What is the best course of treatment for a 27-year-old female with intermittent, stabbing foot pain near the toes, exacerbated by exercise or pressure, with normal X-ray results and non-tender physical examination, and a history of pain for five years?

Chronic Intermittent Forefoot Pain in a Young Female

This patient most likely has Morton's neuroma or metatarsalgia with possible plantar plate pathology, and should undergo MRI of the foot without contrast as the next diagnostic step, followed by conservative management including proper footwear, metatarsal pads, and NSAIDs, with referral to a foot specialist if symptoms persist beyond 6-8 weeks. 1, 2, 3

Diagnostic Approach

Most Likely Diagnoses

The clinical presentation—intermittent stabbing pain at the forefoot near the toes, exacerbated by exercise and pressure, with normal radiographs and non-tender examination between episodes—strongly suggests:

• Morton's neuroma (interdigital neuroma): The 5-year history of intermittent stabbing pain with exercise is classic for nerve entrapment between metatarsal heads 4
• Metatarsalgia with plantar plate injury: Chronic forefoot pain worsened by weight-bearing and pressure can indicate plantar plate pathology, which frequently coexists with or mimics neuroma 1, 4
• Stress fracture of metatarsals: The exercise-related pain and need for assistive device raises concern for occult metatarsal stress fracture, though the intermittent nature makes this less likely 1, 3

Key Clinical Clues

The non-tender examination between pain episodes is critical—this suggests the pathology is intermittent compression-related (neuroma) rather than constant inflammatory or structural damage 4. The stabbing quality specifically points toward neurogenic pain 3.

Recommended Imaging

MRI foot without IV contrast is the most appropriate next imaging study after negative radiographs in this clinical scenario 1. The ACR Appropriateness Criteria specifically recommend MRI for chronic forefoot pain when clinical concern includes Morton's neuroma, intermetatarsal bursitis, or chronic plantar plate injury 1.

Alternative considerations:

• High-resolution ultrasound is also appropriate and can differentiate neuroma from plantar plate pathology in experienced hands 1, 4
• MRI is superior to ultrasound for detecting occult metatarsal stress fractures if that remains a concern 1

Contrast is not routinely needed for these diagnoses 1.

Initial Conservative Management

First-Line Treatment (0-6 weeks)

• Footwear modification: Wide toe-box shoes with adequate cushioning; avoid high heels and narrow shoes that compress the forefoot 2, 5
• Metatarsal pads or arch supports: Over-the-counter orthotics to redistribute pressure away from metatarsal heads 2, 5
• NSAIDs: Oral ibuprofen or naproxen for pain relief and anti-inflammatory effect 2, 5, 3
• Activity modification: Reduce high-impact activities temporarily, but avoid complete immobilization to prevent deconditioning 2, 5
• Ice therapy: Apply through wet towel for 10-minute periods after activities 5

If No Improvement After 6-8 Weeks

• Refer to podiatric foot and ankle surgeon or foot specialist 2, 6, 3
• Consider custom orthotics with specific metatarsal support 5, 6
• Corticosteroid injection: May be appropriate for confirmed neuroma or bursitis, but carries risk of plantar plate rupture with repeated injections 4

Advanced Treatment Options (After 2-3 Months)

• Surgical neurectomy for confirmed Morton's neuroma refractory to conservative care 4
• Plantar plate repair if imaging confirms rupture 4

Critical Pitfalls to Avoid

• Do not assume neuroma is the sole cause: Forefoot pain is frequently misattributed to Morton's neuroma when plantar plate pathology is actually responsible 4
• Avoid corticosteroid injections without imaging confirmation: Injections can cause or worsen plantar plate rupture if the diagnosis is incorrect 4
• Do not overlook stress fracture: The 5-year duration makes this less likely, but the exercise-related pattern and need for walking stick warrant consideration, especially given stress fractures can be radiographically occult initially 1, 6, 3
• Recognize examination limitations: The non-tender examination between episodes does not rule out significant pathology—this is characteristic of intermittent compression syndromes 4

When to Escalate Care Urgently

While this presentation is not emergent, refer immediately if:

• Pain becomes constant at rest (suggests infection or severe structural damage) 5
• Numbness or progressive neurological symptoms develop (suggests worsening nerve compression) 5, 3
• Increasing swelling or redness appears (suggests infection) 5

Expected Timeline

Most patients with forefoot pain respond to conservative treatment within 6-8 weeks if the diagnosis is correct and treatment is appropriate 2, 6. The 5-year duration suggests either inadequate prior treatment or an incorrect diagnosis, making imaging essential before proceeding further 1.