Intermetatarsal Bursitis Treatment – The Forefoot Pain Often Mistaken for Morton’s Neuroma

At The Barn Clinic we specialise in the assessment and treatment of forefoot nerve and soft-tissue pain. One of the most common — and most frequently misdiagnosed — causes of pain in the ball of the foot is intermetatarsal bursitis. Many patients come to us having been told they have a Morton’s neuroma, when careful imaging shows that the real problem is an inflamed intermetatarsal bursa, or the two together.

What Is Intermetatarsal Bursitis?

The intermetatarsal bursae are small, fluid-filled sacs that sit between the long bones of the forefoot and act as buffers, cushioning the soft tissues against the pressure and shear generated with every step. Under sustained mechanical overload — narrow or heel-elevated footwear, high-impact activity, or an abnormal foot posture — a bursa can become inflamed, and then thickened and fibrotic.

As it enlarges, the bursa can press on the adjacent plantar digital nerve. That compression can irritate the nerve and, over time, contribute to the thickening recognised as a Morton’s neuroma. This is why the two conditions so often occur together, and why telling them apart matters.

Key points

Intermetatarsal bursitis is a common cause of pain in the ball of the foot.
Its symptoms closely mimic those of a Morton’s neuroma.
It frequently coexists with a neuroma — the neuroma–bursa complex.
It is most reliably identified with dynamic, high-resolution ultrasound.

Why Forefoot Pain Is So Often Mistaken for Morton’s Neuroma

Pain in the ball of the foot is routinely labelled “Morton’s neuroma” before the underlying cause has been confirmed on imaging — and the evidence suggests that label is often wrong. In a prospective study of patients with intermetatarsal pain, Larsen et al. (2025) found that around 54% had intermetatarsal bursitis on MRI, compared with around 19% who had a Morton’s neuroma. Earlier sonographic work by Iagnocco et al. (2001) similarly found bursitis to be the most common finding in patients with metatarsalgia.

These findings can also be present in people with no symptoms at all. In 70 asymptomatic volunteers, Zanetti et al. (1997) found fluid in the intermetatarsal bursae in up to half of forefeet, and presumed neuromas in around a third — a reminder that an imaging finding only matters when it correlates with the clinical picture.

Because an inflamed bursa and a neuroma can produce near-identical symptoms — burning, tingling and the sensation of “walking on a pebble” — the two are very difficult to separate on clinical examination alone. This is why accurate diagnosis is the foundation of everything that follows.

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Intermetatarsal bursitis · part 1

Intermetatarsal Bursitis and Morton's Neuroma: Telling Them Apart

What the intermetatarsal bursa does, how chronic bursitis can lead to a Morton's neuroma, and why the two are so often confused.

What the intermetatarsal bursa does. Bursas are small sacs of synovial fluid sitting around joints and between the structures of the forefoot that act as lubricating mechanical buffers.
Bursitis as a precursor to Morton's neuroma. When a forefoot bursa becomes chronically inflamed, fibrotic and enlarged, it presses on the adjacent plantar nerve — causing nerve compression, thickening and fibrosis that leads to a Morton's neuroma.
High rate of co-existence and misdiagnosis. Around 40% to 50% of patients presenting with Morton's neuroma have co-existing bursopathy. Imaging studies show that only around 20% of patients who think they have a neuroma actually have one on scan — the remaining 80% have other causes, most frequently intermetatarsal bursitis.
Why clinical separation is difficult. Because an inflamed bursa compressing the nerve generates identical symptoms to a Morton's neuroma, diagnostic ultrasound imaging is essential to separate the two.

Read the full transcript

Hi, I'm Robin. I'm on holiday, I'm here with my lovely wife Clare, and before I have my first beer, I'm going to talk to you about intermetatarsal bursitis. Bursas: what are they, what do they do, why do they become a problem, and more importantly, what can you do to fix them?

So bursas are little sacs of fluid that you find, typically around joints, and they are buffers. Bursas contain synovial fluid, which keeps everything lubricated. Commonly you find bursas in the knee, in the hip, and in the elbow — they're very common places to find bursas — and you also get them in the forefoot, because you've got a lot of structures in the forefoot that have the potential to rub against each other. So bursas form a buffering function; that's what they do.

Can they become a problem in themselves? Yes, they can, because the bursas themselves can actually become inflamed, fibrotic, and enlarged. And when they become very enlarged, inflamed, and fibrotic, they press on the nerve. When they press on the nerve, that causes compression, which causes the nerve in turn to change: the nerve thickens up, becomes fibrotic itself, and then you have a neuroma. So many people think that bursitis is actually a precursor to Morton's neuroma, and that does make sense.

