Metatarsalgia: Causes, symptoms, and treatment

Metatarsalgia treatment consists mostly of focusing on the things you can control, such as getting the right metatarsalgia insoles and shoes, and adapting your activities to reduce your metatarsalgia pain. This article also discusses some underlying causes of metatarsalgia that we can’t do much about, such as the shape of your foot and lax ligaments, as well as recovery times. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.

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In this article:

1. What is metatarsalgia?

2. Some causes of metatarsalgia

3. Metatarsalgia symptoms

4. Recovery times for metatarsalgia

5. Treatment for metatarsalgia

6. Exercises for metatarsalgia?

7. Running with metatarsalgia

8. How we can help

I've also made a video about this, where I discuss my own experience of metatarsalgia in some more detail:

What is metatarsalgia?

Metatarsalgia refers to pain in the ball of your foot. In the X-ray image below, you can see the metatarsal bones coming down from the mid-foot towards the toes, ending in the metatarsal heads, which are circled in red. It is this area that get injured when you have metatarsalgia.

Picture adapted from Chahal, G. S., et al. (2020)

The metatarsal heads form the ball of your foot. They take most of your weight as you roll forwards on your foot to propel yourself when walking or running. It also shares bearing your weight with your heel when you’re standing.

When you look at a scan of a foot with metatarsalgia, you can usually see several things that cause the patient pain, which might include bone bruising and swelling (bone oedema) as well as inflammation and thickening of the soft tissue (ligaments and joint capsules). There may also be damage to the ligaments, or plantar plate, which are meant to support and protect the metatarsal heads.

Some causes of metatarsalgia

This condition is caused when the metatarsal heads take too much strain when you're walking or running, and then they become injured.

Often, there’s an underlying issue which doesn’t cause metatarsalgia on its own but predisposes you to get it when something else changes, which then triggers it.

Examples of issues that can predispose you to metatarsalgia

Foot shape

The shape of your foot may predispose you to this condition. The foot in the X-ray above has a high-arched, rigid midfoot, which causes the metatarsal heads to make contact with the floor more than would be the case for a less rigid or lower arched foot.

Lax ligaments

People with lax ligaments (severe cases of this are referred to as hypermobility syndrome) are prone to metatarsalgia, because the foot arch is not as stiff as those of other people, causing the foot to “collapse” when they run or walk. This can increase the impact on the metatarsal heads.

Conditions like hypermobility syndrome may also mean that your ligaments are not very strong and damage more easily, which can also contribute.

Long second toe or short big toe

Some people have a really long second toe or a very short first toe; this can cause the metatarsal heads of the mid-portion of the ball of the foot to take more strain.

A longer second toe can predispose you to getting metatarsalgia.

Examples of changes that can trigger metatarsalgia

These underlying issues can remain dormant, without causing any problems, until something changes that triggers the metatarsalgia.

Change in footwear

If you’re used to wearing shoes with softer soles, such as trainers, and then you change to wearing sandals or flip-flops, it can increase the strain on your metatarsal heads. The same applies if you change from cushioned running shoes to minimalist shoes or running barefoot.

Change in the surface on which you walk or run

If you usually walk on carpets or wooden floors when indoors, and then there’s a change to your living or work environment where the surface you walk on is tiles or concrete, it will cause more pressure on the metatarsal heads.

The same might happen if you’re used to trail running or running on a treadmill or tartan track and then change to running on asphalt or tarmac.

Activities (type or intensity) that your feet aren’t used to

Examples would be if you take up running or hillwalking and overdo it right from the start by not allowing your body and feet enough time to adapt, or you change jobs and the new job requires you to now walk long distances.

A good way to avoid injuries like metatarsalgia is to gradually ease into new activities over several weeks or months.

It often takes a combination of factors to cause metatarsalgia, e.g. a certain foot shape + shoes that lack cushioning + sudden increase in time on feet.

