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Diagnosis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

The diagnosis is mainly clinical and further investigations are done as required to rule out other possible causes (1):

  • clinical examination is the mainstay of diagnosis with pain at the intermetatarsal space rather than on the plantar or dorsal aspects of the MTPJs
    • neuroma generally located at the level of and just distal to the metatarsal heads
    • there may be some dorsal MTPJ tenderness due to retraction of the toes as they try to reduce pressure from beneath the ball of the foot
    • compression of the forefoot with pressure at the intermetatarsal space often elicits a click as the nerve is pushed between the metatarsals (termed a Mulder's click) - compression of the forefoot in this manner may or may not be symptomatic
    • there may be a reduction in sensation to the associated web space
  • x-ray - useful in ruling out musculoskeletal pathology (neuromas are not visible) (1)
  • ultrasound (US) and magnetic resonance imaging (MRI) scans are both helpful in the diagnosis and can help to differentiate diagnosis, although sensitivity and specificity can be examiner-dependent
    • US
      • considered by many as the diagnostic test of choice
      • reported to be between 94% and 100%
      • appears as an ovoid, hypoechoic mass just proximal to the metatarsal heads
      • finding a sonographic mass supports the clinical diagnosis but the absence of a mass does not exclude Morton’s neuroma (3)
    • MRI.
      • routine use is not recommended
      • used for atypical presentation and to rule out multiple neuromas (1)

One prospective study which evaluated the accuracy of pre-operative clinical assessment, US and MRI concluded that

  • clinical assessment was the most sensitive and specific modality
  • US and MRI had similar accuracy but was dependent on size
  • accuracy of US was less for small lesions (4)

Reference:

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