clinical UM Guideline

This document addresses the indications for injection treatment of Morton neuroma, a common paroxysmal neuralgia affecting the web spaces of the toes, also known as interdigital neuroma.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

Injections of anesthetic, sclerosing (neurolytic), or steroid agents are considered medically necessary for treatment of Morton neuroma when all of the following conservative therapies have failed:

1. Padding or orthotic devices (these can provide support to reduce pressure and compression on the nerve); and
2. Activity modification (to reduce repetitive pressure on the nerve); and
3. Changes in shoe wear (that is, shoes with a wide toe box to reduce compression of the metatarsal heads and reduce pressure on the nerve); and
4. Medications unless otherwise contraindicated (for example, nonsteroidal anti-inflammatory drugs which help reduce inflammation).

Not Medically Necessary:

Injection treatment of Morton neuroma is considered not medically necessary when the above criteria are not met.

This document discusses several treatment options to address nerve pain affecting the web spaces of the toes, a condition called Morton neuroma. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Morton neuroma is a painful condition in the front of the foot. It happens when tissue around a nerve leading to the toes becomes thick and irritated. This most often occurs between the third and fourth toes. People may feel burning pain, tingling, or numbness. Injection treatments use medicines placed near the nerve to reduce pain. These may include a local anesthetic to numb the area, a corticosteroid drugs to reduce swelling, or alcohol to damage part of the nerve so it no longer transmits pain signals. Injections may help some people when simple treatments have not worked. However, results can vary, and some people may still need surgery. Injections also have risks, such as pain during the shot or thinning of fat in the foot.

What the Studies Show

Morton neuroma is not a tumor. It is a thickening of tissue around a nerve in the forefoot. It may be caused by pressure, foot shape, injury, or tight shoes. Early care usually includes shoe changes, padding, orthotic devices, activity changes, or anti-inflammatory drugs. If these steps do not help, injections may be tried. Corticosteroid drugs may be used to reduce swelling. Local anesthetics numb the nerve. Alcohol injections aim to damage part of the nerve to reduce pain. Surgery removes the affected nerve if other treatments fail.

Studies show mixed results. Some studies found that alcohol injections reduced pain for many people in the short term. For example, in one study, most people reported pain relief at about 10 months. However, longer follow up found that many people had pain return within 5 years, and some needed surgery. Alcohol injections can also cause severe pain at the time of injection. Corticosteroid injections have shown short term pain relief in several studies, including randomized controlled trials. In one study, people who received a corticosteroid drugs plus anesthetic had better foot health scores at 3 months than those who received anesthetic alone. However, other studies found little to no long-term difference. A large review found moderate certainty evidence that ultrasound guided corticosteroid injections probably reduce pain and improve function, but other evidence showed little to no difference. Repeated corticosteroid injections may cause thinning of the fat pad in the foot or joint problems. Overall, corticosteroid injections are supported by several high quality reviews, but benefits may lessen over time.

When are Injections for Morton Neuroma Clinically Appropriate?

Injection treatment with a local anesthetic, corticosteroid drugs, or alcohol may be appropriate in these situations:

The person has Morton neuroma; and

• Padding or orthotic devices have been tried and did not relieve symptoms; and
• Activity changes have been tried and did not relieve symptoms; and
• Shoe changes, such as wearing shoes with a wide toe box, have been tried and did not relieve symptoms; and
• Medicines, such as nonsteroidal anti-inflammatory drugs, have been tried unless there is a medical reason they cannot be used.

When is this not Clinically Appropriate?

Injection treatment for Morton neuroma is not clinically appropriate when the criteria above are not met. This means it should not be used before trying the conservative treatments listed above. Using injections too early may expose people to risks, such as injection pain or tissue changes, without clear added benefit. In addition, studies show that some injections only provide short term relief, and some people still need surgery later. Morton neuroma injections are not clinically appropriate in scenarios other than those listed above.

