Metatarsalgia (Pain in the Ball of the Foot)

Metatarsalgia is pain in the ball of the foot, usually under the second and third toes. It happens when too much weight passes through the front of the foot, and it often feels like walking on pebbles. Most people improve with cushioned insoles, better footwear and calf stretches. Surgery is reserved for persistent cases.

Metatarsalgia is a description of where the pain is rather than a single diagnosis. The heads of the metatarsal bones form the ball of the foot. If weight is not spread evenly across them, one or two take more load than they should and become painful. A long second or third metatarsal, or a high-arched foot, makes this more likely. Pain in the ball of the foot is a common complaint.

What are the symptoms of metatarsalgia?

• Pain under the second or third toe, in the ball of the foot
• A feeling of walking on pebbles or marbles
• Pain that worsens with standing or walking, especially barefoot or on hard surfaces
• Calluses (hard skin) under the ball of the foot

Some people describe a vaguer ache or burning rather than a sharp pain. It can affect one or two toes, or the whole forefoot of one or both feet.

What causes it?

• Foot shape: a long second or third metatarsal, or a high arch
• Tight calf muscles and Achilles tendon (the posterior chain), which push more load onto the forefoot
• Footwear, particularly high heels or thin-soled shoes
• Overuse, such as running or jumping sports
• Related conditions, such as Morton's neuroma or a plantar plate injury

Other risk factors include a bunion or arthritis in the big toe, previous big toe surgery, being overweight, clawed or hammer toes, and a stiff ankle that cannot bend up to a right angle. Each of these shifts extra pressure onto the lesser metatarsal heads.

Non-surgical treatment

Most cases settle without surgery. Treatment aims to take pressure off the ball of the foot:

• Padded insoles or metatarsal pads (felt or silicone) to offload the painful area
• Wide, well-cushioned shoes with a lower heel
• Regular calf and Achilles stretching to reduce forefoot load
• Activity modification, avoiding high-impact activities while symptoms settle

For a flare of pain, the NHS suggests holding an ice pack wrapped in a towel on the area for up to 20 minutes every two to three hours, resting with the foot raised, and using paracetamol or ibuprofen gel. Keeping to a healthy weight also reduces the load through the forefoot.

When is surgery recommended?

If pain persists despite these measures, surgery may be considered. The aim is to rebalance the load across the metatarsal heads. This typically involves a small corrective osteotomy of the metatarsal bone: shortening and elevating the bone to reduce pressure on the ball of the foot, fixed with a small screw. The procedure is performed under general anaesthetic.

What is recovery like after metatarsal surgery?

After a metatarsal osteotomy, a surgical shoe is worn while the bone heals, with a return to normal footwear by 6–8 weeks. Swelling in the forefoot can take some months to settle completely.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Pain in the ball of the foot. NHS. https://www.nhs.uk/symptoms/foot-pain/pain-in-the-ball-of-the-foot/
2. Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev. 2016;1(11):409–419. PMID: 28461920. https://pubmed.ncbi.nlm.nih.gov/28461920/
3. Flat feet. NHS. https://www.nhs.uk/conditions/flat-feet/