Metatarsalgia: causes, symptoms, diagnosis and treatment

By Cristiano Antonino Last updated May 29, 2023

A painful sensation in the anterior area of the foot, where the so-called metatarsal bones are located, could be a symptom of metatarsalgia, a fairly common foot disorder

There are several factors that can cause the onset of this painful condition, which requires a thorough test and careful analysis of the patient’s medical history in order to be recognised and to establish the best therapy to be undertaken depending on the case.

Metatarsalgia: What is it?

Metatarsalgia is a disorder that is described as pain in the forefoot, of an inflammatory nature, localised in the plantar region, more precisely at the metatarsal bones that articulate to the phalanges.

Anyone can suffer from metatarsalgia but, according to various epidemiological studies, the condition is more frequent in women who frequently wear high heels, overweight individuals, those with severe anatomical deformities in their feet, those suffering from gout or rheumatoid arthritis, and in individuals who engage in strenuous motor activity such as walking or running.

Various classifications have been made over the years, but the most commonly used one recognises two different types of metatarsalgia

Biomechanical metatarsalgia: the most frequent, it is linked to an altered support of the bones that make up the foot on the ground. In these cases, a pathological distribution of the body’s weight on the metatarsals is determined. This imbalance of load distribution leads, in the long run, to painful symptoms.
Non-biomechanical metatarsalgia: caused by systemic diseases such as rheumatoid arthritis, systemic lupus erythematosus, etc., or by local affections such as septic arthritis.

Another subdivision, useful to better identify the causes of metatarsalgia, is that which divides it into: primary, secondary and iatrogenic

Primary metatarsalgia can be caused by anatomical abnormalities of the metatarsals that affect the correct relationship with the rest of the foot. Other causes of primary metatarsalgia may be excessive length of the second or third metatarsals, congenital deformities of the metatarsal heads, excessive tension of the gastrocnemius or triceps muscles, hollow foot, equinism of the foot and, in general, any abnormality that causes overloading of the forefoot.

Secondary metatarsalgia, on the other hand, occurs as a consequence of trauma, while iatrogenic metatarsalgia can occur following unsuccessful reconstructive surgery.

What are the triggering causes?

Very rarely is metatarsalgia caused by a single factor.

More often, in fact, it is a combination of very different causes which, taken individually, would not have triggered the painful condition.

Let’s take a look at a list of the most common causes:

Congenital or acquired foot deformities such as hollow foot, hammer toes or hallux valgus.
Very intense motor activity. Those who practise sport, especially at a competitive level with daily training, tend to often suffer from metatarsalgia. Particularly at risk are those who play sports that involve a lot of running or movements that continually produce an impact with a hard and/or uneven surface (tennis, football, baseball, running, etc.).
The continuous use of certain types of footwear such as, for example, heeled shoes or boots required in certain types of sport.
Obesity and overweight. Excess body weight leads to overloading of the lower limbs and more damage to the knees, ankles and feet. This predisposes the subject to more injuries and painful conditions, including metatarsalgia.
Stress fractures, i.e. minor bone fractures caused by repeated microtrauma. These fractures can cause the subject to assume incorrect positions resulting in overloading of the forefoot, which can lead to the development of metatarsalgia over time.
Ankle pain or inflammation of the Achilles tendon. Two disorders that lead the subject to assume an abnormal posture when walking in order to feel less pain, which may lead to an overload in the metatarsal area.
Morton’s neuroma, a particularly painful disorder that affects the interdigital nerves of the feet, i.e. the nerve endings between the various metatarsals.
Diabetes, one of the main complications of which is degeneration of the nerve endings that can affect the toes.
Rheumatoid arthritis or gout. Both are inflammatory diseases of the joints that can cause painful symptoms in the ankles as well as in the forefoot.
Freiberg disease, also called metatarsal osteochondrosis, which causes a process of necrosis involving the second metatarsal of the foot.
Metatarsalgia can occur either due to the factors listed or, as mentioned above, a combination of these factors.

For example, individuals who suffer from obesity and are in the habit of wearing the wrong footwear, or people who, despite having ankle pain, continue to exercise instead of observing a rest period are more prone to metatarsalgia.

What are the symptoms of metatarsalgia?

Individuals suffering from metatarsalgia experience pain of varying intensity in the forefoot.

The painful sensation may be very sharp, dull or burning and tends to worsen after spending many hours standing or after a long walk or run.

Other common symptoms are stabbing pain, tingling sensation and numbness in the toes and the feeling of having pebbles in the shoes.

The presence of hyperkeratosis, i.e. plantar callosities at the level of the metatarsal heads, is one of the most common signs of metatarsalgia, caused by excessive loading in that specific area of the foot.

In individuals who are overweight or suffer from obesity, rheumatoid arthritis and foot deformities, metatarsalgia appears more frequently in a gradual manner.

In contrast, those who engage in strenuous sporting activity or wear tight shoes or high heels, this disorder tends to occur suddenly.

If neglected or badly treated, metatarsalgia tends to worsen, with the pain in the affected foot becoming more acute.

In addition, it can lead to the onset of other back or hip problems.

Even before seeking medical advice, it is advisable to keep the painful foot at rest for a short time.

Very often, in fact, metatarsalgia can be mild and resolve itself by observing a few simple measures.

However, if the painful situation does not tend to disappear but rather worsens, it becomes essential to consult a specialist doctor as soon as possible for a thorough examination.

How is metatarsalgia diagnosed?

There are numerous pathologies of the foot that cause the same symptoms.

For this reason, an accurate anamnesis, an objective examination and, if necessary, further diagnostic investigations by means of instrumental tests are required in order to make a correct diagnosis.

The purpose of the anamnesis is to gather all information about the patient’s medical history: any traumas, previous surgeries, history of diabetic neuropathy, habits, etc. Then, through the objective test, the doctor will observe the patient’s gait and assess whether any deformities such as hollow foot, hallux vagi, hammer toes, etc. are present.

Finally, further instrumental tests may be necessary for diagnostic confirmation, including:

Echography
Radiography
Magnetic resonance imaging

Once the diagnosis has been made and the causes of the disorder have been established, the doctor can determine the most suitable treatment for the case.

Metatarsalgia: possible therapies and cures

Usually, metatarsalgia requires conservative treatment to be cured.

However, in cases where the symptoms are severe and the triggering causes tend to worsen, surgical treatment may be necessary.

Conservative therapies

Conservative therapy treatments include:

Rest.
Apply ice packs to the painful foot 4-5 times a day for at least 20 minutes;
Elevating the suffering foot to reduce stress on the limb.
Taking pain-relieving and anti-inflammatory medication in case of very acute pain.
Use of appropriate footwear that helps distribute body weight correctly on the foot.
Use of special anti-shock insoles (made of gel, rubber or cork) to reduce the impact of the foot against the ground.
Use of special insoles for those who suffer from hollow feet, which are useful for normalising the conformation of the arch of the foot and guaranteeing a more correct foot support.
Treating, as far as possible, pathologies that act as risk factors for the development of metatarsalgia such as obesity, gout or rheumatoid arthritis.

Surgical Treatment

Surgery to resolve metatarsalgia is considered very rarely and only when conservative remedies are ineffective.

In fact, the operation is performed in subjects with very severe foot deformities or in subjects suffering from Morton’s neuroma, which causes very severe and long-lasting symptoms.

How to prevent the onset of the disorder?

In order not to run the risk of developing metatarsalgia, it is important to pay attention to the footwear worn, use anti-shock insoles, especially when practising daily sports, and keep weight under control so as not to overload the structures of the lower limbs such as the knees, ankles and feet.

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