Anatomy of the Foot and Toes

The foot is divided into three sections, the forefoot, the midfoot and the hindfoot. The forefoot has five toes (14 phalanges) and five longer bones (metatarsals). One phalanx of each of the five toes connects to one of the five metatarsals. Each of the four lesser digits, or smaller toes, contains three joints. The metatarsophalangeal joint (MTP) connects the toe to the foot. The middle joint is the proximal interphalangeal joint (PIP). The small joint at the end of the toe is the distal interphalangeal joint (DIP). The big toe, or great toe (hallux), contains two joints, the MTP and DIP.

Nearly one-fourth of all bones in the human body are in the feet. These complex, flexible structures contain bones, joints, and more than 100 muscles, tendons and ligaments, all working together to enable movement and balance.

Difficulties with the feet and toes can lead to more serious problems, not only for the feet, but also for other areas, including the spine. In some cases, these problems may be caused by footwear that fits improperly, does not accommodate normal foot alignment, or that interferes with natural movement and balance of the body.

What is Metatarsalgia?

Metatarsalgia is pain and inflammation in the forefoot, or ball of the foot (located on the sole, or bottom, of the foot between the toes and arch). While not generally considered a serious condition, left untreated, metatarsalgia can worsen and have a negative impact on daily life.

There are three types of metatarsalgia, depending on the cause of the condition.

Primary metatarsalgia—Occurs as a result of increased pressure on the forefoot due to an issue with other parts of the foot, such as bunions, hammer toes, high arches, calluses, or second toe longer than the big toe (Morton’s toe).

Secondary metatarsalgia—Occurs as a result of: increased pressure on the forefoot due to high-impact activities like jumping and running on hard surfaces; inflammatory conditions such as rheumatoid arthritis, gout, or Morton’s neuroma; neurological disorders such as Charcot-Marie Tooth disease; metabolic problems such as obesity and diabetes; torn ligaments, and other health issues; or ill-fitting shoes.

Latrogenic metatarsalgia—Although rare, this condition is typically the result of complications from a previous bunion surgery or other forefoot surgery that has altered the biomechanics of the foot.

Symptoms of Metatarsalgia

  • Sharp, shooting, burning or aching pain in the ball of the foot
  • Pain is worse when standing, running, or walking, especially when barefoot on a hard surface
  • Numbness or tingling in the toes (paresthesia)
  • Pain when flexing the affected foot
  • Uncomfortable sensation like having a stone in your shoe
  • Pain may occur suddenly or develop gradually

Causes and Risk Factors

  • Participation in high-impact sports, intense training, or other strenuous activities
  • Frequently wearing high heels, cleats, athletic shoes without proper padding and support, shoes with a pointed toe or narrow toe box, or other ill-fitting footwear
  • Excess weight or obesity
  • Stress fractures
  • Foot shape, deformities, or issues
  • Tight Achilles tendon
  • Preexisting inflammatory, neurological, or metabolic conditions; certain injuries

Diagnosing Metatarsalgia

Your physician may examine your foot manually, moving joints, checking spaces between metatarsal bones, touching the bottom of the foot, and squeezing the foot from top to bottom and over the joints. You may also be asked about your symptoms, daily activities, and footwear. While a diagnosis can often be made during the exam, your specialist may also require diagnostic imaging studies such as X-rays may be needed to rule out any stress fractures or other issues causing or contributing to the condition.

Nonsurgical Treatment

Nonsurgical treatment is typically all that’s necessary to relieve the signs and symptoms of metatarsalgia. However, if nonsurgical measures have been unsuccessful, you may consider discussing surgical options with your podiatrist. In rare cases where conservative treatment does not provide relief or there is an additional, underlying foot condition, surgery may be considered to realign metatarsal bones.

If metatarsalgia is not properly treated, it may lead to other foot and ankle problems and you may begin to compensate by walking abnormally, causing additional problems in your lower back or hip.

Conservative, nonsurgical treatment includes:

Activity changes—Modify your daily routine to avoid activities that cause or aggravate symptoms

RICE (Rest, Ice, Compression, Elevation)—Use of the RICE method may help relieve discomfort.

Over-the-counter nonsteroidal anti-inflammatory medication (NSAIDs)—Drugs such as ibuprofen or naproxen, sometimes in combination with acetaminophen, may be prescribed to help reduce swelling and relieve pain. Most people are familiar with these medications, however, whether using over-the-counter or prescription strength, they must be used carefully and according to directions. Using these medications for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.

Physical therapy exercises—Your physician may prescribe specific foot and ankle stretching exercises.

Shoe inserts (orthotics)—Inserting soft insoles or metatarsal pads in your shoes may help relieve discomfort. Arch supports may also be helpful

Properly fitting footwear—Make sure your shoes are comfortable and the proper size, avoid or limit pointed toes or high heels, and choose athletic or other shoes that are supportive and appropriate for your activities.