GPAtlas🧭 When to suspect
Suspect Morton's neuroma (interdigital neuroma) in an adult with well-localised forefoot pain in an intermetatarsal (web) space:
• Most often the third space, between the third and fourth metatarsal heads (around 80–85% of cases).
• Next most often the second space (around 10–15%).
Despite the name it is not a true tumour but a compressive neuropathy with perineural thickening of the common plantar digital nerve.
The pain is typically burning or shooting, radiates into the adjacent toes, and is often described as "walking on a pebble".
• There may be numbness or tingling on the facing surfaces of the affected toes.
• Symptoms are aggravated by weight-bearing and tight or high-heeled footwear and relieved by resting and removing the shoe.
Morton's neuroma is commoner in women, usually between 40 and 60. It is associated with narrow footwear, high-impact activity, foot deformity (hallux valgus, hammer toes, pes planus) and inflammatory arthritis.
Recognise the characteristic picture and treat conservatively, but actively exclude the mimics of forefoot pain before settling on the diagnosis.
| Differential to consider | Pointers that favour it over neuroma |
|---|---|
| Intermetatarsal bursitis | • Closest mimic – near-identical symptoms • Often more diffuse forefoot swelling • Managed the same way conservatively |
| Metatarsophalangeal (MTP) synovitis or plantar plate tear | Pain and tenderness over the metatarsophalangeal (MTP) joint line (commonly the 2nd), with toe malalignment, crossover or a positive drawer. |
| Metatarsal stress fracture | • Localised bony tenderness and swelling, recent increase in activity • Pain on the metatarsal shaft rather than the web space |
| Inflammatory arthritis | Polyarticular pain, early-morning stiffness, tenderness on squeezing across all MTP joints, systemic features. |
| Freiberg's disease | • Pain and tenderness localised to a metatarsal head (classically the 2nd) in a younger patient • Characteristic changes on X-ray |
Source: BOFAS
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