A note on this column: This article is general medical information, not a description of a service offered at this practice. Dr. Ishiguro's surgical practice is focused on adult hip and knee conditions — he does not treat Morton's neuroma or other forefoot conditions. This column is written to help readers understand a common source of foot pain and know when and how to seek the right specialist, typically a foot and ankle orthopedist or podiatrist.
What Morton's neuroma actually is
Despite the name, Morton's neuroma isn't a true tumor of nerve tissue — it's a reactive, non-cancerous thickening (perineural fibrosis) of the tissue surrounding one of the small interdigital nerves that run between the metatarsal bones in the ball of the foot. Repeated compression and irritation of this nerve, usually where it passes beneath the ligament connecting two metatarsal heads, causes the surrounding tissue to swell and scar, which further compresses the nerve — a cycle that produces the characteristic burning, tingling, or sharp pain.
It develops almost exclusively in one of two locations: about 70% of cases occur in the third intermetatarsal space (between the third and fourth toes), and roughly 30% occur in the second space (between the second and third toes). Involvement of other spaces is unusual enough that it should prompt consideration of an alternative diagnosis.
Who gets it — and how common it is
Morton's neuroma is one of the more common compressive neuropathies seen in general practice, and it disproportionately affects women. A UK primary-care database study calculating age-standardized incidence rates for common compressive neuropathies found a rate of 87.5 per 100,000 person-years in women compared with 50.2 per 100,000 in men (Latinovic, Gulliford & Hughes, J Neurol Neurosurg Psychiatry, 2006). Footwear is thought to be a major contributor to this gap: narrow, tight, or high-heeled shoes compress the forefoot and push the toes into the front of the shoe, increasing pressure on the interdigital nerves — though footwear is best understood as one contributing factor among several (including forefoot biomechanics and activities that load the forefoot repetitively) rather than the sole cause.
Symptoms
The classic description is a burning or sharp pain localized to the ball of the foot, often radiating into the adjacent toes, that's frequently described as "walking on a pebble," a fold in the sock, or a marble under the foot. Numbness or tingling in the affected toes is also common. Symptoms are typically aggravated by tight or narrow shoes, high heels, and walking or standing on hard surfaces, and are often relieved — at least temporarily — by removing the shoe and massaging the forefoot. Unlike a stress fracture or joint problem, there is usually no visible swelling or bruising, which can make the diagnosis easy to underestimate on casual self-examination.
How the diagnosis is made
Morton's neuroma is primarily diagnosed clinically, based on the history and a focused physical exam. Interestingly, the evidence suggests that a careful clinical assessment can be more informative than imaging for confirming the diagnosis.
What the evidence shows: A systematic review of diagnostic accuracy for subjective symptoms and physical exam tests found that a patient's own report of a "clicking" sensation between the toes was highly specific for Morton's neuroma (specificity 0.96, positive likelihood ratio 13.14) — meaning it's a strong rule-in sign when present. The modified webspace tenderness test (a thumb-and-index-finger squeeze of the affected webspace) was highly sensitive (0.96, negative likelihood ratio 0.04), making it useful for ruling the diagnosis out when negative. In contrast, commonly described symptoms like "walking on a pebble" or "burning pain" were only moderately informative on their own, with sensitivities in the 43–57% range (Pitcher et al., Foot Ankle Orthop, 2024).
Imaging is generally reserved for confirming an uncertain clinical diagnosis, characterizing neuroma size before a procedure, or excluding other causes of forefoot pain such as a stress fracture, intermetatarsal bursitis, or a joint synovitis. Both ultrasound and MRI are used, each with distinct strengths.
| Method | Reported sensitivity | Reported specificity |
|---|---|---|
| Ultrasound | 90% | 88% |
| MRI | 93% | 68% |
What the evidence shows: A systematic review pooling 12 studies (241 ultrasound examinations, 217 MRI examinations) found ultrasound had greater overall diagnostic accuracy than MRI for Morton's neuroma, largely driven by higher specificity — meaning MRI was more prone to false positives, sometimes identifying incidental thickening in people without symptoms (Xu et al., Clin Radiol, 2015). In practice, ultrasound is often favored as a first-line imaging test because it's lower cost, radiation-free, dynamic, and can guide an injection in the same visit — though a skilled sonographer is important, as accuracy for small lesions in particular is more operator-dependent.
