Who to refer

Refer if no improvement after 3 months of conservative treatment.

How to refer

SCI Gateway/Orthopaedics/Foot and Ankle Service.
Referral will be vetted by an AHP and directed to most appropriate professional.

Information to include when referring

  • Duration and cause of symptoms.
  • Site/spread of pain, constant/intermittent, sleep disturbance.
  • Indicate ROM, effect on walking, work/hobbies/sports.
  • Include treatment to date (injections).

 

Symptoms and signs

  • Paroxysmal neuralgia affecting web spaces and toes (most common at toes 2,3,4).
  • Pain and/ or 'click' on Mulder's test (transverse pressure to metatarsal heads whilst palpating the symptomatic inter-metatarsal space).
  • Mainly a clinical diagnosis and further investigations are done as indicated.

Initial Management

  • Provide with patient information leaflet to support self-management.
  • Advice re footwear (avoid high heels and narrow toe box shoes).
  • Analgesia & NSAIDs as appropriate.
  • Steroid injection if appropriately trained.

Primary Care diagnostics

  • Consider ultrasound scan to confirm diagnosis if necessary
  • Consider arranging an X-ray to exclude other pathology, such as fracture or arthropathy.
  • Consider checking full blood count, erythrocyte sedimentation rate, and uric acid to exclude conditions such as osteomyelitis, gout, and inflammatory arthritis.

Useful resources

Editorial Information

Next review date: 11/07/2026