Metatarsalgia is the medical term used to describe pain in your foot, specifically at the ball of your foot where the edges or heads of your metatarsal bones are located.¹ It is usually a result of abnormal pressure on, or wear and tear of the bones in the ball of your foot. You might be walking differently and feel like you have an imaginary stone in your shoe when you’re walking.¹ It can be accompanied with inflammation, making the ball of your foot tender and/or swollen. Metatarsalgia is usually a symptom or an effect of something else happening inside your body, such as a bone fracture, wear and tear in your muscles or tendons from running or wearing high heels, deformities you were born with such as bunions (also known as hallux valgus), or inflammatory conditions such as arthritis, to name a few.² 

Treatment and management of metatarsalgia relies on the severity of your pain as well as its causes. The causes of metatarsalgia are put into 3 different groups or classifications- primary, secondary and iatrogenic.²

Anatomy of the foot 

Your foot is divided into three parts, forefoot, midfoot, and hindfoot. Within your forefoot, you have your phalanges, which make up your toes, and your metatarsal bones, each of which are connected to a phalange. This means that your first metacarpal will be connected to the phalanges in your big toe, and your second to the ones in your second toe. These are the parts that are most important for your knowledge of metatarsalgia.³

Primary (Causes of) Metatarsalgia 

If you have primary metatarsalgia, then your pain is caused by the structure of your metatarsals, and the relationship they have with each other and other parts of the foot. Common primary problems include: 

• First ray insufficiency- when the ‘first ray’ (a group of bones in the foot consisting of the big toe/1^st phalange,1^st metatarsal bone and the medial cuneiform bone) are not working correctly. They are important for pushing forward and bearing the body’s weight during walking. When there’s an insufficiency, the other metatarsals compensate by taking on the weight and pressure which leads to pain, thickening skin, and, in severe cases, open sores. Causes of first ray insufficiency are: 

• Bunions, also called hallux valgus. This makes the 1^st metatarsal shift to the side, weakening it¹
• Pes planus, or flat feet.Lacking an arch at the ball of your redirects the pressure to all metacarpals, distorting the systematic way your feet help you move
• Having a metatarsal that is abnormally smaller than the others, also known as brachymetatarsia. You can be born with it, or it can develop through foot injuries. It usually manifests as an abnormally smaller toe than the rest⁸ 

• Metatarsal length discrepancy. This is when the metatarsal bones are naturally different lengths. Typically, in such cases, the second metatarsal is unusually longer than the rest, causing an imbalance in weight bearing and pressure, leading to pain² 
• Metatarsal head deformity. is when the top of the metatarsal bone is deformed, usually due to wear and tear or infection. This leads to pain and inflammation⁵
• Forefoot equinus. When you can’t bend your ankle upwards fully¹
• Excessive metatarsal plantarflexion. When you can bend your ankle upwards at an abnormally high angle⁷

Secondary (Causes of) Metatarsalgia 

Secondary metatarsalgia is caused by indirectly overloading pressure or weight onto the forefoot. You might have recently experienced physical trauma on your foot, or you may have a medical condition that does not directly affect your foot, but its effect on your body results in pain at the ball of your foot.¹

Trauma may be caused by over exertional activities such as running or jumping sports, as well as roles that require standing on hard floor surfaces. Wearing tight-fitting shoes or shoes that disrupt the normal pressures of weight onto the foot, such as high heels, in the long term can cause pain in the foot.²

Pre-existing conditions that can increase the weight on the forefoot indirectly are as follows: 

• Hallux rigidus, or a stiff big toe. This is due to a stiff joint at the point that the metatarsal bone connects with the phalangeal bone, resulting in pain. In turn this increases pressure on the other metatarsal bones^1,5
• Morton’s neuroma. Where an irritated or damaged nerve has thickening tissue around it⁷
• Tarsel tunnel syndrome, where the pain is caused by a damaged tibial nerve which runs towards the foot²
• Freiberg infraction. When the muscle at the top of a metatarsal bone loses its blood supply and inevitably dies¹
• Chronic inflammatory diseases like rheumatoid arthritis or gout² 

