Metatarsalgia: Pain in the midfoot

If you’re one of the many people who suffer from metatarsalgia, you know how debilitating the pain in the metatarsus can be. Whether it feels like drilling, stabbing, or burning, this pain can make even the simplest tasks, like walking, unbearable. It can also make it difficult to wear your favorite shoes. Instead of resorting to surgery, is there another way to alleviate this pain? In this article, we’ll explore the causes of metatarsalgia and discuss various treatment options, both surgical and non-surgical, that can help you find relief.

What is metatarsalgia?

Metatarsalgia is a common foot condition that refers to pain in the metatarsal bones, which are located in the midfoot. The term is used as a collective for various types of pain that can affect the second to fifth metatarsal bones. It is important to note that pain in the first metatarsal bone is referred to by a different name. The condition can be caused by a variety of factors such as overuse, injury, or structural issues in the foot. Depending on the underlying cause of the pain, metatarsalgia can be classified into two types: acute and chronic. Acute metatarsalgia is caused by a sudden injury or strain, while chronic metatarsalgia develops over time as a result of repetitive stress or overuse. It’s important to understand that metatarsalgia is a common condition and there are various treatment options available to alleviate the pain and prevent future recurrence.

Forms of Metatarsalgia

When it comes to metatarsalgia, there are two main types: primary and secondary.

Primary metatarsalgia is caused by a problem with the metatarsal bones themselves, such as a splayfoot. This type of metatarsalgia can be caused by overuse, injury, or structural issues in the foot.

Secondary metatarsalgia, on the other hand, is caused by a systemic issue that affects the entire body, such as circulatory disorders. This type of metatarsalgia can be caused by conditions such as rheumatoid arthritis or diabetes.

It’s important to note that both types of metatarsalgia can present with similar symptoms, but the underlying causes and treatment options can vary. An accurate diagnosis by a medical professional is crucial in determining the best course of treatment.

Causes and what happens in the foot

As metatarsalgia is a broad term that encompasses various types of pain, the causes can vary widely. To better understand the condition, it’s helpful to explore the specific causes and how they manifest in the foot. Some common causes of metatarsalgia include:

Hallux valgus and splayfoot

Hallux valgus and splayfoot are common foot conditions that can lead to metatarsalgia. Hallux valgus, also known as a bunion, is a condition where the big toe is angled towards the second toe. Splayfoot, on the other hand, is a condition where the arch of the foot collapses, resulting in the foot appearing wider than normal.

In splayfoot, the first metatarsal bone is loose and over-mobile, which causes it to move upward when the foot rolls. This means that the first metatarsal bone absorbs less stress, but unfortunately, the second metatarsal bone is firmly connected to the foot and cannot evade the load, it has to bear the load, plus the load which was not taken over by the first bone. As a result, the second metatarsophalangeal joint suffers from this heavy load and metatarsalgia occurs.

In Hallux valgus, the big toe is angled towards the second toe. This misalignment causes the bones in the foot to shift out of their normal position, leading to a change in the distribution of weight and pressure on the metatarsal bones. This can result in pain and inflammation in the metatarsals, known as metatarsalgia.

It’s important to understand that both splayfoot and hallux valgus are common conditions that can be treated with proper care and management. Consulting a medical professional is crucial for an accurate diagnosis and for determining the best course of treatment.

Claw toes and hammer toes

Claw toes and hammer toes are common foot conditions that can lead to metatarsalgia. They are caused by the tightening or shortening of the tendons and ligaments in the toes, which results in the toes being bent in a claw-like or hammer-like shape. These conditions are often caused by tight footwear or genetics.

In claw toes and hammer toes, the small toes are overstretched in the base joint, which causes the metatarsal heads to be stretched upwards and bent strongly in their further joints. This stretching upwards at the metatarsal heads is important as it causes the joints to bulge out, exposing the metatarsophalangeal joints.

When we walk, the small toes are responsible for absorbing the load. However, due to their bent shape, they are not able to do so effectively. As a result, the foot rolls over the metatarsal heads, leading to overloading and inflammation. This can cause metatarsal pain, known as metatarsalgia.


Calluses, also known as callosity, may not seem like an obvious cause of metatarsalgia, but as the author of this article experienced with a patient, they can be a contributing factor. Calluses are areas of thick, hardened skin that develop on the feet as a result of pressure or friction. They are usually found on the soles of the feet, but in some cases, they can also develop on the tops or sides of the toes.

