Morton's neuroma is a nerve disorder. Intermetatarsal bursitis is inflammation or distention of the bursa between metatarsal heads. Metatarsalgia is a broader symptom label for forefoot pain. Because all three can hurt in the same region, diagnosis depends on symptom quality, toe radiation, plantar tenderness, compression testing and imaging when necessary.
What the diagnostic research shows
Patient-reported click
0.96
specificity for neuroma; a negative webspace squeeze test had 0.96 sensitivity
PMID 39564390
MRI in intermetatarsal pain
14 vs 5
of 26 patients had bursitis vs neuroma
PMID 40506910
Imaging sensitivity
0.91 / 0.90
ultrasound and MRI for Morton’s neuroma
PMID 25809742
No single symptom, test or scan settles the diagnosis. The findings have to fit together.
Three labels, one region
The webspaces between the metatarsal heads hold a common plantar digital nerve and an intermetatarsal bursa within a few millimeters of each other, with the metatarsal heads and plantar plates on either side. That is why so many forefoot problems hurt in nearly the same place, and why a label based on location alone is not enough.
Metatarsalgia describes where the foot hurts. It does not identify which structure is causing the pain. Morton's neuroma and intermetatarsal bursitis are specific structural diagnoses that sit inside that broader label, alongside plantar plate injury, MTP joint problems, stress injury and mechanical overload.
What Morton's neuroma is
Morton's neuroma is a painful interdigital nerve disorder rather than a tumor. Symptoms commonly include burning, tingling or electric forefoot pain radiating into adjacent toes. A systematic review of non-surgical treatment described it as a compressive neuropathy of the common plantar digital nerve that limits footwear choices and weight-bearing activity (Matthews, 2019). It most often affects the third webspace, between the third and fourth metatarsal heads, and sometimes the second.
Typical features include burning, tingling or numbness in two adjacent toes, a sensation like walking on a pebble or a fold in the sock, pain that is worse in narrow or high-heeled shoes, and relief when the shoe is removed and the forefoot is rubbed.
How reliable are the classic symptoms and tests?
A 2024 systematic review of nine diagnostic studies found that a click reported by the patient was highly specific for neuroma (0.96, positive likelihood ratio 13.14), and that a modified webspace tenderness test, a thumb-and-index-finger squeeze of the webspace, was highly sensitive (0.96, negative likelihood ratio 0.04). The commonly described "walking on a pebble" sensation and burning pain had sensitivities around 43% to 57% and specificities around 50%. Only one included study had a low risk of bias (Pitcher, 2024).
In practice, a reported click helps rule neuroma in and a negative webspace squeeze helps rule it out, while burning or pebble-like pain is not reliable by itself. A Mulder-type click or symptom reproduction can support the diagnosis, but no single provocative maneuver should be used in isolation.
What a Mulder-type maneuver involves
The examiner squeezes the forefoot from side to side with one hand while pressing up into the webspace from below with the other. A palpable or audible click, or reproduction of the patient's familiar burning or tingling, supports a neuroma. The maneuver can also be uncomfortable with bursitis or other webspace problems, which is why it is combined with the rest of the history and examination rather than used as a yes-or-no test.
Why symptoms come and go
Neuroma symptoms are often intermittent. They tend to appear in tight or high-heeled shoes, during long walks or runs, or after standing on hard floors, and settle quickly when the shoe comes off. That on-off pattern helps separate a nerve problem from a stress injury, which usually becomes steadily worse with continued loading, and from joint synovitis, which tends to produce more constant aching and swelling.
What intermetatarsal bursitis is
Intermetatarsal bursitis is inflammation or distention of the bursa that sits between the metatarsal heads, just above the plantar nerve. Intermetatarsal bursitis is one of the most important mimics of Morton's neuroma because both can produce webspace pain and forefoot compression symptoms. Features may include webspace pain, a sense of fullness between the metatarsal heads, pain that builds with loading and pain on forefoot squeezing.
A 2023 systematic review concluded that bursitis should be considered as a cause of pain in patients with metatarsalgia and in patients with rheumatic diseases, in whom it is frequent, and that toes spreading apart in a V shape should prompt the diagnosis. Some studies suggest bursitis contributes to neuroma development, while others treat it as a separate diagnosis (Larsen, 2023). When several joints are swollen or stiff, inflammatory arthritis is part of the differential.
How often is it bursitis rather than neuroma?
In a 2025 prospective study, 26 patients with intermetatarsal pain and 13 controls had both MRI and ultrasound of one forefoot. On MRI, 14 patients (53.8%) had bursitis and 5 (19.2%) had a neuroma. Ultrasound identified bursitis in 25 patients and a neuroma in none. Four controls without pain also had webspace findings, and normal bursas can appear as small hypoechoic structures on ultrasound. The authors concluded that bursitis is frequent in intermetatarsal pain and that separating it from neuroma on ultrasound is complex and should be done with caution (Larsen, 2025).
That study is small, but its message is important: an ultrasound report of a webspace "mass" is not automatically a neuroma, and an incidental finding is not automatically the pain source.
