What Is Metatarsalgia?
The metatarsals are the five long bones of the foot that connect with the toes. When one or more of these bones, or the metatarsophalangeal (MTP) joints at their ends, become overloaded or irritated, pain can develop in the ball of the foot.
Treatment depends on the underlying cause and may range from conservative care to surgical correction when symptoms persist. The goal is to reduce painful pressure, improve foot mechanics, and restore comfortable movement.
What Causes Metatarsalgia?
Metatarsalgia can develop from several different causes. These may arise directly from the metatarsal bones, result from other conditions affecting the foot, or occur following previous surgery.
Primary Causes
- Abnormal metatarsal length
- Structural deformities of the metatarsal bones
- Stress fractures or other bone injuries
- Arthritis affecting the MTP joints
Secondary Causes
- Bunions (hallux valgus), which can shift weight toward the lesser toes
- Hammertoes or claw toes that alter pressure distribution
- Tight calf muscles
- Plantar plate tears involving the ligaments beneath the toe joints
- Morton’s neuroma
- Excess body weight
Contributing Factors
Other factors that may increase pressure on the forefoot include:
- High-impact activities such as running, jumping, or dancing
- High heels or poorly fitting shoes
- High arches or flat feet
- Aging and loss of the natural fat pad beneath the ball of the foot
- Inflammatory conditions such as rheumatoid arthritis
In patients who also have bunions, metatarsalgia may be associated with factors such as Achilles tendon tightness, excess weight, and accompanying toe deformities rather than the bunion alone.
What Are the Symptoms of Metatarsalgia?
Symptoms typically affect the ball of the foot and may become more noticeable during weight-bearing activities.
Pain Symptoms
- Sharp, aching, or burning pain in the ball of the foot
- Pain that worsens while walking, running, or standing
- A sensation similar to walking on a marble or small pebbles
- Discomfort that may extend toward the toes
- Symptoms that develop gradually and worsen over time
Physical Signs
- Swelling or inflammation in the forefoot
- Calluses or thickened skin beneath the ball of the foot
- Tenderness when pressure is applied to the affected area
- Changes in toe position or alignment
- Difficulty wearing certain shoes
Effect on Daily Activity
As symptoms progress, patients may have difficulty walking or standing for extended periods, avoid high-impact activities, or change the way they walk to reduce pressure on the painful area. This can affect overall mobility and everyday activities.
Non-Surgical Treatment Options
Treatment generally begins with conservative measures aimed at reducing pressure on the forefoot and relieving symptoms.
Footwear Modifications
- Shoes with a wide toe box and adequate cushioning
- Avoiding high heels and narrow footwear
- Rocker-bottom shoes to help reduce forefoot pressure
- Appropriate arch support
Orthotic Devices
- Prefabricated shoe inserts
- Metatarsal pads to redistribute pressure away from painful areas
- Arch supports to improve foot mechanics
Activity Modification
- Reducing high-impact activities that aggravate symptoms
- Choosing lower-impact exercise such as swimming or cycling
- Gradually returning to normal activities as symptoms improve
Physical Therapy
- Stretching the calf muscles and Achilles tendon
- Strengthening the muscles of the foot
- Gait training to improve walking mechanics
Medications
Over-the-counter pain relievers and anti-inflammatory medications may be used when appropriate to help manage pain and inflammation.
Weight Management
Achieving and maintaining a healthy weight can help reduce pressure placed on the forefoot.
Conservative treatment can provide significant relief for many patients. However, these measures do not correct every underlying structural problem. When symptoms continue despite appropriate non-surgical treatment, surgery may be considered.
Surgical Treatment: Minimally Invasive Metatarsal Osteotomy
When conservative treatment does not provide adequate relief, minimally invasive metatarsal osteotomy may be used to address structural problems contributing to metatarsalgia.
What Is a Minimally Invasive Metatarsal Osteotomy?
A minimally invasive, or percutaneous, metatarsal osteotomy is performed through very small incisions using specialized surgical instruments.
The procedure allows the affected metatarsal to be shortened, elevated, or otherwise corrected while limiting disruption to the surrounding soft tissues.
Compared with traditional open surgery, which requires larger incisions to access the metatarsal bones, the minimally invasive approach is designed to reduce surgical trauma while achieving the necessary correction.
How Is the Procedure Performed?
The procedure may include:
- Small skin incisions
- Specialized surgical instruments used to cut, shorten, or elevate the affected metatarsal
- Real-time X-ray guidance (fluoroscopy) to guide the bone correction
- Treatment of multiple metatarsals during the same procedure when necessary
Following correction, the metatarsal gradually heals in its new position. Depending on the technique used, internal fixation with screws or plates may not be required.