(Return to Description)

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

A neuroma can be described as a benign proliferation of nerve tissue. Morton neuroma is not a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. The cause of Morton neuroma is unclear and most frequently develops between the third and fourth toes. Possible causes include nerve entrapment, the abnormal anatomy of the plantar nerve in this location, structural/mechanical foot abnormalities, trauma, or excessive pressure.

Multiple treatment approaches have been utilized for Morton neuroma including conservative care, such as orthotics, padding, and alternative shoe styles to relieve the pressure on the forefoot. More invasive treatments include anesthetic blocks, sclerosing or steroid injections, and surgical excision of the painful nerve. The peer-reviewed literature contains varied conclusions.

Serial ethanol injection therapy has been reported as an effective alternative to surgical excision at 10 months follow-up (Fanucci, 2004). Hughes and colleagues (2007) reported on a case series of 101 individuals with a confirmed diagnosis of Morton neuroma. A total of four ultrasound-guided injections (total, 0.5 mL of 20% ethanol) were administered at 14-day intervals with an average follow-up of 10.5 months after the last injection. Additional injections were performed at 14-day intervals if the response was partial or incomplete based on participant-assessed level of pain. The main outcome was pain measured on a visual analog scale (VAS) scored from 0 to 10. Partial or total symptom improvement was reported by 94% of the participants, with 84% becoming totally pain-free. The median VAS pain score decreased from 8 before treatment to 0 after treatment (p<0.001). No major complications were reported. A total of 3 participants went on to surgical resection. Musson and colleagues (2012) reported on outcomes of a case series of 75 individuals who received intralesional alcohol injections for symptomatic Morton neuroma. A standard course of treatment consisted of 4 injections administered 2 weeks apart. Outcomes were participant-reported pain score on a VAS scale (range, 0-10) with a mean follow-up of approximately 14 months (range, 6-26 months). The mean VAS pain score was 8.5 (range, 4-10) before treatment and 4.2 (range, 0-10) after treatment (p<0.001). At follow-up, 32% of participants reported complete symptom resolution, 33% reported partial relief, and 35% reported no relief. Complications of the injections were rare (n=3) and self-resolving. A total of 17 participants (20%) went on to surgery at the time of last follow-up.

Success rates with corticosteroid injections for Morton neuroma vary greatly. Marcovic and colleagues (2008) found that 26 of 39 individuals (66%) had a positive outcome at 9 months after a single ultrasound-guided cortisone injection. Complete pain relief was achieved in 11 of 39 (28%) neuromas after treatment. A total of 12 of 39 (31%) neuromas did not respond to conservative treatment and required surgery. The results of treatment suggested improvement in efficacy if injection was used early. The size of the lesion measured on ultrasound showed no correlation with pain relief after injection. Makki and colleagues (2012) prospectively compared the effectiveness of a single ultrasound-guided steroid injection in the treatment of Morton neuroma and whether the response to injection correlated with the size of the neuroma. A total of 43 participants with clinical features of Morton neuroma underwent ultrasound scan assessment. A single corticosteroid injection was given using 40 mg of methylprednisolone along with 1% lidocaine. Participants were divided into two groups on the basis of the size of the lesion measured on the scan. Group 1 included participants with neuromas of 5 mm or less and group 2 participants had neuromas larger than 5 mm. A VAS score for pain (scale 0 to 10), an American Orthopaedic Foot and Ankle Society (AOFAS) score, and a Johnson satisfaction scale were used to assess participants before injection and at 6 weeks, 6 months, and 12 months following the injection. Group 1 (lesion ≤ 5 mm) included 17 participants and group 2 (lesion > 5 mm) had 22 participants. The VAS scores, AOFAS scores, and Johnson scale improved significantly in both groups at 6 weeks (p<0.0001). At 6 months post injection, this improvement remained significant only in group 1 with all scores (p<0.001). At 12 months, there was no difference between both groups and outcome scores nearly approached preinjection scores. At the final review, 2 participants in group 1 and 4 participants in group 2 had severe recurrent symptoms and underwent surgical excision of the neuroma after they rejected the offer for a repeat injection (p=0.6). The authors concluded that the effectiveness of cortisone injection appears to be more significant and long-lasting for Morton neuroma lesions smaller than 5 mm.