In the case of the author’s patient, a small corn (a type of callus) on the sole of the foot was causing severe metatarsal pain throughout the left forefoot. Despite treatment for the metatarsal pain, the patient’s symptoms were not improving. Eventually, a pedicure revealed that the corn was pressing on a specific spot, which was causing the pain to radiate throughout the entire forefoot. After the corn was removed, the patient’s pain subsided.

This experience highlights that the causes of metatarsalgia can be complex and multifaceted. It also emphasizes the importance of considering all possible causes and not relying solely on textbook knowledge. It’s important to keep in mind that the treatment of callosity may be necessary to alleviate metatarsalgia symptoms.

Morton’s neuroma

Morton’s neuroma is a condition that can cause metatarsalgia. It is caused by the thickening of the nerve tissue that runs between the third and fourth toes. This thickening can cause the nerve to become irritated and compressed, leading to pain, tingling, and numbness in the affected area. The pain is often described as a burning or shooting sensation and is usually felt on the bottom of the foot, between the third and fourth toes.

Morton’s neuroma is commonly caused by wearing tight or high-heeled shoes, which can put pressure on the toes and compress the nerve. It can also be caused by a structural problem, such as a high arch or a bunion, which can cause the toes to be squeezed together.

When left untreated, Morton’s neuroma can lead to chronic pain and discomfort in the affected area, which can make it difficult to walk or wear shoes comfortably. It’s important to seek medical attention if you suspect you have Morton’s neuroma as it can be treated with therapy, medication, and in severe cases, surgery.

It’s important to keep in mind that Morton’s neuroma can be a contributing factor to metatarsalgia and addressing it can help alleviate the symptoms.

Morbus Köhler

Morbus Köhler is a rare condition that can cause metatarsalgia. It is a degenerative disorder of the metatarsal bones in the foot, characterized by abnormal growth and thickening of the bones. This thickening can cause pain, stiffness, and difficulty in walking. The condition is most commonly seen in the second metatarsal bone, but it can also affect other bones in the foot.

The exact cause of Morbus Köhler is not well understood, but it is believed to be related to a genetic defect in the growth plate of the metatarsal bones. It is a rare condition, but it is more common in men than women.

Symptoms of Morbus Köhler include pain and stiffness in the affected foot, difficulty in walking, and sometimes a bump or lump on the top of the foot. The condition can also lead to the development of a bunion or hammertoe.

Morbus Köhler is a chronic condition that requires long-term treatment. Treatment options include pain management, physical therapy, and in some cases, surgery to remove the affected bone. It’s important to seek medical attention if you suspect you have Morbus Köhler as it can be a cause of metatarsalgia and addressing it can help alleviate the symptoms.


Diabetes is a systemic disease that can lead to metatarsalgia. Diabetes is a metabolic disorder characterized by high blood sugar levels, which can damage blood vessels and nerves throughout the body.

Diabetic neuropathy, a complication of diabetes, can affect the feet and cause pain, tingling, and numbness in the toes and feet. This can make it difficult to feel injuries or blisters on the feet, which can lead to ulceration and infection. The nerve damage caused by diabetic neuropathy can also cause the muscles in the foot to weaken and change the way a person walks, leading to increased stress on the metatarsals and causing metatarsalgia.

Diabetes can also cause poor circulation, which can lead to slow healing of injuries and increased risk of infection. This can make it difficult to treat and manage metatarsalgia.

It’s important for people with diabetes to closely monitor their blood sugar levels and to take steps to control their diabetes. Regular foot exams, maintaining healthy blood sugar levels, and good foot hygiene are important in preventing and managing metatarsalgia in people with diabetes.

