Metatarsalgia

Do you have pain under the front of your foot? Does it feel like you're walking on a pebble? Metatarsalgia affects many people, from runners to women who frequently wear high heels. The good news is that the first-line treatment—that is, the one you try before anything else—isn’t surgery. It involves conservative measures, meaning approaches that don’t require surgery: stretching, changing your shoes, and using insoles¹. These approaches fall within the field of physical therapy.

This article explains the possible causes of pain under the front of the foot, the signs to look for, and treatments that can help you walk more comfortably.

What is metatarsalgia?

Metatarsalgia refers to pain under the front of the foot, at the level of the metatarsal heads—the rounded ends of the bones that connect to the toes. This area is located at the base of the toes, where the foot makes contact with the ground when you walk or run.

The metatarsals are five rod-shaped bones that form the forefoot. Pressure can concentrate under the second and third metatarsals. A measurement taken on 107 asymptomatic feet while standing placed the pressure points of the forefoot precisely under the second or third metatarsal heads². In this standing measurement, the forefoot bore approximately 28% of the load supported by the foot, compared to approximately 60% for the heel². These percentages are based on a measurement taken with bare feet, while standing still, on 107 pain-free feet; the midfoot bore 8%. They apply to standing, not to walking or running.

The term metatarsalgia describes a symptom, not a precise diagnosis. Several causes can be responsible. This is why a professional evaluation helps to accurately target treatment and achieve better results.

What are the causes of metatarsalgia?

Metatarsalgia may be related to footwear, a sudden increase in activity, or the shape and movement of the foot. Repeated stress can exceed what the forefoot can tolerate. Pain, however, is not a direct measure of damage. According to the International Association for the Study of Pain, it is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or resembling such an experience³. Its intensity alone does not indicate the extent of tissue damage. A foot under heavy load does not always hurt, and pain can exist without visible damage.

Compared to flat shoes, high heels shift pressure toward the front of the foot. In a laboratory study, the higher the heel—ranging from 3 cm to 8.2 cm—the greater the pressure beneath the first metatarsal and the center of the forefoot. At the same time, pressure decreased beneath the heel and the middle of the foot⁴. In this study, twenty women walked on a treadmill while wearing three different heel heights, with a 0.2-cm flat shoe serving as a control. Twenty people is a small sample size, and a treadmill does not replicate a full day spent standing in dress shoes. These results describe the pressure experienced while walking in these shoes; they do not compare the prevalence of metatarsalgia between women and men.

For runners, switching to minimalist shoes with less cushioning—or a sudden increase in training—requires some adjustment.⁵ In a study of 36 runners, 10 of the 19 participants who gradually switched to minimalist shoes showed increased fluid in at least one foot bone on MRI scans taken after ten weeks. This sign of increased stress on the bone was observed more frequently than in the group that continued wearing their usual shoes. The study by Ridge and colleagues calls for a cautious transition; it does not measure metatarsalgia alone. A shift toward forefoot running also alters the way the foot strikes the ground. A recent increase in activity without sufficient recovery can contribute to overuse injuries of the foot in runners.⁶

A high-arched foot—that is, a foot with a higher-than-average arch—concentrates the load on a smaller surface area. In a study of 68 adults—34 with high arches and 34 with normal arches—the contact area with the ground measured 118 square centimeters compared to 165. The maximum pressure measured was also higher, at 656 kilopascals compared to 504; the kilopascal is the unit used to measure pressure⁷. Claw toes may be accompanied by a forward displacement of the fat pad that protects the metatarsal heads. One study compared 13 people with diabetes and deformed toes to 13 without this deformity. All had neuropathy, meaning damaged nerves in the foot. Pressure reached 626 kilopascals in the first group, compared to 363 in the second⁸. The displacement of the fat pad may contribute to this difference. These figures do not represent the general population. Hallux valgus (bunion) is associated with a different distribution of weight-bearing between the big toe and the outer edge of the forefoot. Among 61 feet examined, the more the big toe deviated, the less weight it bore, and the greater the force and pressure under the head of the fifth metatarsal⁹.

What are the symptoms of metatarsalgia?

The main symptom of metatarsalgia is pain under the ball of the foot. It often feels like walking on a pebble. The pain may worsen when walking—especially when barefoot or wearing heels—and then subside with rest.

The pain is typically located under the heads of the second, third, or fourth metatarsals. Some people also describe a burning sensation under the foot.

Calluses—areas of thickened skin—may form under the metatarsal heads. They may result from repeated pressure or friction. A sensation of numbness between the toes may indicate Morton’s neuroma, which is irritation with thickening around a nerve between the toes. This condition warrants special attention during the evaluation.

Very localized pain accompanied by swelling and tenderness when weight is borne, especially after an increase in training intensity, may indicate a stress fracture. This hairline fracture in a bone can occur after repeated strain. A metatarsal fracture is a possible cause of forefoot pain. Have this possibility evaluated before continuing your exercises.⁶

How is metatarsalgia diagnosed?

