Metatarsalgia refers to pain and inflammation in the ball of the foot, typically located under the heads of the second, third, and fourth metatarsal bones. It is one of the most common causes of forefoot pain and may affect both active individuals and those with underlying biomechanical abnormalities. Although not usually serious, metatarsalgia can significantly limit mobility and quality of life if untreated.
How Common It Is and Who Gets It? (Epidemiology)
Metatarsalgia is common in adults, particularly middle-aged and older individuals and athletes involved in running or jumping sports. Women are more frequently affected, largely due to footwear choices such as high heels or narrow toe boxes. The prevalence in active populations can exceed 20%, especially among runners and those with high arches or structural forefoot deformities such as hammertoes or bunions.
Why It Happens – Causes (Etiology and Pathophysiology)
Metatarsalgia occurs when abnormal pressure or stress is placed on the metatarsal heads, leading to irritation of soft tissues and bone.
It is broadly categorized into three types:
- Primary Metatarsalgia – Caused by anatomical or biomechanical abnormalities:
- Long second metatarsal (Morton’s foot).
- High-arched (cavus) foot or plantarflexed metatarsal.
- Forefoot pronation or hallux valgus deformity.
- Secondary Metatarsalgia – Caused by systemic diseases or external conditions:
- Rheumatoid arthritis, gout, or diabetes-related neuropathy.
- Trauma or repetitive stress leading to bone or soft-tissue changes.
- Iatrogenic Metatarsalgia – Occurs after foot surgery:
- Hallux valgus correction or metatarsal osteotomy altering forefoot load distribution.
Excessive loading during the third rocker phase of gait (toe-off stage) is the most common biomechanical trigger, where the metatarsal heads absorb high impact forces, especially on hard surfaces.
How the Body Part Normally Works? (Relevant Anatomy)
The metatarsals are five long bones forming the forefoot. They act as levers during walking and running, distributing body weight evenly across the foot. The second and third metatarsal heads bear the greatest pressure during propulsion. When any of these bones are misaligned or subjected to excessive stress, pain develops at the plantar surface of the forefoot. The protective fat pad beneath the metatarsal heads may also thin with age or injury, worsening pressure and discomfort.
What You Might Feel – Symptoms (Clinical Presentation)
- Sharp, aching, or burning pain in the ball of the foot, worsened by standing, walking, or running.
- Pain that improves with rest but recurs during activity.
- Sensation of walking on a pebble or fullness under the toes.
- Swelling, tenderness, or calluses beneath the metatarsal heads.
- Numbness or tingling radiating into the toes (especially with Morton’s neuroma).
Pain is usually aggravated by tight or high-heeled shoes and relieved by barefoot walking on soft surfaces.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is primarily clinical but may include imaging to rule out associated conditions.
- History and examination: Focus on pain location, footwear, activity level, and foot structure.
- Physical exam: Palpation of metatarsal heads, assessment for deformities, and evaluation of gait.
- X-rays: Identify fractures, long metatarsals, arthritis, or prior surgical changes.
- MRI or ultrasound: Useful for detecting soft-tissue causes such as Morton’s neuroma, plantar plate tears, or stress fractures.
Classification
Metatarsalgia can be functionally classified by underlying pathology:
- Mechanical/structural: Abnormal weight distribution (long or plantarflexed metatarsal).
- Inflammatory: Associated with arthritis or bursitis.
- Neuropathic: Due to nerve entrapment or diabetic neuropathy.
- Post-surgical: Following hallux valgus or other forefoot procedures.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Morton’s neuroma (nerve irritation between metatarsal heads).
- Stress fractures of the metatarsals.
- Freiberg’s infraction (avascular necrosis of metatarsal head).
- Capsulitis or plantar plate tear.
- Fat pad atrophy.
- Gout or inflammatory arthritis.
