Morton's Neuroma vs Metatarsalgia vs Metatarsal Stress Fracture: Forefoot Pain Diagnosis
Lower Limb · 7 min read · 2026-04-18
The Forefoot Pain Triad
Forefoot pain is one of the most frequently misdiagnosed complaints in primary care. Three conditions account for the majority of presentations: Morton's neuroma, mechanical metatarsalgia, and metatarsal stress fracture. Each has a unique anatomical fingerprint.
Morton's Neuroma
Despite the name, Morton's neuroma is not a true neuroma — it is a perineural fibrosis of the common plantar digital nerve, most often in the third intermetatarsal space (between the third and fourth metatarsals).
Pain pattern: burning, electric, or "walking on a pebble" sensation between the third and fourth toes. Often radiates into the toes. Worse with tight footwear and high heels.
Key exam findings:
- Mulder's click: squeezing the forefoot transversely while pressing the affected web space produces an audible or palpable click with pain reproduction — pathognomonic
- Tenderness localised to the web space, not the metatarsal heads
- Sensory disturbance in the affected toes
- No bony tenderness
Metatarsalgia
A mechanical overload syndrome of the metatarsal heads, often from foot deformity (claw toes, hallux valgus), high-impact activity, or footwear with inadequate cushioning.
Pain pattern: aching or burning under the plantar metatarsal heads (commonly the second and third). Worse with weight-bearing, relieved by rest.
Key exam findings:
- Tenderness directly under the metatarsal heads on the plantar surface
- Calluses under the affected heads
- No web space tenderness
- Negative Mulder's click
- Often associated with foot deformity
Metatarsal Stress Fracture
A microscopic cortical fracture from repetitive loading. Classically the second metatarsal shaft ("march fracture"), but the fifth metatarsal base is a notable danger zone (Jones fracture).
Pain pattern: gradual onset of dorsal forefoot pain in a runner, dancer, or military recruit. Worsens through activity and may be present at rest in late stages.
Key exam findings:
- Point tenderness over the metatarsal SHAFT, not the head
- Tuning fork test: vibration applied to the bone reproduces pain
- Localised swelling on the dorsum of the foot
- Antalgic gait
- Plain X-ray often negative for the first 2–3 weeks; MRI or bone scan confirms
The Differentiating Algorithm
The Three-Finger Test
Use three fingers to localise the pain in any forefoot complaint:
- Web space between the third and fourth toes → Morton's neuroma
- Plantar surface of a metatarsal head → metatarsalgia
- Dorsal shaft of a metatarsal → stress fracture
This single sequence, performed in 20 seconds, will correctly direct most forefoot diagnoses.
Common Pitfall
A jogger with forefoot pain and a "negative X-ray" is often sent home with a metatarsalgia diagnosis. Stress fractures are radiographically silent for the first two to three weeks. If the history fits and the bone is point-tender, treat as a stress fracture and re-image at three weeks or order MRI.
Clinical Pearl
A fifth metatarsal base fracture is not a benign injury. The proximal diaphyseal "Jones fracture" zone has a tenuous blood supply and is prone to non-union. These often require surgical fixation in athletes — never dismiss a tender fifth metatarsal base as a "simple sprain."
Summary
Web-space click = Morton's neuroma. Plantar metatarsal head pain = metatarsalgia. Dorsal shaft tenderness with positive tuning fork = stress fracture. Three locations, three tests, three diagnoses.