What is Metatarsalgia? 

Metatarsalgia is a term used to describe pain affecting the structures around the knuckles of your feet , usually around the ends of the five long bones called the metatarsals. These bones connect the middle of your foot to your toes and play an important role in supporting your body weight. It is not the name of any one specific condition but rather refers to the feeling of pain and inflammation with a wide range of causes.

There are numerous structures in this relatively small area, including bones, joints, tendons, ligaments, nerves and soft tissue. Pain can develop when excessive or uneven pressure is placed on these structures, following an injury, because of a change in foot shape or function, or as a result of another condition affecting the forefoot.

As skilled podiatrists who have been treating patients with metatarsalgia since 1986, The Bell Practice have outlined what might be causing your ball of foot pain and the most common treatments below.

Symptoms of metatarsalgia 

Metatarsalgia symptoms can develop gradually and vary considerably in severity. You may initially notice a mild ache after a long walk or exercise session, before the discomfort starts appearing during everyday activities.

The pain may improve when you rest and take the weight off your foot, only to return when you become active again.

The sensation is often described as feeling as though there is a stone inside your shoe, burning sensation or a sock has become bunched up underneath your foot.

Other common symptoms include:

• Aching or bruised feeling pain beneath the ball of the foot
• Sharp or stabbing pain
• Burning or shooting sensations
• Tingling or pins and needles
• Numbness extending towards the toes
• Pain that becomes worse when standing, walking or running
• Discomfort that is particularly noticeable when walking barefoot on a hard surface
• Pain affecting one particular area beneath a toe joint or spreading across the forefoot

It is possible for the symptoms of metatarsalgia to overlap with other conditions, including Morton's neuroma, bursitis, stress fractures and problems affecting the joints or soft tissues of the forefoot. This is one reason why persistent ball of foot pain should not simply be assumed to be metatarsalgia.

What causes metatarsalgia? 

There is no leading cause of metatarsalgia. Pain often develops because the structures at the front of the foot are exposed to more pressure than they can comfortably tolerate (forefoot over loading), but it can be caused by nerve impingements (Morton's neuroma), arthritis and atrophy of the protective fat pad under the ball of the foot.

This can happen after a sudden increase in activity, prolonged standing, wearing unsuitable footwear or because the natural structure and movement of your feet causes pressure to be concentrated in particular areas.

Structural issues with the foot

The shape and structure of your feet can have a significant influence on where pressure is distributed when you stand and walk.

For example, high arches can increase pressure through the forefoot, while certain flatter foot types can also alter the way weight is transferred through the foot. Toe issues such as bunions, hammer toes and claw toes can further change the mechanics of the forefoot and increase pressure around individual metatarsal heads. 

This does not mean that having a particular foot shape automatically causes metatarsalgia; your individual foot structure can make certain areas more susceptible to overload, particularly when combined with other factors such as unsuitable footwear or increased activity. We can assess this in clinic with a 3D weightbearing scan of your feet to identify and offload the high pressure areas.

A sudden increase in exercise

High impact activities repeatedly load the forefoot. If you suddenly increase the intensity or frequency of exercise, your feet may not have enough time to adapt. This can result in repetitive stress and small amounts of tissue irritation around the metatarsal region that, over time, can develop into disruptive pain. 

Unsuitable footwear

Your shoes can make a significant difference to the amount of pressure placed through the ball of your foot.

High heels shift more of your body weight towards the front of the foot. Narrow or pointed shoes can compress the toes and forefoot. Shoes with very thin or hard soles may also provide insufficient cushioning when your feet are repeatedly exposed to impact. 

For someone already experiencing metatarsalgia, continuing to wear footwear that aggravates the forefoot can make it considerably harder for symptoms to settle. 

Changes to the natural cushioning beneath your foot

There is a natural layer of fatty tissue beneath the ball of the foot that helps cushion the metatarsal heads and distribute pressure. As we get older, this cushioning can gradually become thinner. This can leave the structures underneath the foot more exposed to repetitive pressure and may contribute to discomfort, particularly during walking or prolonged standing. 

Tight calf muscles

The calf muscles and Achilles tendon influence the way your ankle and foot move when you walk. If these structures are tight, they can contribute to increased pressure being transferred towards the front of the foot.

This is one reason why stretching and strengthening exercises can sometimes form part of a treatment plan for metatarsalgia. 

Foot and toe conditions

Metatarsalgia can occur alongside, or as a result of, other problems affecting the foot. These can include:

• Bunions
• Hammer or claw toes
• Arthritis
• Morton’s neuroma
• Bursitis
• Plantar plate injuries
• Previous foot injuries or surgery
• Stress fractures
• Inflammatory conditions such as rheumatoid arthritis or gout

Diabetes can also contribute to changes in foot structure or nerve function, which can alter how pressure is experienced through the foot. 

