Is your ball-of-foot pain Morton's neuroma or metatarsalgia?

Both cause pain in the ball of the foot that builds with walking and with tight or high-heeled shoes, and both can feel like walking on a pebble, which is why they are easy to mix up. Morton's neuroma is a thickened, irritated nerve between two of the long foot bones, most often between the third and fourth toes, so it tends to burn, shoot or tingle into those two toes. Metatarsalgia describes pain under the ends of the long foot bones (the metatarsal heads) rather than one diagnosis, so it tends to ache like a bruise right under the bone, and the work is finding what is overloading it. Here the comparison is between a neuroma, a nerve squeezed between the bone ends, and pain mainly from pressure under the bone ends; other causes can overlap with either.

Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. An in-person exam usually narrows it down, though the two can overlap and some cases need imaging or a second look.

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Other Comparisons

Condition A

Morton's Neuroma

Forefoot nerve compression causing numbness and burning painRead the full Morton's neuroma page Condition B

Metatarsalgia

Ball of foot pain, forefoot overload syndromeRead the full metatarsalgia page

Side by side

The patterns that separate Morton's neuroma from metatarsalgia in clinic. Read across each row and compare.

Aspect	Morton's neuroma	Metatarsalgia
Where it hurts	In the ball of the foot between two toes, most often the third and fourth (the third web space) and less often the second and third, with pain that can shoot into those two toes.	Under the ball of the foot, right under the end of one or more long foot bones (the metatarsal heads), most often behind the second and third toes. It sits under the bone ends rather than between them.
What it feels like	Burning, electric or shooting pain, often with a feeling of walking on a pebble or a fold in the sock.	An aching or bruised feeling under the bone ends that builds with time on your feet. It can also burn or feel sharp, and some people describe walking on stones or bunched socks.
Numbness and tingling	Numbness or tingling in the two toes either side of the sore space is common and points to the nerve. Its absence does not rule a neuroma out: in one study, reduced feeling showed up on testing in only about a quarter of feet with a confirmed neuroma.	Not part of simple overload. Tingling alongside ball-of-foot pain can mean a neuroma is there as well, or that a problem in a nearby toe joint is irritating the nerve. Numbness that spreads across the foot, or in both feet, needs your family doctor.
Shoes and heels	A narrow toe box pushes the ends of the long foot bones together and adds pressure on the irritated nerve, and raised heels add to it. Taking the shoe off and rubbing the forefoot often brings quick relief.	High heels shift your weight onto the ball of the foot, and thin or worn-out soles cushion it less. It eases with rest and when the shoes come off. In one group of people with metatarsalgia, many had worn high heels daily or done standing work for several years.
Pressing on it, and the skin	Tender when the space between the two bone ends is squeezed from top and bottom. Squeezing the forefoot from side to side can bring on the pain, sometimes with a click (Mulder's click). Calluses are not part of the neuroma.	Tender when pressing directly under the end of the bone (the metatarsal head), often with a callus or corn over the sore spot.
Typical story	Creeps in gradually: at first only in certain shoes, then with most shoes, and eventually even barefoot. Narrow or high-heeled shoes are often part of the story.	Builds gradually, at first only with high-impact activity and later with normal walking, and gets worse as the day goes on. Long spells of standing, high heels, a bunion or a stiff big toe, and the cushioning pad under the forefoot thinning with age can all add to it.
What scans show	Usually recognised from the history and examination. Ultrasound or magnetic resonance imaging (MRI) can show a thickened nerve, but in one MRI study a similar thickening turned up in about 3 in 10 feet without symptoms, so a scan is read alongside the exam.	Metatarsalgia describes where it hurts, so imaging, when it is needed, looks for the cause: standing X-rays for the shape of the foot and the bones, and ultrasound or MRI for a plantar plate tear or a stress injury in the bone. I cannot order imaging; when it would change the plan, I flag it to your family doctor or sports medicine physician and refer you.
How long it takes	Many people notice some change within several weeks of footwear changes and padding, and improvement can continue over a few months. Long-standing cases may take longer.	Many people notice some improvement within several weeks of offloading and footwear changes, and recovery can take a few months depending on the underlying cause and how the forefoot load is managed.

