Metatarsalgia

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Expert Patient Guide · London & North London

Metatarsalgia: Pain Under the Front of the Foot

A comprehensive patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH) Stanmore and UCL — London, UK.

At a Glance: Metatarsalgia (Ball-of-Foot Pain)

Key factMetatarsalgia
ConditionPain under the ball of the foot, where the ends of the long foot bones (metatarsal heads) take your weight.
Who It AffectsRunners and people who play sports like tennis, people on their feet all day, people with bunions, and some people who have had foot surgery before.
Main DriverHow your foot works — around 90% of cases are caused by the way weight passes through the foot.
Two Patterns“Static” – pain when standing; “dynamic” – pain when pushing off to walk or run.
DiagnosisAn examination, including a check for a tight calf, and scans such as standing X-rays, a standing 3D CT scan (Weight-Bearing CT), ultrasound or MRI.
Non-Surgical CareCalf stretches, shoes with a curved (rocker) sole, made-to-measure insoles and pads, and podiatry. These are tried first, for at least 6 months.
Surgical OptionsDepending on the cause: calf release, repair of the ligament under a toe joint, tendon transfer, bunion correction, or reshaping a foot bone (Weil osteotomy or keyhole DMMO).
SpecialistMr Matthew Welck — Consultant Foot & Ankle Surgeon, RNOH Stanmore & UCL, London. matthewwelck.com

01

What Is Metatarsalgia?

Metatarsalgia means pain under the ball of your foot. The ball of the foot is formed by the knuckle-like ends (metatarsal heads) of the five long bones in your foot. It is not a single disease. It is a symptom with many possible causes, so it is important to find the cause before choosing a treatment.

Normally, every time you take a step, these bone ends share your body weight evenly. If one bone is too long or sits too low, or if the rest of your foot and leg put extra pressure on the front of the foot, too much weight goes through one spot and it becomes painful. We now know that the problem often starts higher up — in a tight calf, the ankle, or the shape of the foot. Seeing a specialist Consultant Foot & Ankle Surgeon such as Mr Matthew Welck in London gives you the widest choice of treatments.

02

How Common Is It?

Metatarsalgia is one of the most common reasons people see a foot and ankle specialist. It can affect people of any age. It is especially common in people who stand for long hours, and in active people and athletes — pushing off through the front of the foot again and again makes it a common sports injury.

Research suggests that around 90% of cases are caused by the way weight and pressure pass through the foot, rather than by a disease of the bone itself. In the past, it was seen as a problem of the front of the foot alone, often linked to bunions. Specialists now look at the whole leg.

03

What Causes Metatarsalgia?

There are two main types of cause. Static causes are to do with the shape of your foot and leg. Dynamic causes are to do with how your foot and leg move when you walk or run. Many people have a bit of both. Everyday things can also add pressure and tip the balance into pain: your weight, your shoes (especially high heels and narrow shoes), long hours on your feet, and how much — and on what surface — you train. These are often the easiest things to change.

Static causes — the shape of your foot and leg

  • One of the long bones in the middle of the foot (usually the second or third metatarsal) is longer than the bones next to it, or the big-toe bone is short or sits too high
  • The bones at the front of the foot point down too steeply, or the front of the foot curves inwards (metatarsus adductus)
  • An ankle that stays pointing down (fixed equinus), or ankle arthritis with bony lumps (spurs)
  • Knock knees or bow legs
  • Arthritis in the toe joints, including inflammatory arthritis such as rheumatoid arthritis, gout or psoriatic arthritis. This can make the joints swollen and push the natural fat cushion under the ball of the foot out of place
  • Freiberg’s disease (damage to the end of one of these bones), or a broken bone in the foot that has healed in the wrong position
  • Previous foot surgery that has left a bone too short, too high or too low — for example, bunion surgery that has shortened or lifted the big-toe bone too much, or an operation to remove the end of one of the bones

Dynamic causes — how your foot and leg move

  • Tight calf muscles, which push your weight forward onto the ball of the foot
  • A stiff ankle that does not bend upwards enough
  • Flat feet, or very high arches (pes cavus)
  • A bunion (hallux valgus) or other big-toe problem, which means the big toe takes less weight and the second toe takes more
  • A damaged or loose toe joint — for example a tear in the strong ligament under the joint (the plantar plate). This can make a toe drift or cross over the toe next to it
  • Weak or unbalanced muscles, including from nerve conditions such as Charcot-Marie-Tooth disease

04

What Are the Symptoms?

  • Pain under the ball of the foot, often described as walking on a stone or a folded sock
  • Pain that is worse when standing, walking barefoot, running or wearing heels
  • Hard skin (callus) under the ball of the foot
  • Swelling, clicking or a wobbly feeling at the base of a toe
  • A toe that drifts sideways, lifts off the ground or crosses over the toe next to it
  • Pain that spreads towards the toes as you push off to take a step

There are two main patterns of pain. Knowing which one you have helps guide treatment:

Feature“Static” metatarsalgia“Dynamic” metatarsalgia
When it hurtsWhen standing, with the foot flat on the groundWhen pushing off, as the heel lifts
Main causeFoot bones that point down too steeplyA foot bone that is longer than the ones next to it
Hard skinSpread out, or centred under the ball of the footIn one spot, stretching towards the toe
How commonLess commonThe most common type

Is it Morton’s neuroma?

