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), and 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. It is commoner in women, usually between 40 and 60, and is associated with narrow footwear, high-impact activity, foot deformity (hallux valgus, hammer toes, pes planus) and inflammatory arthritis.
The key primary-care skill is twofold: recognise the characteristic picture and treat conservatively, and 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. |
| MTP synovitis / 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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