Telling them apart
| Feature | Morton's neuroma | Intermetatarsal bursitis | Other metatarsalgia |
|---|---|---|---|
| Main location | Between metatarsal heads, often third webspace | Between metatarsal heads | Under a metatarsal head, joint or bone |
| Symptom quality | Burning, tingling, electric, numb toes | Aching, fullness, load-related pain | Aching or bruised; focal bone pain in stress injury |
| Toe radiation | Common, into two adjacent toes | Less typical | Usually absent |
| Forefoot squeeze | Often painful; click may occur | Often painful | Variable |
| Helpful extra clues | Patient-reported click | Toes spreading apart; inflammatory arthritis | Toe drift or instability; focal bone tenderness |
| Imaging | Ultrasound or MRI | MRI often clearer; ultrasound needs care | MRI or ultrasound depending on structure |
These patterns overlap. A table can organize the reasoning, but it cannot replace the examination.
Plantar plate injury: the other major mimic
The plantar plate stabilizes the lesser MTP joints on the underside of the toe. Plantar plate injury is primarily a stabilizing-structure problem of the MTP joint rather than an interdigital nerve disorder. It usually causes pain directly beneath the second or third metatarsal head, swelling at the base of the toe, and sometimes a toe that drifts, lifts or crosses over its neighbor. A 2025 review noted that plantar plate injury overlaps clinically with Morton's neuroma and synovitis and is frequently underdiagnosed (Park, 2025). The details are in plantar plate injury vs. metatarsalgia.
When it is bone
Focal tenderness on a metatarsal shaft or neck, pain that progresses with walking or running, swelling on top of the foot and a recent increase in activity point toward a stress reaction or fracture. This needs imaging and load protection. Shockwave and manual therapy are not first responses to a suspected stress fracture that has not been characterized.
When it is the joint, the sesamoids or the nerve more broadly
MTP joint synovitis or arthritis causes joint swelling, stiffness and pain with toe movement. Pain under the big-toe joint suggests sesamoid pathology. Freiberg disease, an uncommon osteonecrosis of a metatarsal head that most often affects the second metatarsal in younger people, is confirmed on imaging. Numbness or burning in both feet, or symptoms that extend beyond two toes, suggest peripheral neuropathy or a more proximal nerve problem rather than a single neuroma.
When imaging matters
Ultrasound is particularly useful when the key question is whether pain arises from an interdigital nerve, bursa or plantar plate, while MRI provides a broader structural assessment when the diagnosis remains uncertain. A meta-analysis of 14 studies using surgery as the reference standard found similar sensitivity for ultrasound (0.91) and MRI (0.90) in Morton's neuroma (Bignotti, 2015). The 2025 bursitis study shows why the operator's understanding of both conditions matters, and why imaging findings must be matched to the examination rather than read in isolation.
Questions the examination tries to answer
- Is the pain between the metatarsal heads, under a joint or on a bone?
- Are there burning, tingling or numb toes, and do they radiate into two adjacent toes?
- Does a webspace squeeze or Mulder-type maneuver reproduce the familiar symptoms?
- Is a toe drifting or unstable, suggesting the plantar plate?
- Is there focal bone tenderness suggesting a stress injury?
- Are other joints swollen, raising the possibility of inflammatory arthritis?
- Would ultrasound or MRI change the plan?
How diagnosis changes treatment
- Morton's neuroma: wider footwear, forefoot offloading, a metatarsal pad or orthotic support where mechanically indicated, and shockwave for selected persistent cases, as reviewed in shockwave therapy for Morton's neuroma; injection or surgical opinion for refractory symptoms
- Intermetatarsal bursitis: load modification and footwear changes, and assessment for inflammatory arthritis when relevant
- Plantar plate injury: protection of the joint, taping or offloading, and orthopedic or podiatric referral for instability or progressive deformity
- Stress injury: imaging and load protection
- Mechanical overload: progressive foot and calf rehabilitation, footwear changes and selective orthotic support
The goal of orthotic treatment is to redistribute load, not to claim that a device removes the neuroma.
How Novo approaches forefoot pain
We localize the pain, test webspace compression and toe stability, look for bone and joint causes and nerve symptoms beyond the webspace, and use ultrasound or MRI when the structure matters. See how we approach forefoot pain, metatarsalgia and Morton's neuroma.
References
- Pitcher M, Moulson A, Pitcher D, Herbland A, Cert G, Cairns MC. Diagnostic accuracy of subjective features and physical examination tests for Morton neuroma: a systematic review. Foot & Ankle Orthopaedics. 2024;9(4):24730114241291055. PMID 39564390. (link)
- Larsen SB, Offersen CM, Dyrberg E, Johansen JK, Lange NB, Bech BH, et al. Morton's neuroma or intermetatarsal bursitis: a prospective diagnostic study of intermetatarsal pain. Diagnostics. 2025;15(11):1339. PMID 40506910. (link)
- Larsen SB, Søgaard SB, Nielsen MB, Torp-Pedersen ST. Diagnostic considerations of intermetatarsal bursitis: a systematic review. Diagnostics. 2023;13(2):211. PMID 36673020. (link)
- Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. European Radiology. 2015;25(8):2254-2262. PMID 25809742. (link)
- Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. Journal of Foot and Ankle Research. 2019;12:12. PMID 30809275. (link)
- Park JJ, Seok HG, Park CH. Diagnosing plantar plate injuries: a narrative review of clinical and imaging approaches. Diagnostics. 2025;15(17):2188. PMID 40941676. (link)