Gurdezi and colleagues (2013) reported on the long-term effectiveness of alcohol injection for Morton neuroma (mean follow-up: 61 months, range, 33-73 months) in 45 individuals from the original cohort of the Hughes study (2013). Of the 45 individuals evaluable at 5 years, 16 (36%) had undergone surgical treatment and 13 (29%) individuals had only transient relief of symptoms (2 weeks or fewer). Only 29% (13 of 45) remained symptom free. The authors concluded that alcohol injection for Morton neuroma does not offer permanent resolution of symptoms for most individuals and can be associated with complications such as immense pain at the time of injection despite local anesthetic infiltration (n=9 of 12 adverse events). Despite wide use of alcohol injection, no randomized, double blind, placebo-controlled study exists to verify the efficacy of this treatment in comparison to longstanding similar therapies such as corticosteroid injection for the treatment of Morton neuroma.

Thomson and colleagues (2013) conducted a pragmatic, participant-blinded randomized controlled trial (RCT) to determine whether corticosteroid injection was an effective treatment for Morton neuroma. A total of 131 participants with Morton neuroma (mean age, 53 years) were randomized to receive either corticosteroid and anesthetic (1 ml methylprednisolone [40 mg] and 1 ml 2% lignocaine) or anesthetic alone (2 ml 1% lidocaine). An ultrasonographic image was obtained before treatment, and injections were performed with the needle placed under ultrasonographic guidance. The primary outcome was the difference in patient global assessment of foot health between the 2 groups at 3 months after injection as measured by a 100-unit VAS score using parameters of “best imaginable health state” and “worst imaginable health state.” The global assessment of foot health in the corticosteroid group was significantly better at 3 months compared with the control group (mean difference, 14.1 scale points [95% confidence interval [CI], 5.5 to 22.8 points]; p=0.002). The difference between the groups was also significant at 1 month. Significant and nonsignificant improvements associated with the corticosteroid injection were observed for measures of pain, function, and patient global assessment of general health at 1 and 3 months after injection. The size of the neuroma as determined by ultrasonography did not significantly influence the treatment effect.

Jain and colleagues (2013) reviewed the peer-reviewed published literature of the available treatment options for Morton neuroma, stating current nonoperative treatment strategies include shoe-wear modifications, custom made orthoses, and injections of local anesthetic agents, sclerosing agents, and steroids; however, despite a lack of high quality evidence-based research, some success was reported with use of local steroid injection, nerve decompression, and neurectomy.

Morgan and colleagues (2014) performed a systematic review that largely included the studies previously discussed. The review compared the need for subsequent surgery after alcohol injections for Morton neuroma under ultrasound guidance versus unguided injections. The authors suggested the use of ultrasound guidance for alcohol injections to treat Morton neuroma can reduce the need for subsequent surgery compared with unguided treatments.

Pasquali and colleagues (2015) retrospectively assessed the effectiveness of ultrasound-guided alcohol injection to treat Morton neuroma. A total of 508 individuals with 540 second or third web-space Morton neuromas who had failed 3 months of conservative treatment (insoles and nonsteroidal anti-inflammatory drugs) were included in this study. A mean number of 3.0 (range, 1 to 4) injections were performed for each neuroma. The mean local inflammatory reaction was 0.7 (range, 0 to 2). There were no other local or systemic complications. The overall mean pre-injection VAS score was 8.7 (range, 6 to 10), while the post-injection VAS score at 1 year was 3.6 (range, 0 to 9). The delta VAS between the pre- and post-injection was statistically significant (p<0.0001). At 1-year follow-up 74.5% of participants were satisfied with the procedure.

