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Musculoskeletal Neurological

Morton's neuroma

Last revised in April 2026

Morton's neuroma is a benign fibrotic thickening of a plantar interdigital nerve that is a response to irritation.

Morton's neuroma: Summary

  • Morton's neuroma is a compression neuropathy of the common digital plantar nerve.
    • It occurs mostly in the third intermetatarsal space (66% of cases), less commonly in the second intermetatarsal space (30% of cases), and rarely in the first and fourth intermetatarsal spaces.
    • A neuroma may rarely occur in more than one intermetatarsal space and is bilateral in 21% of cases.
  • Morton’s neuroma is not a true neuroma, but a benign fibrotic thickening of the nerve due to constant irritation.
    • Histologic findings do not demonstrate typical features of a neuroma, where there is a neoplastic or proliferative process, but that of perineural fibrosis, neural degeneration, and demyelination.
    • Morton’s neuroma is also referred to as Morton metatarsalgia, interdigital neuritis, Morton entrapment, interdigital neuralgia, interdigital neuroma, interdigital nerve compression syndrome, and intermetatarsal neuroma.
  • Mechanisms thought to cause irritation of the nerve include:
    • Chronic, repetitive trauma.
    • Nerve ischaemia.
    • Intermetatarsal bursitis.
    • Compression or entrapment of the nerve.
  • Risk factors include:
    • High-arch feet.
    • Regularly wearing tight/ill-fitting shoes — thought to cause Morton's neuroma by squeezing of the forefoot or increasing pressure on the balls of the feet, such as with high-heeled shoes. Regularly wearing tight/ill-fitting or high-heeled shoes — thought to cause Morton's neuroma by squeezing of the forefoot or increasing pressure on the balls of the feet.
    • Repetitive, heavy impact on the feet, for example, during running, dancing, or athletics. 
  • Morton's neuroma is a common condition. It is four times more common in women than in men.
  • The mean age at presentation is 50–55 years. 
  • Typical symptoms include:
    • Pain in the forefoot, most commonly in the third intermetatarsal space.
    • Pain whilst walking, exacerbated by increased activity or particular footwear, and relieved by removal of footwear and massaging the toes.
    • The sensation of having a 'pebble' or 'lump' under the metatarsal region when walking.
    • A sharp, stabbing, burning, or tingling sensation (sometimes described as feeling like an electric shock) in the distribution of the affected nerve.
  • First-line management is to avoid shoes with thin soles, high heels, or a constricting toe box. A metatarsal pad (available over-the-counter) may also reduce pressure from the nerve. Nonsteroidal anti-inflammatory drugs can be considered if necessary.
  • If symptoms persist for more than 3 months even with footwear modifications, referral to an orthotist is recommended for a metatarsal dome orthotic. If this is not available or not successful, referral should be arranged to an orthopaedic surgeon with a special interest in the foot, a musculoskeletal clinic, or a podiatric surgeon (depending on local policy and service provision) for consideration of specialist treatments, such as corticosteroid injection or surgery. 

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the management of Morton's neuroma.

This CKS topic does not cover the management of other causes of metatarsalgia.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2026 — reviewed.  A literature search was conducted in April 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been no major changes to the clinical recommendations. Minor structural changes have been applied to the topic, including the addition of a section summarizing the complications which may occur if Morton's neuroma is untreated. Updated references have been identified and included in the topic to support the recommendations with current evidence sources.

Previous changes

November 2021 — reviewed. A literature search was conducted in October 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

September 2016 — reviewed. A literature search was conducted in August 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been included as a management option, and there have been minor changes to the recommendations on referral. There have also been minor structural changes to the topic.

July 2010 — minor correction to the Basis for recommendation of the Referral section. Referral to podiatric surgeon (as an alternative to referral to an orthopaedic surgeon) has been included.

March to June 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 April 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 April 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 April 2026.

New policies

No new national policies or guidelines since 1 April 2026.

New safety alerts

No new safety alerts since 1 April 2026.

Changes in product availability

No changes in product availability since 1 April 2026.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Diagnose Morton's neuroma.
  • Manage the condition appropriately in primary care.
  • If required, refer people with Morton's neuroma to the appropriate specialist.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

What causes it?