The diagnosis of the cause of metatarsalgia is based on your symptoms, an examination of your foot, and, if necessary, medical imaging. Your physical therapist will press on the metatarsal heads to locate the pain, observe your gait, and examine your shoes. An X-ray uses X-rays to show the bones. However, a normal X-ray does not rule out a stress fracture, which often remains invisible during the first few weeks. Symptoms, circumstances, and examination findings may suggest a stress fracture, but they are not sufficient to either confirm or rule it out. Several forefoot conditions can cause similar symptoms⁶. If there is still uncertainty, an MRI—a test that uses a magnetic field to produce detailed images—may be necessary¹⁰.

The evaluation includes several steps:

Detailed questionnaire: We’ll ask about your activities, the shoes you usually wear, and how your pain has changed over time. The connection between the onset of symptoms and a change in activity or footwear often guides the diagnosis.

Physical examination: Palpation helps locate the pain. To check for a Morton's neuroma, the healthcare provider may press on the sides of the forefoot. Pain or a clicking sensation during this test—known as Mulder's sign—is interpreted in conjunction with the rest of the examination.¹

Gait Analysis: Observing your gait shows how your foot makes contact with the ground and moves forward. The wear on your shoes provides additional insight into these foot strikes.

The healthcare professional selects the tests based on the suspected cause. Standing X-rays may be used to supplement the foot examination. A suspected stress fracture may require an MRI if the X-ray does not provide a definitive answer.¹

What factors can contribute to metatarsalgia?

High heels, repetitive strain, and certain foot shapes can contribute to forefoot pain. Weight, diabetes, and inflammatory joint disease can also affect pressure on the foot or foot health. Not all of these factors cause pain in every person.

Aging can be accompanied by changes in the tissue under the forefoot. A study of 30 healthy individuals compared a younger group with an older group. The tissue was thinner under both metatarsal heads examined in the older individuals. It was also stiffer under the second metatarsal head¹². This comparison pitted two age groups against each other at a single point in time; it did not track the same feet as they aged.

Diabetes can damage the nerves in the feet. This nerve damage, known as neuropathy, can reduce sensation in the soles of the feet and alter the way a person walks. In people with diabetes who have nerve damage in their feet, the pressure measured under the foot while walking is higher if they have previously had a foot wound¹³. This finding comes from a meta-analysis—a study that combines data from multiple studies to calculate an overall average. Eight studies were included, and the maximum pressure was found to be higher in feet that had previously had a wound. Rheumatoid arthritis, a disease that causes joint inflammation, can deform the joints between the metatarsals and the toes, at the base of the toes. A review published in 2013 describes the persistence of forefoot deformities despite advances in medication. These deformities primarily affect the big toe, which deviates toward the other toes, and the joints at the base of the toes¹⁴.

How does physical therapy treat metatarsalgia?

Physical therapy treats metatarsalgia with exercises, advice on footwear, and—depending on the examination—manual therapy. The physical therapist also assesses your foot strike and gait. The goal is to distribute pressure more evenly and improve your ability to walk or engage in your daily activities.

Our approach includes:

Comprehensive Evaluation: We analyze your foot, ankle, knee, and hip. A stiff ankle can affect your gait. A hip problem can also change the way you walk.¹

Manual therapy: The practitioner may gently move the toe joints with their hands to help improve their mobility and your comfort. A study of mobilization techniques for metatarsalgia found reduced pain and improved mobility in a group of 22 people with joints that had limited mobility, but no reduction in pain in another group of 16 people with retracted joints that had become more permanently stiff. All participants received mobilization techniques; the study did not include a control group that did not receive this treatment. A gentle massage may also be tried for comfort, depending on your response.

Personalized exercise program: We strengthen the intrinsic muscles of the foot—that is, the small muscles located within the foot itself, which do not extend up into the leg. They support the arch and help distribute weight. Among recreational runners, a foot- and ankle-strengthening program has reduced the rate of running-related injuries¹⁵, although its specific effect on metatarsalgia was not measured. This result comes from a randomized trial—that is, a study in which participants are randomly assigned to either follow the program or not. Among 118 runners followed for one year, the risk of injury was 2.42 times higher in the group that did not follow the program than in the group that did. Calf stretches round out the program.¹

Shoe Advice: We examine your shoes and help you choose shoes that are suitable for your condition and activities.

Temporary adhesive bandage: A bandage can support a toe—other than the big toe—when the joint at its base is unstable, meaning it moves excessively. This option is primarily for the early stages of this problem. It is used in conjunction with measures that reduce pressure on painful areas. The healthcare professional fits the bandage and monitors the skin, as prolonged use can cause a wound. The review by Kinter and Hodgkins describes this management approach.

What exercises can help relieve metatarsalgia?

