Synopsis
Localise interdigital nerve pain in the forefoot, distinguish it from metatarsophalangeal, stress and proximal nerve disease, use imaging only when it resolves uncertainty, and progress footwear, metatarsal support, injection and surgery realistically.
- Morton neuroma causes burning or electric plantar forefoot pain radiating into adjacent toes, often described as a pebble in the shoe and relieved by removing tight footwear or massaging the foot.
- The third web space is most commonly affected; local web-space tenderness and symptom reproduction with forefoot squeeze or a Mulder click support the diagnosis.
- First-line investigation is a careful clinical examination including metatarsophalangeal joints, plantar plates, bony stress sites, sensation, pulses and footwear.
- Weight-bearing radiographs exclude fracture, arthritis and metatarsal alignment disease; ultrasound is the preferred focused soft-tissue test when confirmation or injection planning is needed, with MRI for unresolved cases.
- First-line management is a wide toe box, lower heel, reduced forefoot compression and a metatarsal pad placed proximal to the metatarsal heads, not directly beneath the painful nerve.
- Progress calf flexibility, foot strength and activity load while treating coexisting hallux valgus, lesser-toe or metatarsophalangeal instability that alters forefoot pressure.
- One ultrasound-guided local anaesthetic and corticosteroid injection can provide diagnostic and temporary therapeutic benefit; repeated injection risks plantar fat atrophy and nerve injury.
- Refer persistent disabling, well-localised disease for decompression or neurectomy discussion, including expected adjacent-toe numbness, scar tenderness and stump-neuroma recurrence.
Key red flags
An ulcer, spreading warmth, fever or immune compromise requires urgent forefoot infection assessment and pressure offloading.
Cool discoloured toes, rest pain, tissue loss or absent pulses requires vascular assessment before shoe, injection or operative treatment.
Focal metatarsal bony tenderness and pain after abrupt load increase suggests stress fracture even when early radiographs are normal.
Progressive constant numbness, motor weakness or symptoms extending beyond adjacent toes requires proximal nerve, tarsal-tunnel or spinal localisation.
A palpable enlarging mass, night pain or destructive imaging warrants tumour assessment rather than a routine neuroma pathway.
Investigation priorities
Localise web-space neural pain and distinguish joint, plantar plate, bony, bursal and proximal nerve disease.
Assess metatarsal alignment, stress fracture signs, Freiberg disease, arthritis and deformity.
Management branches
Burning forefoot pain radiates into adjacent toes without infection, vascular threat or acute fracture findings.
- Map web-space, joint, plantar-plate and metatarsal tenderness and reproduce the familiar symptom rather than a painless click.
- Assess standing deformity, callus, calf length, tarsal tunnel, sensation, pulses and the patient's actual shoes.
- Use weight-bearing radiographs when bony or alignment disease is plausible and ultrasound only when confirmation changes treatment.
- Explain that the lesion is fibrotic nerve irritation rather than a malignant tumour and agree a functional goal.