Treatment Options
Non-Surgical (Conservative) Management
Conservative treatment is the mainstay and effective in most cases:
- Footwear modification: Wide, cushioned shoes with low heels to reduce forefoot pressure.
- Orthotics: Custom insoles with metatarsal pads redistribute pressure and relieve pain.
- Padding and taping: Silicone pads or toe sleeves reduce friction and support the forefoot.
- Physical therapy: Stretching the gastrocnemius and Achilles tendon improves ankle dorsiflexion and reduces metatarsal load.
- Activity modification: Reduce high-impact activities like running or jumping until symptoms improve.
- Callus care: Regular debridement reduces localized plantar pressure.
- Corticosteroid injections: Provide short-term relief for inflammatory causes but should be used cautiously to avoid fat pad atrophy.
- Protected weight-bearing: In conditions such as Freiberg’s infraction, use of a walking boot or off-loading shoe may be recommended.
Surgical Care
Surgery is indicated for refractory pain or when structural deformity contributes to chronic overload. Procedures include:
- Weil Osteotomy: Shortens and repositions long metatarsals to redistribute load.
- Gastrocnemius Recession: Relieves tight calf muscles that shift weight to the forefoot.
- Tendon transfers: Address muscle imbalance, especially in claw or hammer toe deformities.
- Plantar condylectomy or metatarsal head resection: Considered for severe degenerative or arthritic cases.
Recovery and What to Expect After Treatment
- Most patients improve with non-surgical measures within 6–8 weeks.
- After surgical intervention, limited weight-bearing is maintained for 4–6 weeks, followed by physical therapy.
- Custom orthotics and supportive footwear help prevent recurrence.
Possible Risks or Side Effects (Complications)
- Persistent pain or stiffness.
- Transfer metatarsalgia (pain shifting to adjacent metatarsals after surgery).
- Infection, delayed bone healing, or recurrence.
- Fat pad thinning following steroid injections.
Long-Term Outlook (Prognosis)
The prognosis for metatarsalgia is excellent with early diagnosis and proper management. Conservative treatment resolves most cases, while surgery provides reliable relief in patients with structural abnormalities. Ongoing use of proper footwear and orthotics prevents recurrence.
Out-of-Pocket Costs
Medicare
CPT Code 27687 – Gastrocnemius Recession: $106.77
CPT Code 28313 – Tendon Transfer: $122.65
CPT Code 28308 – Metatarsal (Weil) Osteotomy: $130.95
Medicare Part B covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover this remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce patient responsibility.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans usually cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your metatarsalgia developed or was aggravated by a work-related condition, Workers’ Compensation will cover all medical costs, including surgery, rehabilitation, and follow-up visits. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved treatments.
No-Fault Insurance
If your forefoot pain or metatarsalgia resulted from an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Angela Rivera suffered from chronic metatarsalgia due to tight calf muscles and forefoot overload. She underwent gastrocnemius recession (CPT 27687) and a Weil osteotomy (CPT 28308). Her estimated Medicare out-of-pocket cost for the osteotomy was $130.95. Since Angela had supplemental insurance through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedures.
Frequently Asked Questions (FAQ)
Q. What is metatarsalgia?
A. Metatarsalgia is a condition that causes pain and inflammation in the ball of the foot, usually under the heads of the metatarsal bones.
Q. What are the common symptoms of metatarsalgia?
A. Symptoms include pain in the ball of the foot, especially when standing or walking, burning or aching sensations, and feeling like there is a pebble in the shoe.
Q. What causes metatarsalgia?
A. Metatarsalgia is caused by increased pressure on the metatarsal heads due to abnormal foot mechanics, poorly fitting footwear, high-impact activities, or foot deformities.
Q. Who is at risk for developing metatarsalgia?
A. Athletes, individuals who wear high heels or tight shoes, those with foot deformities, and people who are overweight are at higher risk.
Q. How is metatarsalgia diagnosed?
A. Diagnosis is made through physical examination and a review of symptoms, and may be supported by imaging studies like X-rays.
