From the Clinic; Pain in the ball of the foot… but it wasn't a Morton's neuroma

When people develop pain beneath the ball of the foot, one diagnosis is mentioned more than almost any other: Morton's neuroma.

Many patients arrive at my clinic already convinced that's what they have. Sometimes they've searched their symptoms online, sometimes they've already seen another healthcare professional, and occasionally they've even had treatment without much success.

But one of the biggest lessons I've learnt over the years is that pain in the forefoot is often far more complex than it first appears.

This patient was a perfect example.

Patient presentation

A gentleman attended my clinic complaining of persistent pain beneath the second toe of his right foot.

The discomfort had gradually worsened over several months and was beginning to affect his walking and everyday activities. He described the sensation as feeling as though he was "walking directly on the joint" rather than experiencing the burning or tingling symptoms that patients often associate with nerve pain.

He had already considered that the problem might be a Morton's neuroma, but equally wondered whether arthritis or inflammation could be responsible.

As is often the case, several different diagnoses were possible before I'd even examined him.

Assessment

One of the challenges with forefoot pain is that several conditions can produce remarkably similar symptoms.

A plantar plate injury, Morton's neuroma, capsulitis, stress fracture, bursitis and early arthritis can all cause pain beneath the metatarsal heads. This is why I rarely rely on symptoms alone when making a diagnosis.

During clinical examination I assessed the alignment of the toes, joint stability, areas of tenderness, swelling and the response to specific stress tests designed to identify plantar plate pathology.

The findings suggested the plantar plate may be involved, but I still wanted to exclude several other possibilities before deciding upon treatment.

Diagnostic ultrasound was performed during the consultation.

The scan immediately ruled out one of the most common causes of forefoot pain by demonstrating a completely normal plantar digital nerve. There was no evidence of a Morton's neuroma or intermetatarsal bursitis.

Instead, the ultrasound demonstrated abnormalities within the plantar plate beneath the second metatarsophalangeal joint. The ligament appeared thickened with areas of fibre disruption, and dynamic assessment reproduced the patient's familiar pain. These findings confirmed that the plantar plate—not the nerve—was the source of his symptoms.

Having this information immediately changed both the diagnosis and the management plan.

The diagnosis explained

The plantar plate is a strong fibrocartilaginous ligament situated beneath each of the lesser toe joints.

Its role is to stabilise the toes during walking, running and push-off, preventing them from drifting upwards while helping distribute load across the forefoot.

Over time, repetitive loading, altered foot mechanics or trauma can cause this ligament to weaken or partially tear.

Patients often notice pain directly beneath the toe joint, swelling, and sometimes a feeling that the toe is beginning to separate from the ground or drift slightly. As the condition progresses, the toe may gradually elevate or deviate towards its neighbouring toe.

Unfortunately, because the symptoms overlap considerably with Morton's neuroma, plantar plate injuries are frequently overlooked.

What we did

Once the diagnosis had been confirmed, we discussed why previous assumptions about the cause of the pain no longer fitted the clinical picture.

Rather than treating a nerve problem, our aim became reducing stress on the damaged plantar plate while allowing the tissues the best opportunity to recover.

We discussed activity modification, footwear choices, taping techniques and the role of custom foot orthoses to reduce overload beneath the affected joint. 3D scan 'casts' were taken of his feet within the same session from which we manufactured 3D printed custom orthoses.

Importantly, we also discussed treatments that would be unlikely to help.

For example, an injection aimed at treating a Morton's neuroma would not have addressed the underlying pathology because the nerve itself was completely normal.

Making the correct diagnosis first allows treatment to be targeted appropriately.

The treatment plan

The patient began a programme focused on reducing mechanical overload across the plantar plate.

This included footwear advice, temporary offloading of the affected joint and rehabilitation aimed at restoring more normal forefoot function.

Custom orthoses were issued to redistribute pressure beneath the forefoot and reduce repetitive strain on the plantar plate during walking and weight bearing activity.

We also discussed the importance of monitoring the position of the toe over time. Progressive instability or increasing deformity can occasionally require surgical opinion, although most patients respond well to conservative management when diagnosed early.

Follow-up was arranged to monitor symptoms and ensure the treatment plan was achieving the desired outcome. Most see a drop off in weight bearing pain within weeks, whilst using the orthoses, barefoot pain can take months to normalise.

What can we learn from this?

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

Although neuromas are common, they are only one of several potential causes.

A careful clinical assessment combined with diagnostic ultrasound allowed us to answer several important questions immediately:

• Was there a Morton's neuroma? No.

• Was there intermetatarsal bursitis? No.

• Was the plantar plate damaged? Yes.

• Was that damage reproducing the patient's pain? Yes.

Those answers completely changed the direction of treatment.

It's a good reminder that successful treatment starts with an accurate diagnosis.

My specialist thoughts

Plantar plate injuries are one of the most commonly missed causes of forefoot pain that I see in clinic.

Many patients have spent months believing they have a neuroma because the symptoms sound similar, when in reality the underlying problem is mechanical instability of the toe joint.

This is one of the reasons I value diagnostic ultrasound so highly within my practice. It doesn't simply confirm what I think is happening—it often tells me what isn't happening, allowing me to rule conditions in or out with much greater confidence.

For me, that's one of the most rewarding parts of specialist practice. The aim isn't to fit every patient into the most common diagnosis; it's to understand why this patient has developed their symptoms, so that treatment can be tailored specifically to them rather than following a one-size-fits-all approach.

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.