Often, several of the factors above conspire together. An example would be if you have lax ligaments and it has not caused you any trouble. But then, you go on holiday and change from usually wearing trainers in a carpeted environment to walking miles and miles in flip-flops on hard roads, day after day, to do some sightseeing.

Arthritic conditions

Certain arthritic-type conditions like rheumatoid arthritis or any inflammatory joint disease can predispose you to metatarsalgia. Also, arthritis can change the shape of your feet and your bones, causing the metatarsal heads to take more pressure when you’re walking or running. In these cases, the arthritis has to be treated in the first place, which is not the focus of this article.

Metatarsalgia symptoms

Initially, it feels like there’s a pebble under the ball of your foot. This is because the bone, ligaments, and tendons in that area have become thickened and swollen, and there’s more fluid than usual.

You can also get sharp pains and even something that feels like an electric shock if the nerves that run next to the metatarsals are affected.

Later on, if it’s not treated in time, it can become very painful just to be on your feet, especially first thing in the morning and when you try to walk after sitting still for a long period.

However, there are other conditions that can cause similar symptoms, such a lower back pain with refers pain into that area, tarsal tunnel syndrome, and a stress fracture.

Diagnosing metatarsalgia is quite easy. An experienced physiotherapist, podiatrist, or doctor will be able to diagnose it for you, usually without needing scans.

The pain from metatarsalgia is in the ball of the foot.

Recovery times for metatarsalgia

A mild case that is caught early enough can be resolved within as little as six weeks. If you ignore the condition and soldier on regardless, it can take several months.

Treatment for metatarsalgia

The most obvious thing to do is to minimise the pressure on your metatarsal heads.

Reduce aggravating activities

This doesn’t mean you have to sit with your feet up all day long, but you have to do what you can to reduce the amount of walking and the amount of time you spend on your feet (standing and walking) on hard surfaces to a level that does not cause you pain. I realise this can be hard to do when even walking short distances hurts.

Wear soft shoes

Due to life and work getting in the way, reducing our activities is not always possible to the extent that we would like. However, choice of footwear is something over which we have more control.

So, get shoes with soft soles. I myself had metatarsalgia a few years ago and got myself a pair of Crocs (Literide Clogs). The soles felt like marshmallows, and I was able to walk indoors in these without pain. For outdoors, I found Hoka running shoes (Cliftons with wide toe box) quite comfortable.

Orthotics

Don’t get just any old pair of orthotics or gel pads; they will likely just increase the pressure on your metatarsal heads.

You need to get orthotics with a metatarsal dome, which sits behind the metatarsal heads and lifts the shafts of the metatarsals up (together with their heads) to take the pressure off the painful area.

You can get prefab orthotics on Amazon that include a metatarsal dome, but I have never found them a good fit. My podiatrist made me a custom pair of orthotics with memory foam under my metatarsal heads and a metatarsal dome that worked like a charm.

Insoles for metatarsalgia

Exercises for metatarsalgia?

In my experience, getting the right shoes, supportive insoles, and managing how much you stand, walk, and run is much more important than doing specific exercises. You may benefit a bit from doing calf stretches or foot strengthening exercises, but these will have little effect if your ligaments or the shape of your foot is part of the problem.

Running with metatarsalgia

If you’re a runner and the metatarsalgia is mild, you may find that running is actually less painful than walking.

This is because when you try to walk, and especially if you're trying to walk fast, you tend to push through the front of your foot to propel yourself forwards, and that force just makes things worse. When you run, you can focus on propelling yourself forwards using your larger leg muscles more than your foot.

If you’re lucky enough to be able to run while you have this injury, take care to practice load management. So, how much you run, combined with your other daily activities, must not make your feet feel worse the next morning compared to how things were before the run.

If you can, avoid running up hills or doing sprint drills, because that will increase the pressure on the ball of your foot.

How we can help

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.

References:

Chahal, G. S., et al. (2020). "Treating metatarsalgia: current concepts." Orthopaedics and Trauma 34(1): 30-36.