Burning, tingling or numbness between the third and fourth toes may be a Morton’s neuroma (an irritated nerve) rather than metatarsalgia. You can have both, so both are checked at your appointment.

05

What Tests Might You Need?

  • An examination — watching you walk and stand, checking for a tight calf (the Silfverskiöld test), and gently testing each toe joint for a damaged ligament (the “drawer” test)
  • X-rays of both feet taken while you stand — to compare the lengths of the foot bones and look for bunions or bent toes
  • Weight-bearing CT scan (WBCT) — a low-dose 3D scan taken while you stand. It shows the angle and twist of each foot bone in a way an X-ray cannot. Mr Welck uses it routinely and carries out research on it
  • Ultrasound — a quick scan, done while the toe is moved, to look for a torn ligament under the toe joint (plantar plate), Morton’s neuroma or an inflamed fluid sac (bursitis)
  • MRI scan — to look for ligament damage, small cracks in the bone (stress fractures), Freiberg’s disease or inflamed tendons
  • Blood tests — if an inflammatory arthritis, such as rheumatoid arthritis, is possible

06

Non-Surgical Treatment Options

Most people start with these treatments, and most get better without an operation. They are usually tried for at least six months before surgery is considered:

  • Daily calf stretches (around 20 minutes a day) — for example, lowering your heels off a step with your knees straight, or standing on a sloped board while you brush your teeth. Some people also wear a splint at night
  • Shoes with plenty of room for the toes, a low heel and a thick, fairly stiff sole. A curved (rocker) sole takes pressure off the ball of the foot
  • Made-to-measure insoles, or a small pad or bar placed just behind the sore area to spread the pressure
  • Soft silicone supports for curled (claw or hammer) toes
  • A podiatrist can gently remove painful hard skin, as often as needed
  • Losing weight if needed and, for athletes, changing your training — running less, or changing your running surface or shoes

A note on steroid injections

Steroid injections into a loose toe joint can weaken the ligament underneath and cause the toe to suddenly come out of joint (dislocate). For this reason, they are used very carefully, if at all.

07

Surgical Options for Metatarsalgia

Surgery is only considered when non-surgical treatment has not worked. The aim is to treat the cause, not just the painful spot, and every plan is tailored to you. Often more than one procedure is done at the same time.

Calf (Gastrocnemius) Release

If a tight calf is pushing weight onto the ball of the foot, a small operation to lengthen the calf muscle can relieve the pressure without weakening your push-off. You can walk again soon afterwards. Read more on our calf release page.

Plantar Plate Repair and Tendon Transfer

A torn plantar plate — the strong ligament under each toe joint — makes the toe joint loose and lets the toe drift. It can be stitched back together, or supported by moving a nearby tendon to hold the toe in place. This is often done together with straightening a bent (hammer) toe.

Correcting the Big Toe

When a bunion or big-toe arthritis is the main cause, fixing the big toe often takes pressure off the other foot bones, and may mean they do not need an operation at all.

Weil Osteotomy

This is the most widely used operation on these foot bones in Europe. The bone is cut near its end, shortened by a carefully planned amount and held with a tiny screw. It works well for push-off (dynamic) pain caused by a bone that is too long. The main downside is a stiff toe or a “floating toe” that does not touch the ground, which happens in 12–30% of patients. Daily toe exercises after surgery help reduce this risk.

Minimally Invasive DMMO

DMMO (distal metatarsal metaphyseal osteotomy) is keyhole surgery. The bone is cut through tiny cuts in the skin using a small burr, and no screws are used. When compared directly with the Weil osteotomy, results at one year were similar, but swelling at three months was more common after DMMO (58% compared with 29%). One UK study found that around 13% of patients had a complication. It suits static pain that is spread across the ball of the foot.

The Bigger Picture: Ankle and Hindfoot

A stiff ankle forces the front of the foot to take more weight. If ankle arthritis is the cause, treating the ankle — with keyhole surgery (arthroscopy), ankle fusion or total ankle replacement — can be part of the answer. In the same way, surgery to correct a high-arched or flat foot may be needed, so that the front of the foot is not treated on its own.

Inflammatory Arthritis

When rheumatoid arthritis has changed the shape of the front of the foot, a well-proven option is to fuse (join) the big-toe joint and reshape the ends of the other foot bones. With modern medicines, it is now more often possible to keep the joints instead.

Operations that are no longer recommended

Some older operations — removing the end of a single foot bone, removing the base of a toe bone, or the Helal osteotomy without screws — tend to move the pain to the bones next to them and are no longer advised.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — a specialist orthopaedic hospital that treats complex cases from across the UK — and Honorary Associate Clinical Professor at UCL.