  • There are four main theories as to the cause of Morton's neuroma [Valisena, 2018] [Colò, 2020] [Edwards, 2020] [Puri, 2020] [Mak, 2021] [Afonso, 2023]:
    • Chronic, repetitive trauma — stress from the adjacent forefoot structures causes repetitive trauma to the nerve.
    • Nerve ischaemia — neurofibrosis occurs from reduced blood flow to the nerve via abnormalities to the feeder artery.
    • Intermetatarsal bursitis —  chronic inflammation of the bursa (bursitis) results in adherence between the nerve and the bursa, resulting in pain.
    • Compression or entrapment of the nerve — the nerve becomes entrapped between the plantar aspect of the foot and the transverse intermetatarsal ligament.
  • These pathomechanistic theories are unlikely to be mutually exclusive and probably represent processes that occur concurrently [Mak, 2021].

What are the risk factors?

  • Risk factors include [Edwards, 2020; Puri, 2020; Samaila, 2021] [Mak, 2021] [Afonso, 2023] [Cooper, 2023]:
    • High-arch feet.
    • Regularly wearing tight/ill-fitting, high-heeled or narrow toe-box shoes — thought to cause Morton's neuroma by squeezing of the forefoot or increasing pressure on the balls of the feet.
    • Repetitive, heavy impact on the feet, for example, during running, dancing, or athletics.
    • Any foot deformity that results in toe overcrowding can increase pressure on the lesser toes. This may be particularly true for those with a bunion (hallux valgus). For more information, see the topic on Bunions.
    • Runners may be at higher risk due to increased weight-bearing at the forefoot.

How common is it?

What is the prognosis?

  • Without intervention, the symptoms of Morton's neuroma are unlikely to settle.
  • With intervention, symptom resolution is dependent on the intervention. See the section on Management for more information.

What are the complications?

  • Untreated Morton's neuroma can lead to long-term complications, which could impact quality of life [Bhatia, 2020] [Mak, 2021] [Matthews, 2024]. These may include:
    • Increased pain intensity and more frequent periods of discomfort — pain can be constant in chronic cases [Bhatia, 2020].
    • Altered gait and posture with secondary musculoskeletal complications — pain may limit weight-bearing, thereby altering plantar pressure distribution and gait mechanics, which could contribute to compensatory postural changes and secondary musculoskeletal symptoms [Mak, 2021; Feyzioğlu, 2023].
    • Progressive restriction of physical activity — as a person's mobility is affected, their ability to pursue physical activities becomes impaired [Mak, 2021; Matthews, 2024]. Decreased physical activity is a well-recognised risk factor for cardiometabolic disease and psychosocial complications.

Diagnosis of Morton's neuroma

How should I diagnose Morton's neuroma?