Lizano-Diez and colleagues (2017) conducted a prospective, double-blind, RCT of 41 participants comparing the effectiveness of 3 corticosteroid injections plus a local anesthetic or local anesthetic alone (control) for the treatment of Morton neuroma. VAS score for pain and the AOFAS scores (metatarsophalangeal, interphalangeal) were obtained at baseline, after each injection, and 3 and 6 months after the last injection. At 3 and 6 months after treatment completion, there were no significant between-group differences compared with baseline values in outcomes of pain and functional improvement. The authors concluded that injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and functional improvement in this population with Morton neuroma. Limitations of this study include 15% (6 of 41) of participants were lost to follow-up, no objective outcomes were obtained after the treatment (such as magnetic resonance imaging evaluation), and the short follow-up of 6 months.

In 2021, Hau and colleagues conducted a prospective follow-up study of a previously completed RCT. Originally, 45 neuromas in 36 individuals were injected with a single corticosteroid injection. The original study was designed to determine if ultrasound guidance affected efficacy of the injection; no difference was found. The current study was conducted to determine if efficacy was sustained for a mean follow-up of 4.8 years. The original corticosteroid injection remained effective in 36% (n=16) of participants. In each of these cases, the VAS pain score (p<0.001) and Manchester-Oxford Foot Questionnaire Index (p=0.001) remained significantly improved relative to pretreatment scores. A total of 11 neuromas received a second injection and 55% continued to be asymptomatic over the follow-up period. This study provides additional published evidence of sustainable efficacy of corticosteroid injections for the treatment and management of Morton neuroma.

A number of meta-analyses and systematic reviews have been published establishing corticosteroid injections as a sound treatment option for Morton neuroma that is in accordance with generally accepted standards of medical practice (Choi, 2021; Edwards, 2021; Lu, 2020; Mathews, 2019; Millán-Silva, 2024; Thompson, 2020).

In 2009, the American College of Foot and Ankle Surgeons (ACFAS) released a clinical practice guideline on the diagnosis and treatment of forefoot disorders - Morton intermetatarsal neuroma. The guideline was retitled in 2012 as a clinical consensus statement which identifies the use of conservative care that focuses on elimination of pressure and irritation of the nerve. Other interventions include injection therapies for pain relief using local anesthetic blocks, corticosteroids and neurolytic alcohol injections. The consensus statement reports that 3 to 7 dilute alcohol injections of 4% alcohol injected at 5 to 10 day intervals has been associated with an 89% success rate with 82% of individuals achieving complete relief of symptoms. However, overuse of corticosteroid injections was cautioned as it may result in atrophy of the plantar fat pad as well as joint subluxation.

In 2024, Mathews and colleagues published results of a Cochrane systematic review which included six RCTs involving 373 participants to assess the benefits and harms of interventions for Morton neuroma. The review’s authors concluded:

There is low-certainty evidence that [corticoid injection + local anesthetic injection] may result in little to no difference in pain or function, and moderate-certainty evidence that [ultrasound guided corticoid injection + local anesthetic injection] probably reduces pain and increases function for people with MN [Morton’s neuroma].

Peer Reviewed Publications:

