Morton’s neuroma: A clinical versus radiological diagnosis Philip Pastides MBBS, BSc, MRCS*, Sameh El-Sallakh MD, MCh 1 , Charalambos Charalambides MD, FRCS 1 The Whittington Hospital, Magdala Avenue, London N19 5NF, United Kingdom 1. Introduction Morton’s neuroma (also known as Morton’s metatarsalgia, Morton’s neuralgia, plantar neuroma and intermetatarsal neuro- ma) is a benign neuroma of an intermetatarsal plantar nerve. It most commonly affects the second and third metatarsal spaces. It is more common in middle aged females. The chief complaints are a burning and tingling sensation down the interspace of the involved toes. This is made worse by walking in high-heeled shoes with a narrow toe box and is relieved by rest and by removing the shoe. The condition is named after Thomas George Morton (1835– 1903), an American Orthopaedic surgeon and son of a professor of anatomy, who recognised this condition as a disease entity in itself in 1876 [1]. However, it was described prior to this; by Civinni in 1835 [2] and Durlacher in 1845 [3]. In his treatise, the latter describes it as ‘a kind of neuralgia seated between the toes, but which fortunately is not very common. . .the patient complains of pain between two of the toes, generally the second and third, they can seldom tell. . .it is increased when the toes are pressed together’. There are several theories as to what causes a Morton neuroma, reinforcing the view that there is no single causative factor. Compression of the nerve secondary to swelling of the intermetatarsal bursa [4], repeated trauma to the interdigital nerve at the edge of the intermetatarsal ligament [5] or due to vascular injury are some of the proposed theories [6]. Morton’s neuroma is primarily a clinical diagnosis however, radiological assessment is frequently requested to aid or confirm the diagnosis. The question still arises as to whether imaging is necessary to confirm the diagnosis when the clinical picture eludes to the presence of a Morton’s neuroma. The aim of our study was to assess the accuracy and correlate the clinical, radiological and operative findings of a cohort of patients who underwent operative procedures for excision of these neuromas. 2. Methods Our cohort included all patients who underwent surgical excision of at least one Morton neuroma in a hospital in North London, over a 68-month period (January 2005 to August 2010). All neuromas were excised via a dorsal incision to the affected web space. All pre- and post-operative clinical assessments, pre- operative radiological investigations, ultrasonography (US) and magnetic resonance imaging (MRI) and post-operative histological reports were retrospectively reviewed. 3. Results Our review includes 43 excised Morton’s neuromas in 36 different patients. Of these, 28 were female and 8 were male. The average age was 43.8 years (range 25–71). Foot and Ankle Surgery 18 (2012) 22–24 A R T I C L E I N F O Article history: Received 30 September 2010 Received in revised form 6 January 2011 Accepted 9 January 2011 Keywords: Morton’s neuroma Diagnosis Imaging A B S T R A C T Background: The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton’s neuroma. Methods: Clinical assessments and pre-operative radiological imaging of patients who had excision of a Morton’s neuromas were retrospectively compared. Results: 43 neuromas were excised from 36 patients over 68 months. The commonest clinical symptoms were tenderness on direct palpation (100%), pain on weight bearing (91%) which was relieved by rest (81%). The most sensitive clinical sign was a Mulder’s click. Clinical assessment had a sensitivity of 98% (42/43). Ultrasonography had a sensitivity of 90% (28/31) and magnetic resonance imaging had a sensitivity of 88% (14/16). Conclusion: There is no absolute requirement for imaging patients who clinically have a Morton’s neuroma. The two main indications for imaging are (a) an unclear clinical assessment and (b) cases when more than one web space is affected. Ultrasonography should be the investigation of choice. ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. * Corresponding author at: 19 Alexandra Gardens, Muswell Hill, London N10 3RN, United Kingdom. Tel.: +44 7786512410. E-mail address: ppastides@hotmail.com (P. Pastides). 1 Tel.: +44 02072883427; fax: +44 02072883147. Contents lists available at ScienceDirect Foot and Ankle Surgery jou r nal h o mep age: w ww.els evier .co m/lo c ate/fas 1268-7731/$ – see front matter ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.01.007