  • Ask about the symptoms experienced.
    • The most common symptom is pain in the forefoot, most commonly on the plantar surface in the third intermetatarsal space, often at the level of the metatarsal heads. 
    • Pain is described as sharp, stabbing, burning, and shooting, and may be associated with cramping, tingling, or numbness in the toes, or a clicking sensation in the forefoot. 
    • Altered sensations and feeling a 'pebble' or 'lump' in the shoe on weight bearing is reported by more than 50% of people.
    • Pain is typically intermittent, as episodes often occur for minutes to hours at a time with long intervals (weeks to months) between attacks. However, in chronic cases, the pain could be constant.
    • Night pain and rest pain are reported by about 25% of people.
    • Symptoms are aggravated by increased activity or particular footwear (for example, narrow, tight high-heeled shoes), and relieved by removal of footwear and massaging of the toes (especially early in the onset of the condition).
    • Some people with Morton's neuroma may be asymptomatic, with the neuroma being detected as an incidental finding on examination of the foot for another reason.
  • Examine the person. 
    • Inspect the feet and lower legs, starting at the hindfoot and progressing toward the forefoot.
      • Inspect the hindfoot alignment (valgus or varus), the height of the medial longitudinal arch (normal, high, or planus), and the forefoot in relation to the hindfoot (abducted, adducted, pronated, or supinated).
      • Check for the presence of toe abnormalities (such as hallux valgus, hammer toe, claw toe, and increased gaping between lesser toes).
      • Check for any swelling(s), previous surgical or traumatic scars, skin conditions, and the presence of any plantar callosities. 
      • Observe the person's gait, paying special attention to the heel strike, mid-stance, and toe off. The inability to bear weight on a plantigrade foot provides a clue to where the pathology may be.
      • Check the person's shoes for increased ‘wear and tear’ in certain parts of the shoe soles. 
    • Palpate the foot to identify the area of tenderness. Ask the patient to point to the spot or area where they feel the pain. 
      • In Morton's neuroma, pain is elicited on applying pressure to the involved inter-metatarsophalangeal space. 
        • The thumb-index finger squeeze test (or web-space tenderness test) is performed by compressing the affected metatarsal interspace using the thumb on the plantar side and index finger on the dorsal side of the foot, resulting in tenderness or pain.
        • The Tinel sign is elicited by holding the person's toes in extension and lightly tapping the site of the suspected neuroma, resulting in pain or sudden tingling sensations or numbness in the toes.
      • If there is metatarsophalangeal joint pain or tenderness localized to the metatarsal heads, consider a differential diagnosis, such as rheumatoid arthritis.
    • Assess the neurovascular status of the foot by palpating the dorsalis pedis and tibial artery pulses, and assess sensation in the foot and ankle region.
      • Loss of sensation to the affected toes is a strong indicator of Morton's neuroma, but a sensory deficit may not be apparent on examination.
    • Examine the range of joint motions, passive and active, from the hindfoot to the toes. Compare with the opposite side, if normal.
      • Equinus at the ankle and hypermobile first ray will contribute to excessive forefoot pressure and consequent metatarsalgia. Stiffness at the tarsometatarsal articulation may also cause uneven forefoot weight distribution.
    • Try to elicit Mulder's click:
      • Try to grip the neuroma between your forefinger and thumb (with your thumb on the plantar aspect of the foot).
      • With your other hand, simultaneously squeeze the metatarsal heads (1–5) together in the transverse plane.
      • A click can be felt and heard as the enlarged nerve subluxes between the metatarsal heads as they are compressed.
      • Absence of this sign does not rule out a neuroma.
  • If the diagnosis is uncertain:
    • Consider arranging an X-ray to exclude other pathology, such as fracture or arthropathy.
    • Consider checking full blood count, erythrocyte sedimentation rate, and uric acid to exclude conditions such as osteomyelitis, gout, and inflammatory arthritis.
    • An ultrasound scan or magnetic resonance imaging (MRI) can confirm a diagnosis of Morton's neuroma, although the use of MRI is not usually necessary.

Basis for recommendation

The recommendations on the diagnosis of Morton's neuroma are largely based on recommendations in the Association of Extremity Nerve Surgeons (AENS) Clinical practice guidelines: Morton's entrapment [Association of Extremity Nerve Surgeons, 2014] and the American College of Radiology (ACR) Appropriateness criteria: chronic foot pain [ACR, 2025], evidence summarized in a Cochrane systematic review Treatments for Morton's neuroma [Matthews, 2024], and expert opinion in review articles [Coughlin, 2000; Di Caprio, 2018; Gougoulias, 2019; Bhatia, 2020; Puri, 2020; Mak, 2021; Afonso, 2023; Cooper, 2023].

Diagnosis of Morton's neuroma

History and examination

  • The clinical features of Morton's neuroma are based largely on expert opinion in review articles [Di Caprio, 2018; Gougoulias, 2019; Bhatia, 2020; Puri, 2020; Afonso, 2023; Cooper, 2023; Matthews, 2024].
  • The information on the percentage of people who experience altered sensation, a feeling of 'pebble in the shoes', night pain, and rest pain is based on a review article [Bhatia, 2020].
  • The recommendations on how to examine the person are largely based on expert opinion in review articles [Gougoulias, 2019; Puri, 2020; Afonso, 2023; Cooper, 2023; Matthews, 2024].
    • As stated in an expert opinion review article, the thumb index finger squeeze test was reported to be the most sensitive screening method for Morton's neuroma (96% sensitivity), while Mulder's click may have a wider range of senstivity (94-98%) and a positive sign may be dependent on the size of the neuroma (>1 cm typically more likely to be detected) [Afonso, 2023].

