...many of the differentials dx mentioned by you and angryorthopod are relatively easy to rule out. Avascular necrosis, synovitis, capsulitis, plantar plate tear, etc have their own unique symptoms and are often seen on an MRI. I'm not even sure how you can mis-diagnosis a plantar plate tear as a neuroma if you're doing a proper exam.
Proper exam??? Hey, that takes time... a lot depends on how many patients you see per day. There are only so many lunch breaks in a day. What is next, gait exams and tuning fork, two foot heel raise, systematic exams, Babinski, I have to spend more than a min with nail pts?
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I am not saying that you personally can't make the dx... but many people cannot seem to figure out metatarsalgia. For example I had a poor old man yesterday who was injected a "series" for what is clearly HAV with bad 2nd plantar plate... he has an ecchymotic callus very near ulcer sub 2nd and was getting INJECTS for it, by someone near me who is F&A cert (old doc) but I had thought until then that they were good... trained at a good name program (multiple ACFAS president alumni). Forefoot pain has more pitfalls than rearfoot sometimes... mainly because any and all podiatrists think they can handle everything skin or osseous if it's distal to midtarsal. I have taken out more than a couple completely normal looking "neuroma" nerves (plantar longitudinal as I said... very good visualization) that arrived to me with the "neuroma" idea from another doc, had undergone prior neuroma surgery or multiple dorsal with that doc, had developed nerve pain (scar tissue in interspace from surgery or swing and miss on the "excision"? both?) and had they undoubtedly had who knows how many "neuroma" injects, orthotic, paddings, sclerosing etc for neuromas. I almost wonder if they just had forefoot overload and all the treatments caused most of the nerve pain (for the nerve they still didn't excise when attempted). No joke. They are not usually fun patients
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I don't even know what MRI stands for unless it's a tumor or OCD or something where it's truly needed. I am in private practice now and it's the beginning of the calendar year, so MRIs are a waste of my time to fiddle with a CD and a good way to lose the patient when MRI hits their deductible. It is all about the xray and ultrasound... me thinks MRIs are more for hospital folk to keep their admins happy or orthos who own a share in a rad center?
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...I realize Morton neuromas exist, I just think they are way over-diagnosed, esp by DPMs... mostly the TFP subset. The neuroma pathology might be 25% of forefoot pain dx made and also seems to be a large amount from pt's Google self-dx... yet they are only the actually correct answer for <5% metatarsalgia symptoms in actuality (equinus, parabola, capsulitis/PDS, stress fx, AVN, etc etc as was said). I really don't think the whole "practice management" wave of alcohol sclerosing injections paying very well, being the talk of all APMA meetings in the late 90s and early 2000s, and those injects needing to be done in a series of 4 or 6 or whatever (E&M and a $200 inject each time) helped the "incidence" Morton neuroma go down either. Again, they exist... but they exist 10x the actual rate if you ask TFPs.
That is what Kenneth Johnson's "The Foot Surgery Cripple" (Roger Mann's predecessor/colleague) was talking and writing about: neuroma surgery more than anything... we said it was "basing podiatry," but from their perspective, they often saw the results of ridiculous surgery that was probably never necessary. I tried to post the text chapter version here but the image is too big to attach. Regardless, leave it to podiatry to find codes from another specialty, suddenly find a bunch of that dx to use it on, and hammer the CPT until it breaks (sclerosing now pay what a steroid shot does, not 3x the rate anymore, and mysteriously nobody really uses sclerosing anymore). Sclerosing injects were probably even more over-used than arthroeresis or EPF or nigh splints, if that's possible. It just makes us look like chiro and the way everyone has slight scoliosis and needs adjustments or has some deficiency and needs vitamins. And sure, it happens with every aspect of medicine (probably sleep apnea, gluten sensitivity, etc etc). It is still not a good look, though.
Now, of those that are truly correct dx neuroma, I agree with all above: vast majority do fine with just met pads etc (PowerSteps with met pad for life), occasional inject more for dx moreso than tx in my hands, and the neuroma excis surgery +/- gastroc or Weil etc in the 2% whom met pads and equinus tx and maybe inject doesn't work too great. Still, the
best case for neuroma excis is numb webspace but not painful, as you said... I just don't think that's a great outcome, so I delay or avoid it awhile, jmo. I definitely think that if I'm doing more than a handful of neuroma surgeries per year even as a pretty busy DPM seeing a whole lot of patients, then I'm doing something wrong... same for even much more common plantar fasciitis surgical fascia releases (another thing where half decent conservative makes surgery rare... but that procedure actually works consistently well, doesn't make the sole of foot numb or cause cavus foot,. lol).
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