Symptoms of Metatarsalgia

Symptoms of metatarsalgia can vary widely depending on the underlying cause and severity of the condition. Some common symptoms include:

  • Burning pain in the anterior metatarsus: This is a common symptom of metatarsalgia and can feel like a burning sensation in the front of the foot, specifically in the metatarsal bones.
  • Calluses and thickened skin: Over time, metatarsalgia can cause thickened skin and calluses to develop on the bottom of the foot, particularly in the area of pain.
  • Tarnishing pain: This type of pain typically improves with movement or warming up, but can return when the foot is at rest.
  • Slow gait: People with metatarsalgia may have a slow gait or limp due to pain and discomfort in the affected area.
  • Stabbing pain in the metatarsal heads: This type of pain can feel like sharp, stabbing sensations in the bones of the midfoot.
  • Pain when standing on toes: People with metatarsalgia may experience pain in the front of the foot when standing on their toes.
  • Shooting pain in the toes: Pain from metatarsalgia can also radiate into the toes, causing shooting or stabbing sensations.
  • Spasmodic pain in the anterior sole of the foot: Some people may experience spasmodic or cramping pain in the front of the foot.
  • Pulling pain along the metatarsals: Some people with metatarsalgia may experience a pulling or stretching sensation along the metatarsal bones.

It’s important to note that not everyone will experience all of these symptoms and that the intensity of the symptoms can vary. An accurate diagnosis by a medical professional is crucial in determining the best course of treatment.

Possible consequences of metatarsalgia

When left untreated, metatarsalgia can lead to other problems in the body. Some of the possible complications include:

  • Morton’s neuroma: This is a special form of metatarsalgia in which a nerve is affected. Broken metatarsal bones, swelling, and soft tissue shifts can cause increased pressure on the nerves, leading to a Morton’s neuroma.
  • Pain in the ankle joint: People with metatarsalgia may develop a limp, which can cause the ankle joint to be overloaded as it is no longer rolled properly. This can lead to pain in the ankle joint.
  • Pain in the knee: Overloading of the ankle joint can also affect the knee, causing it to move improperly. This can lead to pain on the inside of the knee.
  • Back pain: Due to a limp, people may make evasive movements in the upper body, which can cause the back to become tense and start to hurt.
  • Heel spur: Overloading of the fascia in the sole of the foot or Achilles tendon can lead to the formation of a heel spur. This can occur either at the heel bone in the sole of the foot, or at the point of attachment of the Achilles tendon.

It’s important to note that these are only some of the potential complications that can occur from metatarsalgia and not everyone will experience them. An early diagnosis and proper treatment can help prevent these complications from occurring or worsening.

Immediate aid

Pause: If metatarsal pain sets in during heavy exertion, pause immediately. Do not continue with sport or work. In some cases it does not work and pain does not come suddenly. But getting stronger during the day. Then after the load if possible spare. After working in work shoes, do not necessarily continue to strain but relax and read the other tips.

Pain gel: I am not a friend of medication. But in some cases it makes sense. Before you can no longer walk at all, grab a pain ointment. However in moderation use. And if the metatarsal pain has disappeared, do not exaggerate again immediately. Many then often overestimate themselves and continue with the strain as before. This can make it even worse, because you can no longer feel the limit so well.

Massage: If you are flexible enough, massage your feet. If not, then let massage. Muscles and tendons want to relax. And with a massage the blood circulation is stimulated. In this way, metabolic waste products and inflammatory substances can be better removed.

Mobilization: Take 2 metatarsal heads with your fingers and move them slightly against each other. If you don’t get it, let someone else do it. Because this gentle movement relaxes the tendons a little, increases the blood circulation and overlays the pain.

Foot bath or warmth: Relax your feet with a foot bath or a hot-water bottle. The warmth also relaxes your muscles and tendons. But enjoy with caution. Because warmth is not appropriate for acute inflammation. The next tip will help.

Cold: Cold quickly overlays pain. If it is an inflammation, it is slightly alleviated. After cooling, the foot heats up again and is better supplied with blood. Several times a day in acute cases.

Shoe change: Your feet hurt in your shoes after some time. Then change them throughout the day. So your feet have some variety and some structures can relax a bit.

When should I go to the doctor for metatarsalgia?

You shouldn’t run to the doctor for every ailment. Does it make sense with metatarsalgia?

As an exception, I say yes now.

Because as you have seen above, pain in the metatarsus has various causes. It can be harmless for you. But maybe not. And caution is better than indulgence. Just let it be clarified.

I have already experienced patients who have broken a bone without noticing it directly. They had only a little pain which disappeared after a few days. Only months later did they experience serious pain. Then the x-ray showed that the bone was broken.

So don’t take metatarsal pain lightly. Let it be clarified for safety’s sake.

You may also like...