Where it hurts: Morton's neuroma
In the ball of the foot between two toes, most often the third and fourth (the third web space) and less often the second and third, with pain that can shoot into those two toes.; Metatarsalgia
Under the ball of the foot, right under the end of one or more long foot bones (the metatarsal heads), most often behind the second and third toes. It sits under the bone ends rather than between them.
What it feels like: Morton's neuroma
Burning, electric or shooting pain, often with a feeling of walking on a pebble or a fold in the sock.; Metatarsalgia
An aching or bruised feeling under the bone ends that builds with time on your feet. It can also burn or feel sharp, and some people describe walking on stones or bunched socks.
Numbness and tingling: Morton's neuroma
Numbness or tingling in the two toes either side of the sore space is common and points to the nerve. Its absence does not rule a neuroma out: in one study, reduced feeling showed up on testing in only about a quarter of feet with a confirmed neuroma.; Metatarsalgia
Not part of simple overload. Tingling alongside ball-of-foot pain can mean a neuroma is there as well, or that a problem in a nearby toe joint is irritating the nerve. Numbness that spreads across the foot, or in both feet, needs your family doctor.
Shoes and heels: Morton's neuroma
A narrow toe box pushes the ends of the long foot bones together and adds pressure on the irritated nerve, and raised heels add to it. Taking the shoe off and rubbing the forefoot often brings quick relief.; Metatarsalgia
High heels shift your weight onto the ball of the foot, and thin or worn-out soles cushion it less. It eases with rest and when the shoes come off. In one group of people with metatarsalgia, many had worn high heels daily or done standing work for several years.
Pressing on it, and the skin: Morton's neuroma
Tender when the space between the two bone ends is squeezed from top and bottom. Squeezing the forefoot from side to side can bring on the pain, sometimes with a click (Mulder's click). Calluses are not part of the neuroma.; Metatarsalgia
Tender when pressing directly under the end of the bone (the metatarsal head), often with a callus or corn over the sore spot.
Typical story: Morton's neuroma
Creeps in gradually: at first only in certain shoes, then with most shoes, and eventually even barefoot. Narrow or high-heeled shoes are often part of the story.; Metatarsalgia
Builds gradually, at first only with high-impact activity and later with normal walking, and gets worse as the day goes on. Long spells of standing, high heels, a bunion or a stiff big toe, and the cushioning pad under the forefoot thinning with age can all add to it.
What scans show: Morton's neuroma
Usually recognised from the history and examination. Ultrasound or magnetic resonance imaging (MRI) can show a thickened nerve, but in one MRI study a similar thickening turned up in about 3 in 10 feet without symptoms, so a scan is read alongside the exam.; Metatarsalgia
Metatarsalgia describes where it hurts, so imaging, when it is needed, looks for the cause: standing X-rays for the shape of the foot and the bones, and ultrasound or MRI for a plantar plate tear or a stress injury in the bone. I cannot order imaging; when it would change the plan, I flag it to your family doctor or sports medicine physician and refer you.
How long it takes: Morton's neuroma
Many people notice some change within several weeks of footwear changes and padding, and improvement can continue over a few months. Long-standing cases may take longer.; Metatarsalgia
Many people notice some improvement within several weeks of offloading and footwear changes, and recovery can take a few months depending on the underlying cause and how the forefoot load is managed.

What I check in person to separate them

These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain how an in-person exam narrows them down.

Pointing to the pain
A finger landing in the gap between two toes, with pain that shoots or tingles into them, points to the nerve. A sore spot right under the ball of the foot, under one bone end, points more to overload or a problem in that toe joint.
Web-space squeeze (thumb and finger squeeze)
I press the space between the two bone ends from top and bottom between a thumb and finger. In one study of feet with a neuroma confirmed on ultrasound, this brought on the pain in nearly all of them, so a pain-free squeeze makes a neuroma less likely. Tenderness right under one bone end instead fits metatarsalgia or a joint problem.
Mulder's click
I squeeze the forefoot from side to side while pressing up into the sore space. A click with your familiar pain supports a neuroma. In the same study it was found in only about 6 in 10 confirmed neuromas, more often in larger ones, so no click does not rule one out.
Pressing under the bone ends and along the bones
I press under each bone end in turn. Pain right under one or more of them fits metatarsalgia. Tenderness at one spot on the bone itself, further back along the shaft, or pain when the bone is tapped, raises the question of a stress fracture, and I stop loading tests there.
Drawer test of the smaller toe joints
I hold the long foot bone steady and move the base of the toe up and down. Too much movement suggests the plantar plate, the tough pad of tissue under the toe joint, is torn or stretched, most often at the second toe; pain during the test alone can also come from other joint problems. Plantar plate problems are common, can be mistaken for either condition and are easily missed. A toe that has started to drift, lift or cross over its neighbour needs your family doctor.
Feeling in the toes
I check light touch on both sides of each toe. Reduced feeling in the two toes either side of one space fits a neuroma, although normal feeling does not rule one out. Numbness beyond two neighbouring toes, or in both feet, sends me to check the nerve at the inner ankle (tarsal tunnel) and to involve your family doctor.