The procedure is generally performed as outpatient surgery under sedation and regional anesthesia and may be combined with other foot procedures when necessary.
How Does Metatarsal Osteotomy Relieve Pain?
The procedure is designed to reduce excessive pressure beneath the affected metatarsal and improve the distribution of weight across the forefoot.
Pressure Redistribution
Shortening or repositioning an overloaded metatarsal reduces pressure beneath its metatarsal head and allows pressure to be distributed more evenly across the forefoot.
Soft Tissue Relaxation
Correcting the metatarsal can decrease tension in the surrounding ligaments, tendons, and joint capsule, helping decompress the MTP joint and reduce irritation.
Joint Decompression
Reducing abnormal pressure within the MTP joint may decrease inflammation and create improved conditions for damaged structures, including the plantar plate, to heal.
Advantages of Minimally Invasive Metatarsal Osteotomy
Compared with traditional open metatarsal surgery, the minimally invasive approach may offer several potential advantages.
Minimal Surgical Trauma
- Very small incisions
- Limited disruption of surrounding soft tissues
- Preservation of blood supply to the area
- Less damage to surrounding structures
Wound and Soft Tissue Considerations
Smaller incisions and reduced soft tissue disruption are intended to limit wound-related concerns, soft tissue scarring, and postoperative stiffness.
Pain and Function
Clinical studies have reported improvement in pain, foot function, and pressure distribution beneath painful metatarsal heads following minimally invasive metatarsal osteotomy.
Recovery
The minimally invasive approach may allow:
- Earlier return to normal activities
- Reduced postoperative pain and swelling
- Faster healing of the small surgical incisions
Cosmetic Results
The small incisions used during minimally invasive surgery generally result in less visible scarring compared with traditional open procedures.
Early Weight-Bearing
Depending on the procedure and individual patient, weight-bearing may be permitted early in the recovery period while wearing protective footwear.
Bone Healing
The corrected metatarsal gradually heals over time. Bone healing is monitored during follow-up appointments, and internal fixation may not be necessary in some cases.
Recovery After Minimally Invasive Metatarsal Osteotomy
Recovery progresses gradually as the bone and surrounding tissues heal. The exact recovery timeline can vary depending on the procedure performed and the individual patient.
Immediately After Surgery
- A surgical shoe or walking boot is used to protect the foot
- Small dressings cover the incisions
- Elevation and ice may be used to help control swelling
- Pain medication may be used as prescribed
Early Recovery
During the early stages of recovery:
- Weight-bearing may be allowed in a protective surgical shoe
- Elevation can help manage swelling
- Incisions should be kept clean and dry as directed
- Follow-up appointments are used to monitor healing and change dressings when necessary
As Healing Progresses
Patients may gradually:
- Increase walking and activity
- Transition from protective footwear to supportive shoes
- Begin gentle range-of-motion exercises when recommended
- Return to normal daily activities as healing allows
Follow-up X-rays may be used to evaluate bone alignment and healing.
Long-Term Recovery
Forefoot swelling may continue for several months following surgery and generally decreases gradually.
As recovery progresses, patients may experience improvements in walking comfort, foot function, and tolerance of regular footwear. Return to higher-impact activities and sports should occur gradually as healing allows.
The final result develops over time as the bone heals, swelling resolves, and the foot adapts to the corrected alignment.
Potential Complications
Although minimally invasive metatarsal osteotomy is designed to limit surgical trauma, complications remain possible.
Common Minor Issues
- Swelling that may persist during recovery
- Temporary stiffness of the toes
- Mild discomfort during the healing process
Less Common Complications
- Transfer metatarsalgia, where pain develops beneath an adjacent metatarsal
- Nonunion, in which the bone does not heal
- Malunion, in which the bone heals in an incorrect position
- Changes or deformity of the toes
Your Surgeon for Metatarsalgia Treatment on Long Island
Kristian Efremov, MD, PhD, is a fellowship-trained orthopedic foot and ankle surgeon. He evaluates and treats metatarsalgia (ball of foot pain) for patients across Nassau and Suffolk County at NYU Langone Ambulatory Care East Meadow, 1530 Front Street, Suite 200, East Meadow, NY 11554.
Options covered on this page range from footwear changes, orthotics and physical therapy to minimally invasive metatarsal osteotomy. The right option depends on your exam, imaging and goals.
Dr. Efremov completed his foot and ankle surgery fellowship at New England Baptist Hospital and is a Clinical Assistant Professor in the Department of Orthopedic Surgery at NYU Grossman Long Island School of Medicine.
To request an appointment, call (516) 324-7500 or read more about Dr. Efremov.
Medical Disclaimer. The information provided on this website is intended for general educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare professional regarding any medical condition, symptoms, or treatment options.