In terms of what I see in my day-to-day practice in the clinic, the majority of patients who present with Morton's neuroma actually do have co-existing bursopathy. It's estimated that about 40% to 50% of patients with Morton's neuroma have co-existing bursopathy.

There are various studies that bear that out about bursopathy and its frequency. Most patients that think they've got a neuroma actually have bursitis. Only about 20% of patients that think they have a neuroma, when they get investigated with imaging, actually have a neuroma. The other 80-odd percent of patients have other causes, and one of the most frequent causes is bursopathy, or bursitis.

Morton's neuroma and bursopathy are very hard to distinguish clinically because they both generate the same symptoms. That inflamed sac of fluid bears down on the nerve and compresses it. And if the nerve is being compressed, that actually generates identical symptoms to Morton's neuroma — it mimics Morton's neuroma. So clinically, it can be hard to separate the two.

The Neuroma–Bursa Complex

In many patients the bursa and the nerve are not separate problems but a single one. A thickened, fibrotic bursa can envelop and compress the plantar digital nerve, and some authors regard bursitis as a contributing factor in the development of a Morton’s neuroma (Larsen et al., 2023). In our clinical experience, a large proportion of patients with a confirmed neuroma also have a co-existing bursopathy sitting alongside it. Where that is the case, treatment needs to address both elements of the complex, not the nerve alone.

Diagram of the neuroma–bursa complex in the forefoot

Symptoms

The symptoms of intermetatarsal bursitis overlap closely with those of a Morton’s neuroma, and may include:

a burning, tingling or shooting pain in the ball of the foot
the sensation of walking on a pebble or a bunched-up sock
pain that is worse in tight or heeled shoes and eases when the shoe is removed
numbness or altered sensation in the adjacent toes
spreading of the toes in longer-standing cases

Diagnosis

Accurate diagnosis is the single most important step, because it determines which structure is treated.

Clinical assessment. Your consultation begins with a detailed history and a hands-on examination of the forefoot, to localise the pain and reproduce the symptoms.

Dynamic ultrasound. Assessment at The Barn Clinic is built around dynamic, high-resolution musculoskeletal ultrasound, performed in the clinic and in real time by the treating specialist. Scanning the forefoot under load allows the bursa and the nerve to be assessed as separate structures, so that treatment can be directed at the true source of pain rather than an assumption.

Conservative Treatment

Because intermetatarsal bursitis is driven by mechanical overload, the first step is usually to reduce the forces acting on the forefoot.

Footwear is often the most important change. A wider toe box removes the side-to-side compression that squeezes the metatarsals together, while a flatter, “zero-drop” shoe — where the heel sits level with the forefoot — shifts load away from the ball of the foot. Where foot posture is a factor, such as excessive pronation or a high-arched foot, custom orthoses can help control alignment and offload the affected interspace.

If symptoms persist, a corticosteroid injection may be offered, and it can give useful short-term relief. We discuss it carefully, however, because an injection into the ball of the foot can thin the protective plantar fat pad, and some patients lose a meaningful proportion of that cushioning — which does not regenerate. Thinning the tissue that shields the forefoot can, in some cases, compound the problem rather than resolve it.

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Intermetatarsal bursitis · part 2

Footwear, Orthotics, and the Risks of Steroid Injections

The mechanical changes that take pressure off the forefoot, where orthotics help, and the long-term drawback of corticosteroid injections.

Addressing mechanical overload via footwear. Narrow shoes and elevated heels throw weight forward onto the ball of the foot. Raising the heel reduces forefoot contact area and shifts load medially beneath the first metatarsal head, increasing pressure there even though total forefoot load is unchanged (Corrigan et al., Foot Ankle 1993). At dress-heel heights the effect is large: going from a 2 cm to a 6 cm heel raised peak pressure under the central metatarsals by 30%, and the pressure-time integral by 48% (Speksnijder et al., The Foot 2005, ten women). Conventional trainers sit far lower, at roughly an 8 to 12 mm heel-to-toe drop, but the direction of effect is the same; zero-drop shoes, where the heel sits level with the ball of the foot, remove it.
Correcting biomechanics with orthotics. Both excessive pronation (feet turning in) and supination (high arches) predispose patients to bursitis and can be addressed with orthotics inside the shoes.
The drawbacks of steroid injections. While corticosteroid injections offer an immediate anti-inflammatory effect, a single steroid injection can cause patients to lose up to 20% of their protective plantar fat pad volume — a loss that does not grow back in the ball of the foot and compounds mechanical pain.

Read the full transcript

First of all, I say to my patients, if you've got bursitis, we need to think about what might be causing it in the first place. So, if there's an obvious candidate — if your shoes are just too small, too narrow, or if you've got a high heel that's throwing all your weight forward onto the ball of your foot — I'd say just address those issues first of all.