Which pattern fits you better?

Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.

More likely

Morton's neuroma

Your pattern more likely fits Morton's neuroma if the pain sits between two toes, most often the third and fourth, burns, shoots or feels electric, and comes with numbness or tingling in those two toes or a feeling of a pebble or a fold in your sock. Narrow or high-heeled shoes bring it on, taking the shoe off and rubbing the forefoot eases it, and squeezing the space between the two bone ends reproduces it.

Read the Morton's neuroma page

More likely

Metatarsalgia

Your pattern more likely fits metatarsalgia if the pain is an ache or bruised feeling right under the ball of the foot, pressing under one or more bone ends finds the sore spot, and there is no tingling or numbness in the toes. It builds with long spells of standing or walking and through the day, eases noticeably within a minute or two of sitting down and taking your shoes off, and may come with a callus over the sore spot, a bunion or a stiff big toe.

Read the metatarsalgia page

If you still cannot tell

It is common not to be sure, partly because metatarsalgia is a description of where it hurts and a neuroma is one of the things that can cause it. I map where the tenderness is, between the bone ends, right under them or along the shaft of a bone; squeeze the space between the bones and check for Mulder's click; test each smaller toe joint with the drawer test, since a plantar plate tear is common and easily missed; check the feeling in your toes; and look at your shoes and how your foot takes load as you walk. A few weeks of wider, low-heeled shoes and a well-placed metatarsal pad are a reasonable start for both, and how you respond adds to the picture. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or sports medicine physician and refer you. An ultrasound or MRI can help when the picture is unclear, but a thickened nerve on a scan is also common in feet without symptoms, so a scan alone does not decide which one is causing your pain.

When both are going on

The two often overlap. In the broad sense, Morton's neuroma is one of the causes of pain in the ball of the foot, so the label metatarsalgia can cover it, and both can be present at once: an overloaded forefoot can be sore under the bone ends while the nerve between them is irritated too. A plantar plate problem under a smaller toe joint can also thicken the tissue around that joint and irritate the nerve nearby, giving nerve symptoms that can be hard to tell from a neuroma. Because shoes and pad position matter for both, I start there. When both are present, easing the overload on the forefoot often eases the squeeze on the nerve as well, and I then look closely at whichever part is lingering.

When to see a doctor first

A foot or toe that suddenly becomes cold, pale or blue, especially with severe pain or new numbness. Go to emergency now; the blood supply may be blocked.
If you have diabetes or reduced feeling in your feet, a new sore, blister or wound. See your doctor or foot care team within 24 hours.
A new sore, blister or wound on the foot with a fever, or you feel unwell. Go to emergency now.
A red, hot, swollen forefoot or toe joint, or fever. Same-day medical assessment for a possible infection or gout.
With diabetes or reduced feeling in your feet, a foot that is newly hot, red or swollen, even with little pain. Same-day medical assessment, and keep weight off the foot until then. Along with infection, this can be a Charcot foot, a bone and joint problem linked to nerve damage.
A hot, red or swollen foot and you feel very unwell, confused or faint. Go to emergency.
Sharp pain at one spot on a long foot bone, especially after a jump in walking or running, or pain there at rest or at night. Possible stress fracture. Stop running and jumping, limit weight on the foot, and see your family doctor or urgent care for an X-ray, the usual first test. An early X-ray can look normal, so follow the treating clinician's plan before loading it again. Do not hop or run to test it.
You cannot put weight on the foot. Get it checked today at urgent care or by your family doctor.
Sudden unexplained weakness or numbness in an arm or leg, even if it improves. Call 911 now; it can be a stroke.
New weakness in the toes or foot, or weakness that keeps getting worse. Same-day medical assessment.
Numbness spreading beyond two neighbouring toes, or numbness or tingling in both feet. See your family doctor promptly, before starting physiotherapy, to check for tarsal tunnel syndrome or a nerve condition such as diabetic neuropathy.
A toe that suddenly starts to drift, lift, or cross over its neighbour. See your family doctor for an orthopaedic opinion on a possible plantar plate tear.

Questions patients ask about telling these apart

It feels like I am walking on a pebble. Does that mean it is a neuroma?

It leans that way, but it does not decide it. The pebble or sock-fold feeling is one of the best-known features of Morton's neuroma, and people with metatarsalgia sometimes describe walking on stones or bunched socks too. What separates them is where the pain is and how it feels: burning or shooting pain between two toes, with tingling or numbness in those toes, points to the nerve, while a bruised ache right under the bone ends, often with a callus, points to overload. A short examination can often tell them apart.