How is metatarsalgia diagnosed? 

A podiatrist will begin by asking about your symptoms, when they started, and what activities or footwear appear to make them worse.

They will then examine your feet and may assess how you stand and walk. Your foot shape, joint movement, muscle strength, areas of tenderness and the distribution of pressure through the foot can all provide useful information.

The purpose of this assessment is not simply to confirm that you have pain in the ball of your foot. It is to establish why that area is being placed under excessive or inappropriate stress.

Depending on your symptoms, further investigations may sometimes be necessary. For example, persistent or sudden pain accompanied by swelling can require assessment for injuries such as a stress fracture. Other symptoms, such as burning, shooting pain or numbness, may point towards a nerve related problem such as Morton's neuroma. 

If your pain is severe, you cannot walk, your foot has changed shape, or the foot is hot, swollen and painful, seek urgent medical advice rather than attempting to diagnose or treat the problem yourself.

How to treat metatarsalgia

There is no single treatment for metatarsalgia because the most effective approach depends on what is causing the pain. The first step is to reduce the amount of pressure being placed through the forefoot and give irritated tissues an opportunity to settle.

Following a thorough assessment of your foot, your podiatrist may recommend, 

Rest from activities that aggravate your symptoms

If running, jumping or another activity clearly makes your pain worse, temporarily reducing or modifying that activity can help.

This does not necessarily mean becoming completely inactive. Lower impact activities such as swimming may allow you to maintain some exercise without repeatedly loading the painful area. 

The important thing is to avoid repeatedly pushing through pain and expecting the problem to disappear while the same source of pressure continues.

Choose more supportive footwear

Footwear is one of the simplest changes you can make when managing metatarsalgia.

Look for shoes with:

• A wide, comfortable toe box
• Plenty of room across the forefoot
• A cushioned sole
• Good overall support
• A relatively low heel
• Enough depth to accommodate your toes without pressure
  
  

Use insoles or orthotic support

Insoles can help to cushion the foot and redistribute pressure away from painful areas. For some people, an off the shelf insole or metatarsal pad may be sufficient. However, when pain is related to the way your feet are structured or how they function during walking, a more personalised approach is needed..

At The Bell Practice, our podiatrists assess your feet before creating custom 3D printed orthotics. To do this a weightbearing , 3D scan is used to create a fully bespoke orthotic designed around your individual foot contours. The aim is to adjust foot posture and redistribute pressure away from problematic areas, with the aim of making everyday movement more comfortable. 

Once we have the scan of your foot we perform a detailed biomechanical assessment checking you for leg length discrepancies, imbalances and foot posture abnormalities. We then assess you in motion  and standing. Finally we CAD CAM design the insole to fit your foot perfectly and build our prescription into into it. Once this is complete we use state of the art purpose built 3D Printer to print out your devices from amaterail specific to your needs. 

We have 45 years experience of producing orthotics,  investing in the latest technology and training, treating patients such as the England Rugby League Team,runners, hikers and elderly patients. We have had patients who travelled from as far as Hong Kong, Australia, Canada, Nigeria and the Middle East to see us.

Despite our experience with athletes and professional sports men and women our speciality is getting elderly people moving and walking, helping with balance, strength and mobility.

Stretching and strengthening

Exercises may be recommended to improve flexibility and strength around the foot and lower leg. In particular, addressing tight calf muscles can be useful because reduced ankle flexibility may contribute to greater pressure through the forefoot. Foot and ankle strengthening can also help improve how your foot handles load. 

Exercises should be appropriate for your individual symptoms. If an exercise increases your pain significantly, stop and seek professional advice rather than continuing to push through it. We have followed many of the premiership football clubs and sports clubs by investing in Vald which allows us to strength test individual muscles and the range of motion at your joints. We can then monitor your progress and prescribe specific meaningful exercises. 

Manage swelling and discomfort

Resting and elevating your foot can help when symptoms are aggravated, while an ice pack wrapped in a towel can be applied for up to 20 minutes at a time. Leave 2-3 hours between applications. We also offer corticosteroid injections for arthritic joint pain and soft tissue complaints like nerve impingements affecting the foot and ankle.

A pharmacist can also advise on appropriate pain relief if required.

Seek guidance from experienced podiatrists 

At The Bell Practice, our focus is on understanding the cause of your discomfort and supporting you with solutions designed specifically for you. With the right care, many common foot issues can be effectively managed or prevented altogether  allowing you to get back to doing what your painful symptom is preventing you doing. If you feel that your feet could benefit from additional support or you’re experiencing persistent, chronic pain in the balls of your feet, we are here to provide expert guidance and care tailored to you; we use 3D printed orthotics, fully bespoke to your feet with a 3 year warranty on the orthotic shell.