X-rays

  • X-rays are insensitive to diagnose Morton’s neuroma. However, they may show widening of the distal intermetatarsal space or divergence of adjacent digits, known as the Sullivan’s sign. X-rays are also useful for excluding other causes of webspace pain, such as osteoarthritis, Freiberg’s infraction, and stress fractures [Di Caprio, 2018; Gougoulias, 2019; Mak, 2021; Afonso, 2023; Cooper, 2023; ACR, 2025].
  • Evidence supports the use of weight bearing foot X-rays as the initial imaging study in people with a painful heel [ACR, 2025].

Ultrasound and magnetic resonance imaging (MRI) 

  • Ultrasound and MRI are the most common imaging modalities used in the diagnosis of Morton neuroma [ACR, 2025].
    • On ultrasound, a Morton’s neuroma appears as a well-circumscribed ovoid hypoechoic lesion in the intermetatarsal space at the level of the metatarsal heads, surrounded by hyperechoic normal fatty tissues in the intermetatarsal spaces [Mak, 2021] .
    • On MRI, Morton’s neuromas are observable as low to intermediate signal intensity (reflecting fibrosis around the nerve) within the intermetatarsal space and centred in the neurovascular bundle on the plantar side of the deep transverse metatarsal ligament [Mak, 2021].
  • Evidence from a systematic review showed greater diagnostic accuracy for ultrasound than MRI for the diagnosis of Morton’s neuroma [Xu, 2015]:
    • Ultrasound had a sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 90%, 88%, 2.77, and 0.16, respectively.
    • MRI had a sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 93%, 68%, 1.89, and 0.19, respectively.
  • Ultrasound has the additional advantage of injecting local anaesthetic to provide diagnostic evidence [Di Caprio, 2018; Puri, 2020]. 
  • Expert opinion in review articles is that [Di Caprio, 2018; Mak, 2021; Afonso, 2023]:
    • Although ultrasound is relatively inexpensive, has virtually no contraindications, is fast and well tolerated, it has a high rate of incidental finding of an asymptomatic interdigital nerve enlargement, which can lead to a false diagnosis of Morton’s neuroma. Moreover, small lesions are difficult to diagnose by imaging, but are still able to cause symptoms.
    • The MRI diagnosis of Morton’s neuroma does not imply symptomatology. Careful correlation between clinical and MRI findings is mandatory before Morton's neuroma is considered clinically relevant.

Serology

  • The recommendation to consider checking full blood count, erythrocyte sedimentation rate, and uric acid to exclude other painful conditions of the foot is based on expert opinion in a review article [Coughlin, 2000] and on what CKS considers to be good clinical practice. The recommendation to consider checking full blood count, erythrocyte sedimentation rate, and uric acid to exclude other painful conditions of the foot is based on what CKS considers to be good clinical practice.

What else might it be?

Differential diagnoses of Morton's neuroma include:

  • Biomechanical problems, such as:
    • Anomalies of the forefoot bone structure, especially in the presence of hallux valgus with lesser toe deformities.
    • Instability issues.
    • Obesity (chronic tension on the plantar fascia).
    • Pregnancy (exaggerates any biomechanical abnormalities).
  • Soft tissue problems, such as:
    • Focal plantar keratosis (corns).
    • Plantar fibromatosis.
    • Plantar fat pad atrophy.
    • Plantar warts.
    • Plantar plate tear (these ARE most common in the second metatarsophalangeal [MTP] joint, and are uncommonly symptomatic).
    • Plantar vein thrombophlebitis.
    • Synovial tissue disease: ganglia, bursitis, capsulitis, gouty tophus, and rheumatoid nodules and bursae.
    • Foreign body granuloma.
    • Vascular disease: ischaemia, venous and lymphatic insufficiency.
    • Neurological problems: sensory dysfunction, entrapment neuropathy (such as tarsal tunnel syndrome), neuritis, alcoholic neuropathy, and nerve root pathology.
    • Muscular pathologies.
    • Cancer.
  • Bone and joint disease, such as:
    • Stress fractures.
    • Osteoarthritis and neuropathic osteoarthropathy.
    • Rheumatoid arthritis.
    • Osteonecrosis of the metatarsal head.
    • Osteomyelitis.
    • Sesamoid pathology.
    • Freiberg's disease (also known as Freiberg's infraction — osteochondritis of the metatarsal head) — causes metatarsalgia, most commonly in the area of the second metatarsophalangeal joint area.
    • Cancer.
  • Be aware that more than one pathology can be present in those with metatarsalgia.