And then, if your bursitis is related more to activity, maybe think about appropriate footwear for that activity. Commonly, zero-drop shoes are used. Zero-drop shoes, if you're not familiar with them, are trainers where the heel sits at the same level as the ball of the foot.

If that doesn't work, or it's too far gone, I think the next step along would be orthotics. If you've got a mechanical imbalance in your foot — if your feet are pronated and turn excessively in, or if, on the other hand, you've got very high arches — both being pronated and supinated is a predisposing factor for the development of bursitis. So if you've got any of those factors in play, deal with those, typically with orthotics that you have inside your shoes.

If you've tried all of that and you're still suffering with bursitis, then what do you do? The NHS typically would offer you steroid injections into and around the bursa. Steroid injections can be very helpful for certain patients; they can offer an immediate anti-inflammatory effect.

However, a common problem that I see with steroid injections is that they can be associated with loss of fat tissue at the site of the injection. If you lose your protective fat tissue in the ball of the foot, it just compounds the problem. Unfortunately, the ball of the foot is the one place that you don't get fat tissue back. It's an irony that as we get older, we tend to develop fat tissue around our abdomen and all over the place, but the one place where you need some fat tissue is the one place where you lose it as you get older. Some people can lose up to 20% of their protective fat tissue volume from a single steroid injection. For that reason, I'm not very keen on steroid injections — but there is a place for them.

Cryosurgery for Intermetatarsal Bursitis

When symptoms persist despite sound conservative care, ultrasound-guided cryosurgery (percutaneous cryoablation) offers a minimally invasive alternative to open surgery. At The Barn Clinic the procedure is performed under local anaesthetic, in clinic, using real-time ultrasound to guide a fine cryoprobe to the affected interspace.

Because the nerve and the enveloping bursa are visualised and treated together, a single controlled freeze can address both halves of the neuroma–bursa complex at once. Where a neuroma is present, we frequently find it is being compressed by the surrounding bursa — so treating the bursa is an essential part of treating the nerve. We have performed ultrasound-guided cryosurgery for forefoot nerve and bursal pain since 2009, and in our clinical experience it has proven a safe and effective option, with complications being uncommon.

Unlike neurectomy (surgical removal of the nerve) or heat-based ablation, cryosurgery is designed to be nerve-sparing. It is intended to settle the inflamed tissue while preserving the nerve’s own protective sheath, which avoids the permanent numbness and the risk of a painful “stump neuroma” associated with cutting a nerve out.

How Cryosurgery Works

As currently understood, cryosurgery appears to act in three complementary ways:

Nerve remodelling. A carefully dosed freeze causes a localised, temporary breakdown of the nerve, known as Wallerian degeneration, after which the nerve can regenerate in a more organised, less pain-prone way.
Scar remodelling. Cryosurgery is a long-established treatment for scar tissue — it has been used for many years on hypertrophic and keloid scars, where it remodels disorganised collagen (Har-Shai et al., 2003; 2008). A similar principle applies to the fibrotic tissue within a chronic neuroma–bursa complex.
Reducing inflammation. It dampens the inflammation in and around the nerve and bursa, which is why follow-up imaging often shows the bursa settling back towards a normal appearance.

Diagram of how cryosurgery works: nerve remodelling, scar remodelling and reduced inflammation

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Intermetatarsal bursitis · part 3

Ultrasound-Guided Cryosurgery as a Restorative Treatment

How cryosurgery treats the thickened nerve and the inflamed bursa together, and what the follow-up imaging shows.

Simultaneous resolution of neuroma and bursitis. Under ultrasound guidance the bursa is frequently seen enveloping and strangling the nerve. Addressing both the Morton's neuroma and the bursitis simultaneously with cryosurgery clears up both conditions at six-month follow-up imaging.
A safety track record since 2009. Performed in clinic since 2009, ultrasound-guided cryosurgery for Morton's neuroma and bursopathy has a strong safety profile, with complications very few and far between.
Restorative rather than destructive. Unlike excision surgery, alcohol injections or radiofrequency — which cause permanent, irreversible changes to the nerve on imaging — cryosurgery is restorative and rejuvenative, with both the nerve and the bursa reverting towards a normal healthy appearance on follow-up scans without negative scarring.

Read the full transcript

When it comes to Morton's neuroma and bursopathy — because the two do go hand in hand — and the treatments thereof, I think the most successful treatment by a long, long way is cryosurgery. And that's borne out by the imaging that we do with patients when we see them back for follow-up.