What the evidence says about treatment
Most patients are managed successfully without surgery, especially when treatment starts before symptoms have been present for a long time.
Commonly used first-line treatment measures
- Footwear modification — switching to shoes with a wide, deep toe box and low heel to reduce forefoot compression
- Metatarsal pads or custom orthotics — designed to spread the metatarsal heads and offload pressure from the affected nerve
- Activity modification — temporarily reducing high-impact activities that load the forefoot repetitively
- Oral anti-inflammatory medication for symptomatic pain relief
- Corticosteroid injection, often combined with the measures above, for patients whose symptoms don't settle with footwear changes alone
What the evidence shows: A systematic review of corticosteroid injection for Morton's neuroma found that across studies with 3 to 12 months of follow-up, injections generally produced satisfactory outcomes by patient satisfaction scoring, with maximal pain reduction typically occurring between one week and three months after injection. However, of 469 pooled patients across the included studies, 140 (about 30%) eventually went on to have surgery for persistent symptoms despite the injection (Choi, Kim & Suh, Clin Orthop Surg, 2021). This is a useful number for setting expectations: injection is a reasonable and often effective next step after footwear changes fail, but it isn't a guaranteed alternative to surgery for everyone, and roughly one in three patients in the pooled data still required an operation.
Other injection-based options — including sclerosing (alcohol) injections, radiofrequency ablation, and cryoablation — have also been studied as alternatives or adjuncts to corticosteroid injection, generally aiming to reduce nerve irritability without surgery. The evidence for these techniques is less mature than for corticosteroid injection, and they are typically considered on a case-by-case basis by a specialist rather than as routine first-line options.
For patients whose pain persists despite an adequate trial of conservative treatment, surgical excision of the affected nerve segment (neurectomy) is a well-established option, usually performed through either a dorsal (top-of-foot) or plantar (sole-of-foot) incision.
What the evidence shows: A systematic review and meta-analysis comparing the dorsal and plantar surgical approaches found no statistically significant difference between them in overall adverse events, sensory loss, incision infection, or deep vein thrombosis. The one clear difference was scar-related problems (tenderness, hyperplasia, sensitivity), which were significantly more common after the plantar approach (odds ratio 2.90, 95% CI 1.40–5.98) (Li, J Foot Ankle Res, 2023). The authors noted the overall evidence base remains limited in size and quality, but the finding is consistent with the general surgical understanding that each approach trades one type of complication risk for another rather than one being uniformly superior — a discussion worth having directly with the operating surgeon.
A recognized long-term risk of surgery, relevant regardless of approach, is the formation of a new "stump neuroma" at the cut end of the resected nerve, reported in the literature at roughly 5–10% of cases, which can cause recurrent pain requiring further treatment.
When to see a specialist
Forefoot pain that persists for more than a few weeks despite simple footwear changes, or that's accompanied by numbness, a distinct "clicking" sensation between the toes, or pain that radiates into the adjacent toes, is reasonable grounds for a clinical evaluation by a foot and ankle specialist. Because several other conditions — stress fractures, intermetatarsal bursitis, and synovitis of the lesser toe joints among them — can mimic Morton's neuroma, a proper clinical exam (and imaging when the picture is unclear) is worthwhile before assuming self-treatment with shoe changes alone will resolve the problem, particularly if symptoms have already been present for several months.
References (PubMed / Journal)
Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry. 2006;77(2):263-265. DOI: 10.1136/jnnp.2005.066696
Xu Z, Duan X, Yu X, Wang H, Dong X, Xiang Z. The accuracy of ultrasonography and magnetic resonance imaging for the diagnosis of Morton's neuroma: a systematic review. Clin Radiol. 2015;70(4):351-358. DOI: 10.1016/j.crad.2014.10.017
Pitcher M, Moulson A, Pitcher D, Herbland A, Cairns MC. Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton Neuroma: A Systematic Review. Foot Ankle Orthop. 2024;9(4). DOI: 10.1177/24730114241291055
Choi JY, Kim MJ, Suh JS. Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review. Clin Orthop Surg. 2021;13(2):266-277. DOI: 10.4055/cios20256
Li Q. Effect of surgical approach on the treatment of Morton's neuroma: a systematic review and meta-analysis. J Foot Ankle Res. 2023;16:57. DOI: 10.1186/s13047-023-00660-w