I have numbness in two toes. Is that a neuroma?

Numbness or tingling in the two toes either side of one space, most often the third and fourth, fits a neuroma well. It is not the whole story: a plantar plate problem under a nearby toe joint can irritate the same nerve, and in one study reduced feeling showed up on testing in only about a quarter of feet with a confirmed neuroma, so normal feeling does not rule one out. Numbness that spreads beyond two neighbouring toes, appears in both feet, or comes with weakness that keeps getting worse needs your family doctor before physiotherapy, to check for tarsal tunnel syndrome or a nerve condition such as diabetic neuropathy.

Do I need an ultrasound or MRI to tell them apart?

Often not. A neuroma is usually recognised from the history and examination, and in one series of people having surgery, the examination identified neuromas at least as well as either scan, though a surgical series cannot show how well it separates a neuroma from other forefoot problems (Sharp et al., 2003). When the picture is unclear, ultrasound and magnetic resonance imaging (MRI) each pick up most neuromas, but in one MRI study a neuroma-like thickening also showed up in about 3 in 10 feet without symptoms, so a scan result has to match the exam. For metatarsalgia, the examination shows where the load is landing, and imaging, when needed, looks for a cause, such as the shape of the bones on standing X-rays, a plantar plate tear or a stress fracture. I cannot order imaging; when imaging would change the plan, I flag it to your family doctor or sports medicine physician and refer you.

Will a metatarsal pad help both, and where does it go?

It can help with both, and it goes in the same kind of place: just behind the sore spot, not on top of it. For a neuroma it sits behind the painful space between the toe bones, lifting the long foot bones from behind to take the squeeze off the nerve. For metatarsalgia it sits just behind the painful bone end and takes the peak pressure off it. A pad set too far forward often makes symptoms worse, so if yours seems to, have its position checked in clinic. In one group given simple metatarsal pad insoles, the 25 people interviewed reported less pain on average, although they were recalling their earlier pain and there was no comparison group. Pair the pad with a toe box that has room to spare and a heel under about 2 cm.

What about injections or surgery?

For a neuroma that has not improved with footwear changes and padding, a physician may offer an injection; I do not give injections. In a Cochrane review, adding a steroid to a numbing injection may make little or no difference to pain at three to six months (low-certainty evidence), guiding the needle with ultrasound probably helped, and the steroid occasionally thinned the skin or the fat pad under the foot. Surgery to remove the nerve is considered when non-surgical care has not helped: in one series of 78 people followed for about four and a half years, about 8 in 10 rated the result excellent or good and 8% had no improvement, though 71% still had some restriction in the shoes they could wear (Pace et al., 2010), and it can leave permanent numbness in the toes. For metatarsalgia, treatment aims at the cause, with footwear changes, insoles and calf stretching first, and surgery considered for some causes, such as a plantar plate tear, when those have not helped. If there is no improvement after about 12 weeks of well-run non-surgical care for metatarsalgia, or 16 weeks for a neuroma, I flag it to your family doctor, who can arrange imaging and an opinion on the next step.

Could it be a stress fracture instead?

It can be, and it is worth thinking about after a jump in walking or running. A stress fracture usually shows itself with tenderness at one spot on the bone itself, often on the shaft of a long foot bone, sharper pain when the bone is tapped, and pain that does not ease promptly when weight is off the foot; aching at rest or at night points the same way. Pain from overload, by contrast, should ease noticeably within a minute or two of sitting down. If you suspect a stress fracture, stop running and jumping, limit weight on the foot and see your family doctor or urgent care for an X-ray; an early X-ray can look normal. Pain at one spot on the outer edge of the foot near the base of the fifth toe bone needs your family doctor promptly, before any loading, because that site can heal poorly.

Evidence this page draws on

Sources I lean on when separating these two conditions in clinic.

A Cochrane review describes Morton's neuroma as a non-cancerous enlargement of a nerve to the toes, most often in the third space between the toes and less often the second, causing burning or shooting pain in that space that spreads to the toes, or the feeling of walking on a pebble. It found only six randomised trials of any treatment, 373 people in all, none free of concerns about bias. Adding a steroid to a numbing injection may have made little or no difference to pain at three to six months, on low-certainty evidence; guiding the injection with ultrasound probably reduced pain compared with an unguided injection, and the steroid occasionally thinned the skin or the fat pad under the foot.

Matthews BG, Thomson CE, Harding MP, et al. "Treatments for Morton's neuroma." Cochrane Database Syst Rev 2024; 2(2): CD014687.