The exercises recommended for metatarsalgia include stretches for the calf and the sole of the foot, as well as strengthening the small muscles of the foot. The plantar fascia is a band of tissue under the foot that helps support its arch. Toe exercises are added based on any stiffness found during the examination. Bradford’s public health service offers exercises and shoe modifications for this condition. The program studied among runners reduced running-related injuries overall¹⁵; however, this effect does not indicate a specific success rate for metatarsalgia. The recommendations below are examples to be adapted with your physical therapist, depending on the cause and your tolerance.

Foot Arch Exercise: This exercise involves shortening the foot by bringing the base of the toes toward the heel without bending the toes. This movement activates the small muscles that support the arch.

These exercises should not cause pain. Start slowly and gradually increase the intensity. Your physical therapist can adjust the exercise program based on how you respond.

For runners, strengthening the foot muscles is one of the helpful strategies. In a controlled trial, a foot muscle-strengthening program reduced the risk of running-related injuries.¹⁵

What shoes should you wear if you have metatarsalgia?

Shoes with a wide toe box, a low or moderate heel, and good cushioning are options to try for metatarsalgia. The choice also depends on the cause and your comfort. A stiff insole, curved upward at the front to facilitate the rolling motion of the foot, can help limit painful movement at the base of the toes¹. In a study of people with osteoarthritis at the base of the big toe—changes in the joint that can become painful—shoes with curved soles reduced pressure under several areas of the forefoot¹⁶. This pressure measurement alone does not guarantee relief. A rigid sole should therefore not be automatically ruled out. High heels and pointed toes can increase discomfort.

Foot orthotics: A metatarsal pad is a small cushion placed behind the metatarsal heads. It can be helpful if its placement suits you. Placed just behind the metatarsal heads, it redistributes pressure to a less sensitive area.¹ An experiment measured the effect of the pad’s placement on pressure. In ten people with metatarsalgia, the peak pressure under the metatarsal head decreased from 678 to 427 kilopascals when the pad was properly positioned¹⁷. When the peak pressure created by the pad was located two rows of sensors further back, the difference in pressure could be attributed to chance. This experiment did not measure pain. Another study surveyed 25 of the 45 people who received insoles with metatarsal cushions. They reported an average reduction in pain of 3.2 points and an increase of 24.2 points on a 100-point foot assessment scale. This study by Männikkö and Sahlman suggests a potential benefit, with a follow-up period of at least one year. It was based on interviews and did not compare the results to a group without insoles. This support can be incorporated into a custom-made insole or purchased separately.

If you need to wear heels occasionally, limit the time you wear them and switch to flatter shoes throughout the day.

How can you track your recovery from metatarsalgia?

Recovery from metatarsalgia depends on the pain you experience when walking and the activities you can resume. The time frame depends on the cause and its duration. In some cases, changing your shoes may be enough; however, persistent pain, a deformity, or a fracture requires appropriate medical follow-up.

Limit activities that increase pain. You may continue with activities that you can tolerate well, as advised by your healthcare professional. If a fracture is suspected or confirmed, follow the instructions for protection and support before resuming exercises.

Pain that does not improve after two weeks of home care warrants an evaluation. Once a treatment plan has been established, the Bradford service recommends a follow-up evaluation after six to twelve weeks if there has been no change. This follow-up guideline does not guarantee recovery within that timeframe. If the condition worsens or if there are any urgent symptoms, seek medical advice sooner.

When should you see a doctor for metatarsalgia?

Metatarsalgia should be evaluated if it limits your activities, gets worse, recurs, or does not improve after two weeks. Numbness, pain at rest or at night, swelling, or a change in skin color also warrant medical attention. If you have diabetes and are experiencing foot pain, seek medical advice.

When should you seek urgent medical advice?

Seek urgent medical attention in the following situations:

• The pain under the ball of your foot is severe, or you are unable to walk.
• The foot has changed shape, or a popping, cracking, or grinding sound occurred at the time of the injury.
• The pain causes a feeling of faintness, dizziness, or nausea.
• The foot is warm, swollen, and painful.
• Pain in the forefoot is accompanied by a sensation of heat, cold, or chills.

These symptoms may indicate a fracture or an infection. If you suspect a fracture, seek medical advice before treating the foot yourself.

In Quebec, you can see a physical therapist directly without a doctor's referral. If your condition requires medical tests, your physical therapist can refer you to the appropriate professional.

At Physioactif, the physical therapist examines your foot, your gait, and the movements that affect your weight distribution. This assessment helps determine the treatment and lifestyle changes that are right for you.

What Should You Know About Metatarsalgia?

Metatarsalgia can be managed with appropriate footwear, exercises, and, if necessary, insoles or manual therapy. These measures can improve comfort and walking ability, depending on the cause. The positive results observed with certain treatments do not indicate a recovery timeframe that applies to all cases of metatarsalgia.

Treatment is tailored to the factors identified during the examination, such as footwear, a recent increase in activity, or the distribution of weight.

If you have pain under the ball of your foot, don't wait for it to become chronic. A professional evaluation can identify the causes and establish a personalized treatment plan tailored to your specific situation.

Sources

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