What causes pain between the great and second toe on the sole with pressure?

Pain Between Great and Second Toe on Sole with Pressure

The most likely diagnosis is Morton's neuroma (intermetatarsal neuroma), which typically presents as pain in the intermetatarsal space between toes with pressure, though you must also rule out metatarsophalangeal joint instability, metatarsalgia, and stress fracture through systematic examination.

Primary Differential Diagnoses

Morton's Neuroma (Most Likely)

• Presents as pain in the intermetatarsal space (typically third or second) with pressure or weight-bearing 1
• Not a true neuroma but fibrosis of the digital nerve caused by repetitive pressure or irritation 1
• Pain is reproduced with direct pressure over the affected intermetatarsal space 1

Metatarsophalangeal Joint Instability

• Vertical stress test reproduces pain while demonstrating joint instability—this is the most prominent physical finding 2
• Often associated with plantar plate rupture at the second MTP joint 2
• Patients describe pain with push-off and forward drive activities 3, 2

Metatarsalgia

• Diffuse pain under metatarsal heads with weight-bearing 4
• Pain localizes to the plantar surface beneath the metatarsal heads rather than between toes 4

Stress Fracture (Metatarsal)

• Progressively worsening pain following increased activity or change to harder walking surface 5
• Point tenderness directly over the metatarsal shaft or neck 4
• Symptoms often precede radiographic findings 5

Critical Examination Findings

Palpation Points

• Direct pressure between the metatarsal heads (intermetatarsal space) reproduces pain in Morton's neuroma 1
• Palpate each metatarsal head individually for focal tenderness suggesting metatarsalgia or stress fracture 4
• Perform vertical stress test on MTP joints: grasp the toe and apply vertical stress while stabilizing the metatarsal—reproduction of pain indicates joint instability 2

Functional Tests

• Assess pain with toe push-off and forward drive (suggests MTP joint pathology or plantar plate injury) 3, 2
• Evaluate for loss of dorsiflexion at the MTP joint (indicates chronic joint injury) 3
• Check for visible toe malalignment or drift (suggests chronic instability) 2

Weight-Bearing Assessment

• Pain worse with shoes versus barefoot suggests Morton's neuroma or metatarsalgia 4
• Pain with direct pressure on the sole between toes is pathognomonic for intermetatarsal pathology 1

Diagnostic Algorithm

Initial Imaging

• Weight-bearing radiographs of the foot are the initial imaging study 5
• Look for metatarsal fractures, Freiberg infraction, or structural abnormalities 4
• Radiographs may be negative initially in stress fractures 5

Advanced Imaging (If Initial Radiographs Negative)

• MRI without contrast if pain persists >1 week with negative radiographs 5
• MRI can identify Morton's neuroma, plantar plate tears, stress fractures, and soft tissue pathology 4
• Ultrasound can visualize Morton's neuroma but is operator-dependent 4

Treatment Approach

Conservative Management (First-Line for All Diagnoses)

For Morton's Neuroma:

• Orthotics with metatarsal pads to redistribute pressure away from the intermetatarsal space 1
• Wider toe-box shoes to reduce compression 1
• Corticosteroid injections into the intermetatarsal space 1
• NSAIDs for pain and inflammation 6

For MTP Joint Instability:

• Taping to stabilize the joint 3
• Shoe wear modification with rigid sole to limit MTP motion 3
• NSAIDs and ice therapy 3
• Toe strengthening program once acute pain subsides 3

For Metatarsalgia:

• Pressure redistribution with cushioning and custom insoles 7
• Metatarsal pads positioned proximal to metatarsal heads 4
• Activity modification and proper footwear with adequate width and depth 7

For Stress Fracture:

• Protect and immobilize the foot with cast or fixed-ankle walker 6
• Strict activity modification until healing confirmed 5
• Gradual return to activity after 6-8 weeks 5

Timeframe for Conservative Treatment

• Implement all first-line treatments and monitor for 6-8 weeks 6
• Most patients respond to conservative treatment within this timeframe 6

Surgical Referral Indications

• No improvement after 6-8 weeks of appropriate conservative treatment 5, 6
• Persistent instability of MTP joint despite conservative measures 2
• For Morton's neuroma: surgical excision through dorsal approach if conservative measures fail 1
• For MTP instability: flexor digitorum longus transfer to stabilize the joint 2

Critical Pitfalls to Avoid

Examination Errors

• Do not overlook the vertical stress test for MTP joint instability—this is the most sensitive clinical finding 2
• Excessive swelling within 48 hours of injury can limit examination; always reexamine 3-5 days post-injury 5
• Point tenderness location is critical: between metatarsals suggests neuroma, over metatarsal head suggests metatarsalgia or fracture 5, 1

Treatment Errors

• Never inject corticosteroids near tendons due to rupture risk 5, 6
• Avoid complete immobilization for non-fracture diagnoses to prevent muscle atrophy 6
• Do not assume isolated plantar fasciitis when pain is localized between toes 5

Diagnostic Errors

• Symptoms of stress fracture often precede radiographic findings—use MRI or bone scan if clinical suspicion is high despite negative X-rays 5
• Do not diagnose based on imaging alone; combine symptoms, clinical signs, and imaging findings 8
• Consider systemic causes (arthritides, infections) when symptoms are bilateral or unexplained by mechanical causes 5, 8