PubMed 38334217

In 40 people (54 feet) diagnosed with Morton's neuroma from the history and examination, an ultrasound scan confirmed a neuroma at the same spot in 53 feet. Squeezing the sore space between thumb and index finger brought on the pain in nearly all of them, while Mulder's click was found in about 6 in 10 and more often with a larger neuroma. Squeezing the forefoot from the sides, tapping it, and testing feeling in the toes each picked up fewer than half. Everyone in the study had a neuroma, so it could not show how often these tests are positive in other forefoot problems.

Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. "Diagnostic Accuracy of Clinical Tests for Morton's Neuroma Compared With Ultrasonography." J Foot Ankle Surg 2015; 54(4): 549-553.

PubMed 25432459

In forefoot magnetic resonance imaging (MRI) scans of 70 adults with no foot symptoms, a thickening that met the scan criteria for a Morton's neuroma showed up in 21 of them (30%). These were smaller on average than 16 painful neuromas confirmed at surgery, but the sizes overlapped, and the authors suggested a scan finding may matter only when it is at least 5 mm across and matches the clinical findings. Small amounts of fluid in the little sacs between the bone ends (intermetatarsal bursae) were also common and can be normal.

Zanetti M, Strehle JK, Zollinger H, Hodler J. "Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers." Radiology 1997; 203(2): 516-520.

PubMed 9114115

In the records of 90 people (109 feet) who had surgery to repair a torn plantar plate, most had pain that came on gradually, with pain and puffiness at the joint behind the second toe. A positive drawer test was found in about 8 in 10 of the tears seen at surgery and was rarely positive when no tear was found, and a toe crossing over its neighbour also pointed toward a tear. The authors note that these tears are frequently missed at the first examination. It was a look back at people who had surgery, so the figures may not hold for everyone with forefoot pain.

Klein EE, Weil L Jr, Weil LS Sr, et al. "Clinical examination of plantar plate abnormality: a diagnostic perspective." Foot Ankle Int 2013; 34(6): 800-804.

PubMed 23696184

Of 45 people with metatarsalgia given simple custom metatarsal pad insoles at a Finnish hospital and followed for at least a year, 25 were interviewed, and their pain scores fell on average. Most were women, with an average age of 56; among the 25 interviewed, 40% wore high heels daily and 68% had done standing work for several years, and on X-rays 42 percent had a bunion and 47 percent arthritis changes at the big toe joint. There was no comparison group, so the study cannot show how much of the improvement came from the pads.

Männikkö K, Sahlman J. "The Effect of Metatarsal Padding on Pain and Functional Ability in Metatarsalgia." Scand J Surg 2017; 106(4): 332-337.

PubMed 28737072

In 29 people diagnosed clinically with Morton's neuroma who had both MRI and ultrasound before surgery to remove the nerve, the clinical assessment was the most sensitive and specific of the three, and both scans were less accurate for small lesions. Because everyone had already been judged to have a neuroma, the study cannot show how well the examination separates a neuroma from other forefoot problems.

Sharp RJ, Wade CM, Hennessy MS, et al. "The role of MRI and ultrasound imaging in Morton's neuroma and the effect of size of lesion on symptoms." J Bone Joint Surg Br 2003; 85(7): 999-1005.

PubMed 14516035

In 78 people (82 feet) who had the nerve removed and were followed for an average of 4.6 years, 82 percent reported an excellent or good result, 10 percent a fair result and 8 percent no improvement, and 71 percent had some restriction in the shoes they could wear. There was no comparison group.

Pace A, Scammell B, Dhar S. "The outcome of Morton's neurectomy in the treatment of metatarsalgia." Int Orthop 2010; 34(4): 511-515.

PubMed 19484237

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Morton's Neuroma

Metatarsalgia

Side by side

What I check in person to separate them

Pointing to the pain

Web-space squeeze (thumb and finger squeeze)

Mulder's click

Pressing under the bone ends and along the bones

Drawer test of the smaller toe joints

Feeling in the toes

Which pattern fits you better?

Morton's neuroma

Metatarsalgia

If you still cannot tell

When both are going on

When to see a doctor first

Questions patients ask about telling these apart

It feels like I am walking on a pebble. Does that mean it is a neuroma?

I have numbness in two toes. Is that a neuroma?

Do I need an ultrasound or MRI to tell them apart?

Will a metatarsal pad help both, and where does it go?

What about injections or surgery?

Could it be a stress fracture instead?

Evidence this page draws on

Treatments that commonly sit inside either plan

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