Iatrogenic (causes of) Metatarsalgia 

Iatrogenic metatarsalgia is a type of pain and inflammation in your forefoot that is a complication after having foot surgery.¹ The most common surgery this occurs on is reconstructive surgery to reduce your bunion, or hallux valgus, where your first metatarsal is either shortened too much, or elevated too much, or both.⁴ Treatment is highly dependent on the cause of pain; if there is an unaddressed issue, then reconstructive surgery to fix the problem may be necessary. If there is a length discrepancy or angle discrepancy, then correctional surgery may be necessary.^4,6 In rare cases, iatrogenic metatarsalgia is caused by incorrectly healed bone fractures.⁶ This can cause calluses to form and a change in the weight distribution to the foot, causing pain. This would also be managed with surgery. 

Frequently Asked Questions 

Is metatarsalgia a disease? 

While it is classed as a medical condition, metatarsalgia is usually a symptom of other diseases such as progressive arthritis, a broken bone, or surgical complications. If you have metatarsalgia, it would be wise to see a doctor to determine the cause and severity so that it can be appropriately treated and adequately managed.^1,2

How do I find out my type of metatarsalgia? 

Ask your doctor about your diagnosis. Typically, when you report your foot pain, they will ask about your medical history, whether you had any surgery, medical conditions you were born with or developed overtime, and your physical activity levels. They may take X-Rays, MRIs or other foot scans to gauge your cause of pain. Knowing your type of metatarsalgia helps with managing your treatment well.^1,4,5 

What does it feel like to have metatarsalgia? 

Metatarsalgia manifests as a sharp, burning or aching pain under the ball of your foot. You may also feel numbness and tingling. People commonly refer to it as feeling like a stone is stuck under their feet. It makes walking around, and exercises such as running and jumping feel painful.^1,2

What happens if I ignore my pain? 

A: Ignoring metatarsalgia may lead to worsening your condition, leading to experiencing long term, severe pain in your feet that can disable you from living like you usually did. Your walking stance will be permanently altered, and you will have less mobility as time goes by. This could lead to additional complications such as hip and back pain. This will make your pain management strategy more complex. So if you are experiencing pain, then you should see a doctor as soon as possible. ^4,5,6,8

What should you avoid doing if you have metatarsalgia? 

A: If you have pain in your foot, try not to put pressure on it. Avoid exercises that put pressure on the balls of your feet such as running or jumping. Try to limit walking long distances or standing for too long. It is also important to wear comfortable footwear. Avoid wearing shoes that are tight or narrow, or weight-shifting shoes such as high heels.⁸ 

Can you recover from metatarsalgia? 

A: Yes. Recovering from metatarsalgia is a multifaceted process requiring understanding your diagnosis and treating it accordingly. Apart from pain relief or anti-inflammatory medications, you need to consider lifestyle changes, strength improving exercises, appropriate footwear, and supportive materials for the ball of your foot. This increases your chances of a full recovery and puts you on track to prevent a relapse of pain.⁴

Summary 

Metatarsalgia is a condition characterised by pain in the balls of your feet, where the metatarsal bones are located. It has three classifications based on their causes. Primary metatarsalgia refers to pain caused by bodily structures that are bound to cause friction, pressure overload and pain. Secondary metatarsalgia is caused by trauma to the foot causing fractures or pre-existing medical conditions that indirectly cause metatarsal pain. Latrogenic metatarsalgia is characterised by its appearance after treatment, which is typically after surgical treatment. Pain arising from improperly healed fractures is also classed as iatrogenic metatarsalgia. Management and treatment depend on the classification of metatarsalgia and its severity, so it is important to understand your diagnosis to properly manage your treatment.