Basis for recommendation

The recommendations on the differential diagnoses for Morton's neuroma are based on expert opinion in review articles [Di Caprio, 2018; Ganguly, 2018; Gougoulias, 2019; Bhatia, 2020; Puri, 2020; Afonso, 2023; Park, 2025].

Management

Scenario: Management

From age 16 years onwards.

Management of Morton's neuroma

  • Primary care treatment aims for Morton's neuroma are to minimise pain and improve foot functionality. 
  • Advise the person:
    • To avoid high heels and shoes with a constricting toe box or thin soles, to reduce pressure on the forefoot.
    • To use a metatarsal pad: 
      • These are available over-the-counter.
      • The pad should be placed just proximal to the metatarsal heads to reduce pressure from the nerve.
    • To avoid (or reduce) impact activities, such as running and jumping.
  • Consider offering nonsteroidal anti-inflammatory drugs (NSAIDs) if necessary. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for prescribing information.
  • Offer written information on Morton's neuroma, such as that available from the NHS website (www.nhs.uk).  
  • If symptoms persist despite 3 months of footwear modifications and using metatarsal pads:
    • Refer the person to an orthotist for a metatarsal dome orthotic.
  • If symptoms persist despite a trial of an orthotic device (or referral to orthotics is not available):
    • Refer to an orthopaedic surgeon with a special interest in the foot, a musculoskeletal clinic, or a podiatric surgeon (depending on local policy and service provision) for consideration of specialist treatments, such as corticosteroid injections, guided alcohol injections, and surgery.

Specialist treatments for Morton's neuroma

  • Corticosteroid injection 
    • Corticosteroid injection is effective in 30–50% of cases [Valisena, 2018; Thomson, 2020; Choi, 2021; Samaila, 2021], with minimal post-injection complications [Thomson, 2020].
    • The beneficial effects have been reported to last for up to 12 months, after which there appears to be a 50% failure rate in pain relief, and about 30% of people require operative treatment [Thomson, 2020; Choi, 2021]. 
      • One prospective follow-up study found that corticosteroid injections remained effective in over 30% of cases for up to almost 5 years [Hau, 2021].
    • Evidence from a systematic review suggests that a neuroma of 6.3 mm is the threshold below which a corticosteroid injection delivers optimal results [Samaila, 2021].
    • Corticosteroid injections may also be combined with local anaesthetics [Mak, 2021; Afonso, 2023]:
      • A Cochrane systematic review pooled data from two small studies and identified moderate‐certainty evidence that, in comparison with unguided administration, ultrasound-guided corticosteroid co-administered with local anaesthetic probably reduces pain, increases function and improves person satisfaction at 6 months post-treatment [Matthews, 2024].
      • When corticosteroid co-administered with local anaesthetic was compared with local anaesthetic alone, there was no clear evidence of improvement in pain, function or quality of life outcomes at 3–6 months [Matthews, 2024].
    • Corticosteroid injections are repeatable only in a limited way as they can lead to atrophy of the plantar fat pad, skin discolouration and skin atrophy at the injection site, and rupture of the metatarsophalangeal joint capsules with deviation of adjacent toes, which can cause persistent pain in the plantar forefoot [Di Caprio, 2018; Cooper, 2023].
  • Alcohol injection 
    • Alcohol injection is beneficial in 25–84% of cases [Valisena, 2018; Thomson, 2020]. However, long-term results showed a deterioration, with approximately 30% of people undergoing surgery, 30% with pain recurrence, and only 29% remaining pain free at 5 years follow up [Di Caprio, 2018; Thomson, 2020].
    • Complications (most commonly intense pain) have been reported in about 26% of people treated with alcohol injection [Thomson, 2020].
    • Alcohol injection is repeatable, but a transitory increase in pain has been reported in 15% of cases [Di Caprio, 2018].
  • Operative (surgical) treatment
  • Other treatments 
    • Extracorporeal shockwave therapy, capsaicin injections, botulinum injections, cryoneurolysis, radiofrequency ablation, hyaluronic acid injections, and laser therapy have been mentioned in the literature, but there is little or no evidence on efficacy to support their use [NICE, 2015; Thomson, 2020; Matthews, 2024].

