1. History: This may include any of the following:
   1. An evaluation of the chief complaint (including the nature, location, duration, onset, course, anything that improves or exacerbates, and any previous treatment).
   2. The past medical history (including allergies, medications, medical history, surgical history, family history, and social history).
2. Physical examination may include:
   1. Peripheral vascular
   2. Neurological (are sensorium in the area intact or altered?)
   3. Orthopedic
   1. Palpation may produce:
      1. A palpable "click" (Mulder's sign)
      2. Pain/symptoms via lateral pressure
      3. Digital splaying/juxtaposing
      4. Palpable interdigital mass
      5. Pain upon palpation (Direct to the intermetatarsal space)
   2. Associated deformities
3. Diagnostic procedures may include:
   1. Radiographic examination: X-ray examination may be used to rule out bony pathology (differential diagnosis). X-rays may be weight bearing, partial weight bearing, or non-weight bearing.
   2. Laboratory tests: Used to rule out inflammatory disease, degenerative joint disease, systemic illness (again, differential diagnosis)
   3. Electrodiagnostic studies: Possibly useful in ruling out other pathology (i.e. tarsal tunnel syndrome), but not definitive in establishing a diagnosis of intermetatarsal neuroma.
   4. Current perceptual threshold (neurometer CPT test) may be used as indicated.
   5. Ultrasound echography
   6. Magnetic resonance imaging (MRI), computed tomography (C-T) scan, or positron emission tomography (PET) scan
4. Differential diagnosis may include:
   1. Fracture
   2. Osteochondritis
   3. Arthritis
   4. Neoplasms (malignant/benign), (nodules i.e., rheumatoid)
   5. Capsulitis
   6. Bursitis
   7. Tendonitis
   8. Synovitis
   9. Neuritis
   10. Tarsal tunnel syndrome
   11. Peripheral neuropathy
   12. Reflex sympathetic dystrophy
   13. Vascular insufficiency
   14. Multiple neuromas may be present in the same foot

1. Goals of treatment: Conservative (nonsurgical) treatment is primarily geared to relieving symptomatology. In most cases, conservative care should be utilized prior to surgery.
2. Types of treatment:
   1. Padding and strapping (taping)
   2. Orthotics
   3. Shoe modifications
   4. Oral anti-inflammatory medications (NSAIDs)
   5. Anti-inflammatory injectables (i.e., corticosteroids)
   6. Injection of local injectables (i.e., peripheral nerve block)
   7. Injection of sclerosing agents (i.e., Vitamin B-12, alcohol)
   8. Analgesics
   9. Physical therapy

1. Goals of treatment: The goal of surgical treatment is not only to relieve the symptom(s), but to correct the underlying deformities, and to improve function as well.
2. The primary reasons for surgical treatment are:
   1. Failure of nonsurgical treatment
   2. Impracticality of nonsurgical treatment
   3. The patient desires correction of a presenting deformity that is painful and/or causes a degree of loss of function.
   4. The patient is informed of the procedure(s) to be performed, the treatment alternatives, and the reasonable risks involved, and elects to have surgical intervention.
3. Site of surgery: The surgical treatment of intermetatarsal neuroma may be performed in the doctor's office. The hospital or ambulatory surgical center may also be appropriate.
4. Anesthesia: Local anesthesia is sufficient, unless there are extenuating circumstances.
5. Hemostasis: Absence of bleeding is not required.
6. Surgical preparation: Aseptic preparation ("usual" aseptic scrub, prep, draping, and sterile technique).
7. Preoperative lab: Necessity based upon the patient's past medical history and current medical status.
8. Prophylactic antibiotics: At the discretion of the surgeon (or based upon requirement: i.e., mitral valve prolapse).
9. Pathological analysis of surgically removed tissue: recommended.
10. Bilateral or multiple surgeries: May be performed at the same surgical session, or in different surgical sessions.
11. Second opinion: At the option of the patient or doctor.

These may include:

1. Neurectomy
   1. Excisional
   2. Electrocautery
   3. Radiocautery
   4. Laser
2. Osteotomy of adjacent metatarsal(s) may be used for intermetatarsal neuroma in the event that the metatarsal is malpositioned or malformed, and that the purpose of the osteotomy is for treatment of both the neuroma and the pathological metatarsal as well.
3. Tendon lengthening/tenotomy/capsulotomy may be used for intermetatarsal neuroma in the event that the purpose of these procedures is both for treatment of the neuroma and the soft tissue pathology.
4. Severing of the intermetatarsal ligament.

1. Radiographs: Necessary only if there is accompanying osseous and/or soft tissue surgery.
2. Postoperative visits: In the absence of complications, the patient should initially be seen within the first week following the procedure(s). Subsequent visits are determined by the procedures performed and the postoperative course.
3. Weight bearing/immobilization: Based upon the procedures performed and upon the individual patient, full, partial, or non-weight bearing may be utilized. A postoperative shoe may be indicated. Generally, a surgical dressing is applied in the immediate postoperative period. This is modified with time and the postoperative course. The return to a normal shoe is based upon the procedure(s) performed and the postoperative course of the individual patient. Casting is usually not necessary.