Metatarsalgia

Metatarsalgia

Differentials

• Morton’s neuroma: Irritation or entrapment of the digital nerve, often between the 3rd and 4th metatarsals

• Hallux valgus: Lateral deviation of the great toe leading to abnormal pressure over the metatarsal heads

• Turf toe: Sprain of the first MTP joint caused by hyperextension

• Sesamoiditis: Inflammation or stress injury of the sesamoid bones beneath the first MTP joint

• Freiberg’s disease: Avascular necrosis of the 2nd metatarsal head

• Stress fractures: Commonly affect the 2nd, 4th, or 5th metatarsals, sometimes the navicular

• Callus, corns, warts: Focal plantar pressure points

• Peroneal tendonitis or dislocation: Lateral foot pain from overuse or instability

• Foot strain: Acute or chronic repetitive load leading to generalised forefoot pain

• Systemic causes: Osteoarthritis, rheumatoid arthritis, gout, spondyloarthritides

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History

• Footwear history: Narrow toe boxes can precipitate neuromas, high heels increase forefoot load

• Activity level: Running, jumping, or prolonged standing can exacerbate metatarsal stress

• Symptom character: Burning or numbness between toes suggests Morton’s neuroma, pinpoint tenderness over a metatarsal head may indicate Freiberg’s or stress fracture

• Recent trauma or hyperextension: Raises concern for turf toe or sesamoiditis

• Systemic signs: Morning stiffness or joint swelling in RA, flare-ups in gout

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Examination

• Look for deformities like hallux valgus, flat foot, or high arches

• Inspect for callus, corns, or plantar warts over pressure points

• Palpate between metatarsal heads for neuroma (Mulder’s click or localised tenderness)

• Check 2nd metatarsal head for Freiberg’s disease with focal pain

• Assess peroneal tendon by resisted foot eversion and palpation along the lateral foot

• Observe gait for pronation or altered load that may worsen pain

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Management

• Investigations

  • Plain X-ray to identify fracture, Freiberg’s disease, or bony deformity

  • MRI or ultrasound if X-rays are inconclusive, especially for suspected soft tissue lesions (e.g. neuroma) or early stress fractures

  • Blood tests (e.g. ESR, CRP, urate) if inflammatory or crystal arthropathy is suspected

• Activity and offloading

  • Reduce or modify high-impact activities

  • Use partial weight-bearing with a moon boot or supportive footwear for suspected stress fractures or severe Freiberg’s disease

  • Encourage wide toe boxes and low-heeled shoes to offload the forefoot

  • Consider metatarsal pads or orthotics to redistribute pressure

• Physiotherapy and podiatry

  • Exercises to strengthen intrinsic foot muscles and improve calf/ankle flexibility

  • Biomechanical assessment for pronation or supination issues

  • Orthotic prescription to correct underlying foot malalignment

• Pharmacology

  • NSAIDs for pain and inflammation relief

  • Topical analgesics as an alternative for mild cases

  • Corticosteroid injection for Morton’s neuroma if conservative measures fail

• Surgical options

  • Neuroma excision for persistent symptomatic Morton’s neuroma

  • Debridement or osteotomy for advanced Freiberg’s disease

  • Sesamoidectomy or stabilising procedures for severe turf toe or sesamoiditis

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Additional Notes

• Freiberg’s disease requires early immobilisation to prevent joint collapse and chronic metatarsal head damage

• Turf toe management may involve splinting or taping the first MTP joint to limit hyperextension

• Consider rheumatological referral if there is suspicion of inflammatory arthritis contributing to forefoot pain

• Properly fitted footwear and foot orthoses can significantly reduce forefoot pressure and recurrence of symptoms