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FOOTWEAR It won't come as a surprise that high- heeled shoes are a major contributor to the biomechanical forces that lead to Morton's neuroma. Wearers of high heels with a narrow toe box are especially prone to this disorder. This probably explains why women are affected nearly five times more frequently than men. But even flat shoes can create a problem if they offer inadequate protection of the metatarsal heads. Worn-down shoes with flattened padding can be as potent a contributor to perineal fibrosis as spike heels. SYMPTOMS, DIAGNOSIS The signs and symptoms of Morton's neuroma are easy to predict, because nerve irritation creates a characteristic shooting, electrical sensation that travels distally. Consequently, if the nerves between the metatarsals are sufficiently irritated, they send a jolt of pain distally to the toes. Long- term irritation may lead to tingling or numbness in the same location. This almost always happens between the 3rd and 4th metatarsals, but it can also happen at the space between the 2nd and 3rd metatarsal. It almost never happens outside this range: pain from far medial or lateral metatarsals must be investigated as something other than Morton's neuroma. A clinical exam for this condition may aim to recreate the pain associated with this condition. Many clinicians also look for a characteristic sound ("Mulder's click") when the metatarsals are compressed. Mulder's click can occur without nerve irritation, however, so it is not in itself a definitive diagnostic marker. If a clinical exam is inconclusive, an MRI or ultrasound might be recommended, but these tests are often unnecessary. Unfortunately, a host of other foot problems can both mimic and occur simultaneously with Morton's neuroma. In order to create the visit massageandbodywork.com to access your digital magazine 113 best possible treatment strategy, these conditions must be either ruled out or identified, along with thickening of the perineurium. A short list of the possibilities for differential diagnosis includes: Tarsal Tunnel Syndrome This is compression or irritation of the tibial nerve as it passes on the medial ankle under the retinaculum ligament. This can occasionally refer pain specifically to the toes. Stress Fractures Tiny hairline fractures of the metatarsals, sometimes called march fractures, can create pain in the distal foot. These can be difficult to see on an X-ray and may need more intrusive testing to definitively identify. Metatarsalgia This is a general name for pain at the ball of the foot. It is often traced to overuse and worn-down footwear. It usually affects more of the foot than Morton's neuroma, and the pain tends to be achy and superficial rather than deep and electric. Osteoarthritis, Rheumatoid Arthritis These conditions involve joint inflammation, but no specific nerve irritation. Hammertoe In this situation, an imbalance in the muscles of the toes creates permanent flexion at the interphalangeal joints. It is most common in the same toes affected by Morton's neuroma and may occur simultaneously with it.