Morton's neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians

The first-line treatment for symptomatic Morton's neuroma in our hospital is a perineural ultrasound-guided injection of corticosteroid and local anaesthetic (USI). The NHS has recently implemented 18-week referral-to-treatment targets. When GPs specifically suggest a diagnosis of Morton's neuroma there are two referral pathways in our hospital: direct referral to radiology for USI (limited slots) or referral to the specialist foot and ankle clinic. Patients with less specific referral letters are also evaluated in clinic and referred for USI as appropriate. A retrospective audit was performed reviewing referral letters from general practitioners (GPs) in 2005-2006. A comparison was made between the referral pathways for time-to-treatment (TTT), accuracy of GP diagnosis, and cost implications. In the directly referred group, the median TTT was 99 days, compared to 206 days for patients who went via a foot and ankle clinic (P < 0.001). Of 57 patients with a GP diagnosis of Morton's neuroma, 40 (70%) had the diagnosis confirmed on USI compared to 44 of 64 (69%) patients referred by a foot and ankle surgeon, showing no significant difference between the groups (P = 0.87). For patients with features highly suggestive of a Morton's neuroma, direct referral from primary care for USI had a similar accuracy to referral from a specialist hospital clinic and the time-to-treatment was significantly shorter. The mean waiting time of this group was within the 18-week government target without any changes to our current radiology protocols.