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Morton's neuroma — MSRA MCQ

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ModerateAnkle and FootMorton's neuromaMSRA

A 46-year-old woman presents with a 4-month history of intermittent burning pain in the plantar forefoot of her right foot. The pain is maximal between the third and fourth metatarsal heads and radiates into the adjacent toes. She describes a sensation of “walking on a pebble” when wearing narrow work shoes. Symptoms settle when she removes her shoes and are worse after prolonged standing. There is no preceding trauma, morning stiffness, diabetes or peripheral neuropathy. Examination shows no swelling, erythema, callus or deformity. There is focal tenderness in the third intermetatarsal space. Compression of the forefoot reproduces the pain and causes paraesthesia in the adjacent toes. There is no metatarsal shaft tenderness and pedal pulses and sensation are otherwise normal. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Advise wide, low-heeled footwear with metatarsal padding or a soft insole, alongside activity modification and simple analgesia

Explanation lettering: E = shown as B · B = shown as C · C = shown as E

This is a clinically typical Morton’s neuroma: burning intermetatarsal pain, radiation into the adjacent toes, a perceived pebble under the forefoot, aggravation by narrow shoes, and reproduction of symptoms by forefoot compression. There are no features suggesting a metatarsal stress fracture, inflammatory arthritis, diabetic neuropathy or acute traumatic injury. Initial management is conservative pressure reduction. Wide, comfortable, low-heeled shoes and metatarsal pads or soft insoles reduce compression of the interdigital nerve; reducing provoking impact activity and using appropriate simple analgesia are also reasonable. Imaging is not needed before first-line treatment when the presentation is clinically characteristic. A is plausible because ultrasound may be used where diagnostic uncertainty remains or when planning injection treatment, but corticosteroid injection is generally a specialist option for severe symptoms or failure of conservative measures. C is unnecessary at this stage because MRI is rarely required for a typical clinical diagnosis. D is not indicated without suspected fracture, significant acute injury or another condition requiring immobilisation. E is reserved for persistent, functionally limiting symptoms after non-operative treatment, often after consideration of injection therapy.

Reference: NHS: Morton's neuroma (Reviewed 2025) — https://www.nhs.uk/conditions/mortons-neuroma/