Q. What non-surgical treatments are available for metatarsalgia?
A. Treatments include rest, ice, anti-inflammatory medications, proper footwear, orthotic devices, and physical therapy.
Q. When is surgery considered for metatarsalgia?
A. Surgery is considered if conservative treatments fail to relieve pain and the condition significantly affects daily activities.
Q. What types of surgical procedures are used to treat metatarsalgia?
A. Surgical options may involve realigning or shortening the metatarsal bones to reduce pressure on the affected area.
Q. What is the recovery time after surgery for metatarsalgia?
A. Recovery can vary but typically involves limited weight-bearing and physical therapy over several weeks to months.
Q. Can metatarsalgia be prevented?
A. Yes, by wearing supportive footwear, using orthotics, avoiding high-impact activities on hard surfaces, and maintaining a healthy weight.
Q. Is metatarsalgia a chronic condition?
A. It can become chronic if left untreated or if underlying causes are not addressed.
Q. How does foot structure contribute to metatarsalgia?
A. High arches, hammertoes, and a second toe longer than the first can increase pressure on the metatarsal heads, leading to pain.
Q. Can orthotics help with metatarsalgia?
A. Yes, custom orthotics can help redistribute pressure away from the painful area and improve foot mechanics.
Summary and Takeaway
Metatarsalgia is a common cause of forefoot pain resulting from increased pressure on the metatarsal heads. It can develop from footwear, structural abnormalities, or systemic disease. Conservative management—such as cushioned shoes, orthotics, and stretching—is effective for most patients. Surgery is reserved for severe or persistent cases and focuses on restoring balanced pressure distribution across the forefoot.
Clinical Insight & Recent Findings
A 2025 educational review published in Insights into Imaging emphasizes the essential role of radiological evaluation in diagnosing metatarsalgia. The authors highlight that most cases arise from static disorders of the foot and recommend weight-bearing radiographs as the first step for assessing structural alignment.
Ultrasound is particularly useful for examining soft tissue and tendons, offering dynamic correlation with symptoms, while MRI serves as the gold standard for detailed soft-tissue visualization and detecting complex causes like Morton’s neuroma, bursitis, or stress fractures.
The review underscores that integrating clinical findings with imaging leads to more precise diagnoses and effective treatment strategies, often avoiding unnecessary surgery. (“Study on radiological approaches to metatarsalgia – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Metatarsalgia is typically managed by orthopedic foot and ankle surgeons, podiatrists, and physical therapists. Collaboration with orthotists ensures proper shoe and insole design.
When to See a Specialist?
Seek evaluation if forefoot pain persists for more than a few days despite rest or footwear changes. Early diagnosis prevents chronic pain and secondary deformities.
When to Go to the Emergency Room?
Emergency care is rarely needed unless there is acute trauma, swelling, or suspected fracture.
What Recovery Really Looks Like?
Patients can expect progressive improvement with non-surgical care. Pain relief usually occurs within a few weeks, with full return to activity in 1–2 months. Surgical patients achieve long-term relief after rehabilitation.
What Happens If You Ignore It?
Untreated metatarsalgia can lead to chronic forefoot pain, callus formation, stress fractures, or compensatory gait changes affecting the knees and hips.
How to Prevent It?
- Wear supportive, cushioned footwear with wide toe boxes.
- Avoid high heels or tight shoes.
- Maintain healthy weight and flexibility in calf muscles.
- Replace worn-out insoles regularly.
Nutrition and Bone or Joint Health
Adequate intake of vitamin D, calcium, and omega-3 fatty acids supports bone and joint resilience. Hydration and balanced nutrition improve tissue recovery after activity or surgery.
Activity and Lifestyle Modifications
Switch to low-impact exercises such as cycling or swimming during flare-ups. Gradually return to walking or running with proper orthotics and supportive shoes to prevent recurrence.
Dr. Mo Athar
