Morton’s Neuroma is a pain in the end of your foot (forefoot). Cyclists often refer to these problems as 'hot spots' or 'hot foot'. It is more generally and medically called ‘metatarsalgia’ – simply meaning pain in the metatarsal area, around or just behind your toes. This term includes two main structures that can become problematic for cyclists. The nerves running between the toes (interdigital nerves) or the small bursa, that sit between each toe and act as a cushion (interdigital bursa)
What causes Morton’s neuroma?
This issue largely arises due to compression, irritation or restriction of movement around the interdigital nerves. The other structure that can become irritated or inflamed alongside the nerve is the bursa (a small fluid filled sac that provides cushioning), hence the term bursitis.
The rigid sole of cycling shoes – limits spreading of toes under load and increases compression
The repetitive nature of cycling
Narrow or ill-fitting shoes
Excessively forward cleat position
Previous bony injury to the foot
Already existing or previous nerve related foot problems e.g. diabetic neuropathy
What are the symptoms?
In the case of nerve-related pain cyclists will commonly report tingling or shooting pain into their toes (most often 3rd/4th toes) when they are cycling.
Pain will be quite easy to localise by either pinching at the gap between (most commonly) 3rd / 4th toe bases, or prodding into top or bottom of this same space.
The other test that can be used is a ‘squeeze test’ where compression is applied on the inner and outer aspect of the forefoot - this essentially squashes the metatarsal heads together to reproduce symptoms of pain.
How can I manage Morton’s neuroma?
A comprehensive bike fitting session will cover shoe sizing and fit. It will take into consideration of whether any insoles may help and any adjustments of cleat position. Then it will aim to ensure that all other aspects of the fit are not creating issues that are leading to symptoms arising at your feet.
Cycling Shoe Fit The first thing you need to establish is whether your cycling shoes are wide enough for your feet. Many have a narrow toe box and this can place great pressure on the nerve, bursa, and blood vessels in the feet.
Met Domes The next course of action is to see if you can use a metatarsal dome in your cycling shoe to reduce compression of the area. If you also have similar symptoms off the bike then a similar strategy can be used. You can either buy pre-cut domes or cut them yourself from 5mm orthopedic felt. Placement is very important for optimal effect and if you are not succeeding in gaining relief from this you should see a specialist to further assess and ensure correct diagnosis and application of the metatarsal dome.
Insoles There are a number of companies that make off the shelf cycling insoles that feature a metatarsal dome (or button). My two recommendations are either the ‘G8 Performance 2620’ (my preferred choice when bike fitting) or the cheaper ‘Specialised BG Insole’ which comes in three different arch density/height types.
Cleats Cleat positioning is another factor that can influence how much pressure goes through the front of the toes, trying to move the cleats backward slightly can in some cases resolve pain in this issue.
Recurrent cases require further investigation in the form of ultrasound or MRI scan. It is important to confirm the diagnosis before proceeding to more invasive measures such as a steroid injection and both must be under the care of a suitably trained specialist in the field.
What else could it be?
Metatarsal Stress fracture
Referred pain, nerve / spinal
Pain from a hallux valgus (bunion)
Sesamoiditis (pain under great toe)
Toe flexor tendon strain
Synovitis of the small toe joints
If you are having issues and want to get in touch about booking a consultation or a bike fit then please email us: firstname.lastname@example.org.