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👣 Morton’s Neuroma vs. Metatarsalgia – Spot the Difference

Today’s question:"What is the difference between Morton’s neuroma and metatarsalgia?"

They both cause pain in the ball of the foot. But how do we tell them apart — especially in a PLAB 2 exam station?


Metatarsalgia – What Is It?

Metatarsalgia is a descriptive term, not a diagnosis. It simply means pain in the ball of the foot, typically under the metatarsal heads.


🔍 Key Features:

  • Dull, aching, or burning pain in the forefoot

  • Triggered by overuse, improper footwear, high-impact sports, or altered biomechanics

  • Worse on standing, walking, or running

  • Improves with rest, footwear change, or using cushioned insoles

🧠 Common causes:

  • Excessive pressure on the metatarsal heads

  • High-heeled or tight shoes

  • Flat feet or high arches

  • Callosities or previous foot surgery


🧠 Morton’s Neuroma – A Specific Condition

Morton’s neuroma is a benign nerve entrapment affecting the plantar digital nerve, most commonly between the 3rd and 4th metatarsal heads.


🔍 Classic Features (NICE CKS):

  • Sharp, stabbing, burning, or shooting pain

  • May feel like cramping or numbness in the toes

  • Many patients describe feeling a "pebble" or "lump" underfoot

  • Pain is intermittent — lasting minutes to hours — but may become constant in chronic cases

  • Aggravated by activity or tight shoes, especially high heels

  • Relieved by removing shoes or massaging toes

  • Night pain or rest pain occurs in about 25% of cases

  • May present asymptomatically and be found incidentally


🦶 Clinical Examination Clues

From the NICE CKS guidance, a detailed foot exam for suspected Morton's neuroma should include:


🔍 Key Findings:

  • Pain on palpation of the intermetatarsal space

  • Mulder’s click: A click or snap felt when compressing the forefoot while palpating the affected space

  • Toe deformities (hallux valgus, hammer toe)

  • Gait abnormalities

  • Sensory changes (loss of sensation may indicate neuroma)

  • Inspect shoes for signs of pressure or uneven wear

🧪 If diagnosis is unclear:

  • Ultrasound or MRI can confirm neuroma

  • X-ray to rule out fractures or arthritis

  • Blood tests (FBC, ESR, uric acid) if suspecting infection or gout


🩺 PLAB 2 Clinical Tip

If a patient presents with forefoot pain, here’s how to reason it out in a PLAB 2 station:

  1. Ask specifically about symptoms:“Do you feel any burning, tingling, or a lump under the foot?”

  2. Examine both feet — check shoes, gait, sensation, and pressure points.

  3. Remember Mulder’s test for neuroma.

  4. Mention conservative management first: footwear change, rest, insoles.

  5. Mention imaging if unsure, especially if symptoms are chronic or diagnosis unclear.


🧾 NICE-Backed Management Advice

For metatarsalgia, the NHS suggests:

✅ Do:

  • Rest and elevate the foot

  • Use cushioned shoes with a low heel

  • Try soft insoles or metatarsal pads

  • Apply ice packs

  • Take simple analgesics

  • Stretch foot and ankle muscles

🚫 Don't:

  • Wear high heels or narrow shoes

  • Stand or walk for long periods

  • Do activities that worsen the pain

🔴 Urgent referral or imaging is needed if:

  • Pain is severe or worsening

  • You’re unable to walk

  • There’s deformity, swelling, or neurological symptoms


📝 Summary – Key PLAB 2 Takeaways

✅ Know This

💡 In the Exam

Metatarsalgia = General pain

Ask about footwear, standing, sports

Morton’s neuroma = Nerve pain

Ask about burning pain, numbness, Mulder’s click

Prioritise conservative care

Rest, footwear change, soft insoles

Know when to refer

Imaging for diagnostic uncertainty or red flags

🎓 Final Words

Metatarsalgia is not a symptom — it's a clinical term that describes pain in the forefoot, particularly under the metatarsal heads. It's more of a syndrome or presenting complaint than a diagnosis.

However:

Morton’s neuroma is one of several possible causes of metatarsalgia.

So, while forefoot pain (metatarsalgia) is commonly experienced in Morton’s neuroma, it’s not accurate to say metatarsalgia is a symptom — rather, it's a clinical feature or label that describes what the patient feels..

🧠 Know your red flags.👟 Understand biomechanics.🗣️ Communicate clearly.

You’re well on your way to exam success.



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