When we see cryosurgery patients in clinic six months down the line and we look at them on ultrasound, not only do we see, thankfully, that they've got no neuroma symptoms and no presence of the neuroma, but we also see that the bursa has cleared up. So the whole environment in the forefoot that used to contain the neuroma and the bursitis is a completely different situation when we revisit six months later. The bursopathy has gone, as has the neuroma, and patients are back again doing the kind of things that they used to do before.

When we treat a Morton's neuroma with cryosurgery, we're guiding a cryoprobe onto the neuroma, and we frequently see that the neuroma is strangled by the bursa — the bursa has actually enveloped the nerve. So by virtue of treating one, we treat the other. When we treat the Morton's neuroma, we have to address the bursitis with the cryosurgery; otherwise, the treatment doesn't work anywhere near as well.

I actually think that cryosurgery for Morton's neuroma and bursopathy is incredibly safe. I've been doing it now since about 2009, and thankfully, complications are very few and far between. Cryosurgery for bursopathy seems extremely effective. When we revisit those patients and look at them on imaging, we find typically that the whole of the area has improved. The bursa frequently has just gone back to normal — it contains a normal amount of fluid — and that pre-existing inflammation and the whole 'angry' state of the bursa has completely changed and reverted back to a normal appearance. So I think it's almost unique.

Cryosurgery for Morton's neuroma has an incredible feature that not many people actually think about or are aware of. The most striking feature, I think, of cryosurgery is that it reverts the nerve back to normal. I can't think of any other treatments that revert the nerve back to normal; it's restorative and it's rejuvenative. If you look at patients that have had cryosurgery and have had a positive outcome, you see a normal-looking, healthy nerve on imaging. I can't think of any other treatment modality that actually facilitates that.

All the other treatments for Morton's neuroma that I can think of — surgery, alcohol injections, radiofrequency, et cetera — all cause permanent, irreversible change to the nerve that can be detected on imaging. Whereas after cryosurgery, you see a restoration of what would be there normally, and it doesn't seem to cause any negative scarring or side effects. So I've found it to be a very helpful, reliable, safe, effective treatment over the years.

Outcomes

When we review patients for follow-up imaging around six months after treatment, we often see the bursa settled to a normal amount of fluid and the inflammation resolved, alongside an improvement in the appearance of the nerve. Many patients treated with cryosurgery experience a significant improvement in symptoms. Our own internal audit of follow-up cases is consistent with the published evidence.

Specialist Assessment

If you have persistent pain in the ball of the foot — or you have been told you have a Morton’s neuroma but treatment has not helped — an accurate diagnosis is the essential first step. At The Barn Clinic in Sheffield and on Harley Street in London, your assessment includes dynamic, in-clinic ultrasound performed by the treating specialist, so that the true cause of your pain is identified and the right treatment matched to it from the outset.

FAQ – Intermetatarsal Bursitis

- Is intermetatarsal bursitis the same as a Morton’s neuroma?

No, but the two are closely related and often occur together. A bursa is an inflamed sac of fluid; a neuroma is a thickened nerve. Because they cause very similar symptoms, they are easily confused, and imaging is needed to tell them apart.

+ How is it diagnosed?

Through clinical examination and dynamic, high-resolution ultrasound performed in clinic, which allows the bursa and nerve to be assessed separately.

+ Will a steroid injection cure it?

A steroid injection can help in the short term, but we weigh it carefully, as injections into the ball of the foot can thin the protective fat pad. It is one option among several, not an automatic first choice.

+ Can cryosurgery treat a neuroma and bursitis at the same time?

Yes. Because the probe treats the affected interspace under ultrasound guidance, a single controlled freeze can address both the nerve and the surrounding bursa together.

+ Is the treatment done in hospital?

No. Cryosurgery is carried out in clinic, under local anaesthetic, as a day procedure.

References

Larsen SB, et al. Morton’s Neuroma or Intermetatarsal Bursitis — A Prospective Diagnostic Study of Intermetatarsal Pain. Diagnostics (Basel). 2025;15(11):1339. doi:10.3390/diagnostics15111339
Larsen SB, et al. Diagnostic Considerations of Intermetatarsal Bursitis: A Systematic Review. Diagnostics (Basel). 2023;13(2):211. doi:10.3390/diagnostics13020211
Zanetti M, et al. Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers. Radiology. 1997;203(2):516–20. PubMed
Iagnocco A, et al. Sonography in the study of metatarsalgia. J Rheumatol. 2001;28(6):1338–40. PubMed
Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg. 2003;111(6):1841–52. doi.org/10.1097/01.PRS.0000056868.42679.05
Har-Shai Y, Brown W, Labbé D, et al. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids following aesthetic surgery: a prospective observational study. Int J Low Extrem Wounds. 2008;7(3):169–75. doi.org/10.1177/1534734608322813

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