1. Choi JY, Lee HI, Hong WH, et al. Corticosteroid injection for Morton's interdigital neuroma: a systematic review. Clin Orthop Surg. 2021; 13(2):266-277.
2. Edwards SR, Fleming S, Landorf KB. Efficacy of a single corticosteroid injection for Morton's neuroma in adults: a systematic review. J Am Podiatr Med Assoc. 2021. 111(4).
3. Fanucci E, Masala S, Fabiano S, et al. Treatment of intermetatarsal Morton's neuroma with alcohol injection under US guide: 10-month follow-up. Eur Radiol. 2004; 14(3):514-518.
4. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton's neuroma: a five-year follow-up. Foot Ankle Int. 2013; 34(8):1064-1067.
5. Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005; 71(6):646-655.
6. Hassouna H, Singh D, Taylor H, Johnson S. Ultrasound guided steroid injection in the treatment of interdigital neuralgia. Acta Orthop Belg. 2007; 73(2):224-229.
7. Hau MYT, Thomson L, Aujla R, Madhadevan D, Bhatia M. Medium-term results of corticosteroid injections for Morton's neuroma. Foot Ankle Int. 2021; 42(4):464-468.
8. Hughes RJ, Ali K, Jones H, et al. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007; 188(6):1535-1539.
9. Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013; 6(4):307-317.
10. Lizano-Diez X, Gines-Cespedosa A, Alentorn-Geli E, et al. Corticosteroid injection for the treatment of Morton's neuroma: a prospective, double-blinded, randomized, placebo-controlled trial. Foot Ankle Int. 2017; 38(9): 944-951.
11. Lu VM, Puffer RC, Everson MC, et al. Treating Morton's neuroma by injection, neurolysis, or neurectomy: a systematic review and meta-analysis of pain and satisfaction outcomes. Acta Neurochir (Wien). 2021; 163(2):531-543.
12. Makki D, Haddad BZ, Mahmood Z, et al. Efficacy of corticosteroid injection versus size of plantar interdigital neuroma. Foot Ankle Int. 2012; 33(9):722-726.
13. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int. 2008; 29(5):483-487.
14. Matthews BG, Hurn SE, Harding MP, et al. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. J Foot Ankle Res. 2019; 12:12.
15. Millán-Silva MO, Munuera-Martínez PV, Távara-Vidalón P. Infiltrative treatment of Morton's neuroma: a systematic review. Pain Manag Nurs. 2024; 25(6):628-637.
16. Morgan P, Monaghan W, Richards S. A systematic review of ultrasound-guided and non-ultrasound-guided therapeutic injections to treat Morton's neuroma. J Am Podiatr Med Assoc. 2014; 104(4):337-448.
17. Mozena JD, Clifford JT. Efficacy of chemical neurolysis for the treatment of interdigital nerve compression of the foot: a retrospective study. J Am Podiatr Med Assoc. 2007; 97(3):203-206.
18. Musson RE, Sawhney JS, Lamb L, et al. Ultrasound guided alcohol ablation of Morton's neuroma. Foot Ankle Int. 2012; 33(3):196-201.
19. Pasquali C, Vulcano E, Novario R, et al. Ultrasound-guided alcohol injection for Morton's neuroma. Foot Ankle Int. 2015; 36(1):55-59.
20. Samaila E, Colò G, Rava A, et al. Effectiveness of corticosteroid injections in Civinini-Morton's Syndrome: a systematic review. Foot Ankle Surg. 2021; 27(4):357-365.
21. Thomson L, Aujla RS, Divall P, Bhatia M. Non-surgical treatments for Morton's neuroma: a systematic review. Foot Ankle Surg. 2020; 26(7):736-743.
22. Thomson CE, Beggs I, Martin DJ, et al. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. J Bone Joint Surg Am. 2013; 95(9):790-798.

Government Agency, Medical Society and Other Authoritative Publications:

1. American College of Foot and Ankle Surgeons (ACFAS). Clinical Practice Guideline Forefoot Disorders Panel: diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. 2009; 48(2):251-256.
2. Matthews BG, Thomson CE, Harding MP, et al. Treatments for Morton's neuroma. Cochrane Database Syst Rev. 2024; 2(2):CD014687.

1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo. Morton’s neuroma. Last reviewed July, 2022. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/mortons-neuroma. Accessed on March 02, 2026.
2. American College of Foot and Ankle Surgeons (ACFAS). Morton's neuroma (Intermetatarsal neuroma). Available at: https://www.foothealthfacts.org/conditions/morton-s-neuroma-(intermetatarsal-neuroma). Accessed on March 02, 2026.

Interdigital Neuroma
Intermetatarsal Neuroma
Morton’s Neuroma

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