From the Clinic; A patient with pain in the ball of the foot that had stopped her enjoying long walks

One of the most common reasons patients attend my clinic is pain beneath the ball of the foot. Many arrive convinced they have a Morton’s neuroma because they've searched their symptoms online, while others have already been diagnosed elsewhere but remain frustrated that previous treatment hasn't worked.

This patient's story was typical.

Patient presentation

A lady attended my clinic complaining of gradually worsening pain beneath the forefoot that had been troubling her for several months. She described a burning discomfort radiating into the third and fourth toes, accompanied by occasional numbness and the sensation of "walking on a pebble."

The symptoms were initially only noticeable during longer walks but had gradually progressed to the point where shopping trips and everyday activities became uncomfortable.

She had already tried changing footwear and had purchased several different insoles without significant improvement.

Assessment

One of the biggest misconceptions surrounding Morton's neuroma is that the diagnosis can be made from symptoms alone.

Although her symptoms were certainly suggestive, there are several other conditions capable of producing almost identical pain, including plantar plate injuries, metatarsophalangeal joint synovitis, stress fractures and intermetatarsal bursitis.

Clinical examination demonstrated tenderness within the third intermetatarsal space and gentle compression of the forefoot reproduced her familiar symptoms.

Point-of-care ultrasound was then performed during the consultation.

The scan demonstrated enlargement of the common plantar digital nerve within the affected interspace with appearances entirely consistent with a Morton's neuroma. There was also a small amount of associated intermetatarsal bursitis. Importantly, the plantar plates, surrounding joints and adjacent tendons appeared normal, helping exclude several alternative

diagnoses that can mimic a neuroma.

Having immediate access to diagnostic ultrasound meant the diagnosis could be confirmed there and then, allowing treatment options to be discussed with confidence rather than uncertainty.

The diagnosis explained

Despite its name, a Morton's neuroma is not actually a true tumour.

Instead, it represents thickening and irritation of one of the small nerves running between the metatarsal bones. Repeated compression causes inflammation and fibrosis around the nerve, producing burning pain, tingling, numbness and the sensation that something is trapped beneath the foot.

Certain footwear, particularly narrow shoes or high heels, can increase compression, although many patients develop the condition despite wearing sensible footwear.

One of the advantages of ultrasound is that it allows us to visualise not only the nerve itself, but also the surrounding structures. This is particularly useful because conditions such as plantar plate injuries frequently produce almost identical symptoms but require different treatment.

What we did

After discussing the findings together, we reviewed the available treatment options.

These included footwear modification, activity modification, custom orthoses, corticosteroid injection, cryoneurolysis and surgery if symptoms failed to settle.

Because her symptoms had persisted despite initial conservative measures, we agreed that an ultrasound-guided corticosteroid injection represented the most appropriate next step.

Using ultrasound guidance allows medication to be placed accurately around the affected nerve while avoiding adjacent structures.

The procedure was performed under ultrasound guidance and the patient was provided with advice regarding activity modification during the following few days together with realistic expectations regarding recovery.

The treatment plan

Treatment rarely finishes with an injection.

Although corticosteroid injections can significantly reduce inflammation around the nerve, they work best when combined with reducing the mechanical compression that caused the problem in the first place.

We therefore discussed wider footwear, avoiding prolonged periods in narrow shoes and, where appropriate, custom orthoses to reduce pressure across the affected intermetatarsal space.

A follow-up appointment was arranged to monitor progress and determine whether further treatment would be required.

Many patients improve substantially following conservative treatment, while others may ultimately benefit from surgical management if symptoms remain persistent.

What can we learn from this?

One of the biggest lessons from this case is that not every pain beneath the ball of the foot is a Morton's neuroma.

Making assumptions based purely on symptoms can sometimes lead to inappropriate treatment and unnecessary delays in recovery.

Diagnostic ultrasound allows us to answer important questions immediately:

• Is it actually a neuroma?

• How large is it?

• Is there associated bursitis?

• Could the symptoms actually be coming from a plantar plate injury or inflamed joint instead?

Those answers help ensure treatment is directed towards the correct diagnosis rather than simply the most likely diagnosis.

My specialist thoughts

Morton's neuroma is one of the conditions I diagnose and treat most frequently.

Perhaps surprisingly, the ultrasound scan is often just as valuable when it doesn't show a neuroma. Some of the most satisfying consultations are those where the scan reveals a completely different explanation for the patient's pain, allowing us to avoid ineffective treatment and focus on the real cause.

For me, the goal is never simply to give an injection.

It's to understand why the patient has developed their symptoms, explain the diagnosis clearly, and build a treatment plan that gives them the best chance of returning to the activities they enjoy.

Mr Liam Stapleton MSc, PGCert, PGDip, FFPM RCPS(Glas), FRCPodM

Mr Liam Stapleton is a Consulting Podiatrist, Independent Prescriber and Specialist in Podiatric Sports Medicine. He has completed postgraduate qualifications in Independent Prescribing, Musculoskeletal Ultrasound, Advanced Clinical Practice, the Theory of Podiatric Surgery, and Podiatric Sports Medicine. His clinical practice focuses on the diagnosis and management of complex foot and ankle conditions, combining detailed clinical assessment with diagnostic ultrasound to provide accurate diagnosis and evidence-based treatment.

If you're struggling with persistent foot or ankle pain and would like a specialist assessment, including diagnostic ultrasound where appropriate, appointments can be booked with Kent Sports Podiatry at clinics across Kent.