He treats only foot and ankle problems, with particular interests in total ankle replacement, complex foot and ankle reconstruction, surgery to put right earlier operations (including ball-of-foot pain after bunion surgery), Weight-Bearing CT and sports injuries. He has authored over 50 peer-reviewed publications, including Weight-Bearing CT research on metatarsal rotation in bunions, completed a double international fellowship, and sits on the BOFAS Education Committee.

Patients are seen across London and North London, with quick access to Weight-Bearing CT, ultrasound and MRI scans, and to a wider team of specialists. Every option is discussed openly, and together you agree a plan that suits you. Visit matthewwelck.com to learn more.

09

Frequently Asked Questions

What is metatarsalgia?

Metatarsalgia is pain under the ball of the foot, where the ends of the long foot bones (metatarsal heads) take your weight. It is a symptom with many possible causes, so treatment works best when the cause is found first.

Is metatarsalgia a sports injury?

It often is. Runners, dancers, sprinters and people who play sports like tennis put a lot of pressure on the ball of the foot when they push off. Tight calf muscles, training too much or worn-out shoes can tip the balance into pain. Most sports-related metatarsalgia settles by cutting back training for a while, calf stretches and changes to shoes or insoles.

Will insoles or metatarsal pads help?

For many people, yes. A pad or bar placed just behind the sore area moves pressure away from it, and made-to-measure insoles can also improve the position of the heel. They work best alongside daily calf stretches and supportive shoes.

Do I need surgery for metatarsalgia?

Most people do not. Treatment without surgery is tried first, usually for at least 6 months. Surgery is only considered if the pain carries on despite this. It should treat the specific cause, such as a tight calf, a bunion, a loose toe joint or a foot bone that is too long.

What is the difference between a Weil osteotomy and DMMO?

Both operations shorten or reposition a foot bone. In a Weil osteotomy, the bone is reached through a small open cut and held with a tiny screw, which allows precise, planned shortening. DMMO is keyhole surgery and no screws are used. Studies comparing the two found similar results at one year, although swelling and pain lasted longer in the first few months after DMMO.

How long is the recovery after metatarsal surgery?

Most people can walk straight away in a special stiff-soled shoe, which is worn for around 4 weeks. Swelling often lasts several months, and daily toe exercises are important to stop the toes getting stiff. Full recovery can take up to a year.

Could my pain be Morton’s neuroma instead?

Possibly. Morton’s neuroma is an irritated nerve that causes burning or tingling between the toes, usually the third and fourth. Metatarsalgia is an ache under the bones that comes on with standing and walking. You can have both, which is why a careful examination, and sometimes an ultrasound scan, helps.

Can bunion surgery cause metatarsalgia?

It can. If the big-toe bone is shortened or lifted too much during bunion surgery, extra weight moves onto the bones next to it. This is called transfer metatarsalgia, and further surgery may be needed to rebalance the foot.

How do I choose a top foot and ankle surgeon in London?

Useful things to check are that the surgeon is on the GMC Specialist Register for Trauma & Orthopaedics, has extra (fellowship) training in foot and ankle surgery, treats only the foot and ankle, is a member of BOFAS (the British Orthopaedic Foot & Ankle Society), has published research, and has access to modern scans such as Weight-Bearing CT.

Where can I see Mr Matthew Welck for metatarsalgia in London?

Mr Welck consults across London and North London. NHS patients are seen at the Royal National Orthopaedic Hospital (RNOH), Stanmore. Private appointments can be booked on 07547 395 270 or by emailing secretary@matthewwelck.com.

10

Book a Consultation

If pain under the front of your foot is limiting your walking, work or sport, seeing a specialist can make a real difference.

Book a private or NHS consultation with Mr Matthew Welck, Consultant Foot & Ankle Surgeon. Getting expert advice early gives you the widest choice of treatments and a good chance of lasting relief.

References

  1. Besse J-L. Metatarsalgia. Orthop Traumatol Surg Res. 2017;103(1S):S29–39. doi:10.1016/j.otsr.2016.06.020
  2. Lopez V, Slullitel G. Metatarsalgia: assessment algorithm and decision making. Foot Ankle Clin. 2019;24(4):561–9. doi:10.1016/j.fcl.2019.08.006
  3. Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008;29:871–9.
  4. Maestro M, Besse JL, Ragusa M, Berthonnaud E. Forefoot morphotype study and planning method for forefoot osteotomy. Foot Ankle Clin. 2003;8:695–710.
  5. Henry J, Besse JL, Fessy MH. Distal osteotomy of the lateral metatarsals: a series of 72 cases comparing the Weil osteotomy and the DMMO percutaneous osteotomy. Orthop Traumatol Surg Res. 2011;97(6 Suppl):S57–65.
  6. Haque S, Kakwani R, Chadwick C, Davies MB, Blundell CM. Outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) for lesser toe metatarsalgia. Foot Ankle Int. 2016;37:58–63.
  7. Migues A, Slullitel G, Bilbao F, et al. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004;25:609–13.
  8. Nery C, Coughlin MJ, Baumfeld D, et al. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014;35:876–85.
  9. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010;31:19–23.

This guide is for general information and does not replace a personal medical consultation.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 10 October 2026

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