Basis for recommendation

The recommendations on the management of Morton's neuroma are largely based on recommendations in the Association of Extremity Nerve Surgeons (AENS) Clinical practice guidelines: Morton's entrapment [Association of Extremity Nerve Surgeons, 2014], evidence summarized in a Cochrane systematic review Treatments for Morton's neuroma [Matthews, 2024], and expert opinion in review articles [Pomeroy, 2015; Arias-Martín, 2018; Di Caprio, 2018; Valisena, 2018; Gougoulias, 2019; Bhatia, 2020; Colò, 2020; Puri, 2020; Cooper, 2023].

Treatment of Morton's neuroma 
Footwear modification and metatarsal pads
  • Orthotics and footwear modification are safe and rational initial treatments and are recommended in guidelines and review articles [Association of Extremity Nerve Surgeons, 2014; Di Caprio, 2018; Gougoulias, 2019; Bhatia, 2020; Puri, 2020; Cooper, 2023].
    • A systematic review identified one study on conservative treatment for Morton's neuroma [Valisena, 2018]:
      • The use of orthoses offered some improvement for 48% of people, but the recurrence rate was high (47%). The rate of complication was not available.
    • Evidence from subsequent systematic reviews showed that the use of custom-made foot orthoses improves the level of forefoot pain in people with secondary metatarsalgia [Arias-Martín, 2018]. However, orthotics and/or shoe modification were not reported to provide convincing benefits after a period of 4.5 months and in people with neuromas larger than 5–6 mm [Colò, 2020].
  • The recommendation to avoid thin-soled shoes, shoes with high heels or a constricting toe box is based on expert opinion in a review article [Cooper, 2023].
  • There is no evidence to support the use of inversion or eversion (supination or pronation) insoles in the management of Morton's neuroma, with studies demonstrating no significant improvement in patient reported outcomes [Bhatia, 2020].
Nonsteroidal anti-inflammatory drugs
  • CKS identified no evidence to support the use of nonsteroidal anti-inflammatory drugs in the treatment of Morton's neuroma specifically. However, their use in this setting is highlighted in review articles [Pomeroy, 2015; Matthews, 2024], yet previous reviewers of this CKS topic consider that they may have limited use in some people.
Referral following conservative treatment
  • CKS found no evidence on the timescale of referral if conservative treatment is not effective. 
  • This recommendation is based on the expert opinion of previous reviewers of this CKS topic.
Referral to an orthotist for a metatarsal dome orthotic
  • This recommendation is based on expert opinion in review articles [Colò, 2020] and from previous reviewers of this CKS topic.
    • Among conservative treatments, orthotics and shoes modifications have been used to off-load the forefoot and reduce pain from weight-bearing pressure. As metatarsal padding helps to spread and cushion metatarsal heads to relieve the pain from the pinched nerve, use of orthotics may be considered a safe and rational treatment before more invasive interventions [Colò, 2020].
Referral to an orthopaedic surgeon with a special interest in the foot, a musculoskeletal clinic, or a podiatric surgeon

Supporting evidence

This CKS topic is largely based on recommendations in the Association of Extremity Nerve Surgeons (AENS) Clinical practice guidelines: Morton's entrapment [Association of Extremity Nerve Surgeons, 2014], the American College of Radiology (ACR) Appropriateness criteria: chronic foot pain [ACR, 2025], evidence summarized in a Cochrane systematic review Treatments for Morton's neuroma [Matthews, 2024], and expert opinion in review articles [Di Caprio, 2018; Valisena, 2018; Gougoulias, 2019; Bhatia, 2020; Colò, 2020; Puri, 2020; Afonso, 2023; Mak, 2021; Cooper, 2023].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Morton's neuroma, with additional searches in the following areas:

  • Diagnosis
  • Investigations
  • Treatments

The search excluded children.

Search dates

August 2021 - April 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • Morton Neuroma / complications
  • Morton Neuroma / diagnosis
  • Morton Neuroma / therapy*
  • (interdigital adj neuroma) or intermetatarsal neuroma) or (interdigital nerve compression syndrome).ti,ab.
  • Morton$ neuroma.ti,ab.,kw.
  • ("civinini morton's syndrome" or CMS).ti,ab,kw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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