Introduction

If you’re looking to understand the signs and symptoms of metatarsalgia, you’re in the right place. This article delivers a clear breakdown of this disease, leaving you confident in taking steps towards effective management.

Metatarsalgia is a common condition, characterised by pain and inflammation around the metatarsophalangeal joints in the ball of the foot, typically beneath the metatarsal heads.¹ It is a group of conditions that can arise from various causes, such as ill-fitting footwear or conditions like arthritis. Discomfort is often associated with this disease, which can worsen during walking or running and significantly affect the quality of life. Thus, understanding the clinical signs and symptoms is important for accurate diagnosis and effective management, minimising the risk of further complications from delayed diagnosis and treatment.

What is the pathophysiology behind this disease?

Metatarsalgia develops when there is excessive pressure or stress on the metatarsal heads, the bones that connect the toes to the midfoot. These bones are essential to distribute body weight evenly. However, repetitive overload of the forefoot can lead to stress on the metatarsal heads, triggering inflammation in tissues, as well as swelling and nerve irritation.² The pain is usually confined to the area across the plantar forefoot, as well as the second through the fourth metatarsal heads.³

What are the clinical signs and symptoms? (NHS)

The main signs and symptoms include:

• Sharp, aching, or burning sensation affecting the ball of the foot
• Sharp, shooting pain in the toes
• Pain worsens with weight-bearing activity
• Pain improves with rest
• Pressure causes thickened skin under the affected area
• Limping during walking
• ‘Pebble in the shoe’ sensation 

What are the causes?

There can be different contributing factors, such as:

• Being overweight
• Age – there is increased pressure at the front of the foot due to the fat pad becoming thin
• Increased swelling in the feet
• Foot deformities such as bunions
• Inflammatory conditions
• Certain foot shapes, such as high-arched feet,  which add extra pressure on the metatarsals
• Hard training – when a person runs, the front of the foot takes in more force
• Poorly fitted shoes – more pressure and weight are added onto the front of the foot

There can be varying severity of metatarsalgia due to the forces applied to the forefoot, with the causes being divided into three groups.

1. Primary metatarsalgia - this occurs due to the anatomical characteristics of the metatarsals that will affect the balance and forces with other parts of the foot. For example, high arches, calluses, and bunions
2. Secondary metatarsalgia - this occurs due to health conditions or activities that can increase pressure on the forefoot, such as rheumatoid arthritis, neurological disorders, such as Freiberg, and trauma from poorly fitted shoes and running
3. Iatrogenic metatarsalgia - this occurs due to complications of forefoot surgery, although this is rare. For example, surgery can lead to changes in the toes, which can then cause metatarsalgia pain and can be a result of fractures that don’t fully heal⁴

How is it treated?

This can usually be treated at home by making the necessary changes to help with recovery. Simple treatments are first undertaken before invasive measures such as surgery, which aim to reduce pressure and inflammation within the joints. For example:⁵

• Resting
• Medications such as ibuprofen
• Stretches – this will lengthen the triceps and decrease the pressure at the forefoot
• Changing footwear to distribute the pressure more evenly on the forefoot
• Shoe inserts 

How is this different from conditions similar to metatarsalgia? 

Morton’s neuroma involves pain and thickening of the nerve under the third and fourth metatarsals, causing a shooting pain or numbness in the toes. It may also feel like a lump or small stone under the foot.⁶ Additionally, Freiberg’s infraction represents avascular necrosis of the second metatarsal head, causing deep localised pain with joint stiffness. Metatarsals, also known as stress fractures, are caused by repetitive microtrauma, causing sharp, localised pain that can worsen with activity. Thus, these conditions all present differently and can be differentiated from metatarsalgia.

Summary

Metatarsalgia is a common condition, with there being pain and inflammation in the ball of the foot. It usually occurs when there is excess pressure on the foot, leading to stress in the metatarsal heads, causing inflammation in nearby tissues. There are many causes of this disease, with the main ones being inflammatory conditions, poorly fitted shoes, and hard training. The main signs and symptoms involve a sharp, shooting pain in the ball of the foot, as well as limping and the pain worsening with weight-bearing activities. However, this can be similar to other conditions; thus, a clear diagnosis and treatment options from a healthcare professional are required to accurately diagnose this. Resting and stretching can lead to some improvement. If this hasn’t improved, more invasive measures such as surgery may be undertaken. However, this is rare. Thus, understanding the clear signs and symptoms of this disease can lead to an accurate diagnosis, with efficient treatment options being undertaken to improve the patient’s quality of life and to prevent chronic discomfort and complications. 

FAQs

What should I not do when I have metatarsalgia? (NHS) 

• Avoid sports or other activities which is causing the pain
• Do not walk for long periods
• Do not wear high heels 

What lifestyle changes can be undertaken to improve the pain?

• Regular stretching
• Lose weight if overweight
• Place an ice pack over the painful area
• Have good arch support and use insoles in your footwear

When should I see a doctor?

Metatarsalgia can usually be treated at home, but if the pain hasn’t improved in two weeks and it begins to impact fundamental daily activities, then you should see your healthcare provider.

Can the disease be prevented?

It can be avoided such as using comfortable shoes, avoiding walking barefoot, and maintaining a healthy weight.