Metatarsalgia

What it is. Metatarsalgia is pain localised to the plantar aspect of the metatarsal heads, typically the lesser metatarsals, second through fifth. It is a symptom complex, not a diagnosis: the end result of abnormal load distribution across the forefoot, with the pain coming from mechanical overload of the lesser metatarsals. Identifying and correcting the underlying mechanical or pathologic cause is the goal of treatment, and the rest of this page is organised around finding it.

Who. It is one of the most common foot complaints in orthopaedic and podiatric practice, and approximately 10-15% of the general population are affected at some point in life.

• Female predominance, 3:1 (high heels, narrow shoes)
• Peak age 40-60 years
• Higher incidence in runners, dancers and sports with repetitive forefoot loading

Why the second metatarsal. The second is the metatarsal most often affected, in 65-70% of cases; the third accounts for 20-25% and the fourth for 5-10%. The second's predisposition has anatomical and biomechanical reasons:

1. It is the longest metatarsal in approximately 60% of the population (the Greek or Morton's foot), in whom it is longer than the first
2. Its tarsometatarsal joint is the most fixed of the Lisfranc articulations, with no movement, unlike the mobile first and fifth rays
3. It sits next to the first ray, so when first ray function is impaired by hallux valgus, hypermobility or prior surgery the load transfers to it
4. Its central position bears significant load during the toe-off phase of gait

The forefoot. Five metatarsals carry the forefoot. The first is the shortest and thickest; the second is typically the longest and the most fixed at the Lisfranc joint. The first ray, the first metatarsal and medial cuneiform together, normally bears approximately 50% of forefoot load during toe-off, and the lesser metatarsals share the rest:

• First ray: 50%
• Second metatarsal: 15-20%
• Third metatarsal: 10-15%
• Fourth metatarsal: 5-10%
• Fifth metatarsal: 5-10%

During toe-off the load shifts anteriorly and concentrates on the metatarsal heads, while the plantar plates and the intrinsic muscles hold the metatarsophalangeal joints stable. Anything that overloads the heads, a long or plantarflexed metatarsal, first ray insufficiency shifting load laterally, clawing of the toes, a tight gastrocnemius or high-heeled footwear, produces a focal high-pressure zone and pain directly beneath the head.

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The plantar plate. A thick fibrocartilaginous plate on the plantar aspect of each metatarsophalangeal joint, analogous to the meniscus and approximately 1-2mm thick, inserting on the plantar base of the proximal phalanx and on the metatarsal neck. It stabilises the joint in the sagittal and transverse planes, is the attachment site for the plantar fascia, protects the metatarsal head from excessive load and prevents dorsal subluxation of the toe.

How it fails. Chronic repetitive stress breaks down the fibrocartilage. The plate degenerates, then attenuates (thins and weakens), then tears, and a partial tear usually originates at the lateral insertion of the second metatarsophalangeal joint; a complete rupture loses all stabilisation. The consequences follow from what the plate normally does:

• Dorsal subluxation of the toe on the metatarsal head
• Medial deviation, the crossover toe, in which the second toe drifts over the hallux
• Metatarsophalangeal instability
• Pain directly under the head, because the protective cushioning is gone
• A positive drawer test, from the excessive dorsal translation

The mechanisms. Each cause of primary metatarsalgia overloads the lesser heads by a different route, and the treatment follows the route:

Secondary causes. Here the forefoot pain comes from a disease process rather than from load. Freiberg's disease is avascular necrosis of a metatarsal head, typically the second, in adolescent females, with fragmentation among its radiographic changes. Morton's neuroma is an interdigital neuroma, a perineural fibrosis between the heads. Rheumatoid arthritis is a systemic inflammatory arthropathy that produces synovitis, erosions and subluxation at multiple metatarsophalangeal joints bilaterally. A stress fracture is tender over the shaft and most often involves the second or third metatarsal, and sesamoiditis is pain under the first metatarsal head, at the sesamoids, and so distinct from lesser-metatarsal metatarsalgia. How each is told apart is set out under differential diagnosis.

History. The patient can point to the specific metatarsal head: the pain is on the plantar forefoot under the heads, aching or burning and sharp with weight-bearing, and worst at the end of the day after cumulative loading. What makes it better and worse localises the load:

• Worse with prolonged standing or walking, high heels (which shift load anteriorly), hard surfaces, barefoot walking and thin-soled shoes
• Better with rest, removing the shoes and massaging the forefoot

What the associated symptoms mean. Each points to a cause or away from a simple mechanical one:

• Numbness or burning in a web space that radiates to the toes suggests Morton's neuroma
• A crossover toe indicates plantar plate rupture
• Callus under a specific head confirms the overload pattern
• A toe that feels as if it "gives way" suggests plantar plate insufficiency
• Prominent dorsal metatarsophalangeal swelling suggests synovitis or arthropathy
• Night pain is a red flag for tumour or infection, and is not typical of mechanical metatarsalgia

Inspection. Start standing, because weight-bearing alignment is the point: foot type (cavus, planus or neutral), the first ray (hallux valgus, first metatarsal elevation) and the lesser toes (crossover toe with the second over the hallux, hammer toes, claw toes). Then seated, look at the callus pattern, whose location and severity indicate which metatarsal is overloaded, at dorsal metatarsophalangeal swelling (synovitis, arthropathy) and at the skin for ulceration (diabetes, rheumatoid arthritis) and colour change.

Palpation. Palpate each metatarsal head individually to localise the pain precisely; the second is the most commonly tender, note which heads are symptomatic, and feel for plantar plate prominence (thickening). Squeeze the web spaces between the heads for Morton's neuroma, with Mulder's click elicited by lateral metatarsal compression while pressing the web space; the third web space is the most common site. Palpate the dorsal metatarsophalangeal joints for synovitis, osteophytes and swelling. Palpation is what separates metatarsalgia, tender over the head, from a neuroma, tender in the web space.

The drawer test. This is the single most important special test for metatarsalgia and is performed in every case. Stabilise the metatarsal head firmly with one hand; with the other, grasp the toe and apply a dorsally directed force to translate it on the head. An intact plate resists. A positive test shows excessive translation, more than 2-3mm compared with the adjacent toes and the contralateral foot, reproduces the patient's symptoms, and indicates a plantar plate tear or severe attenuation. Always perform it bilaterally to establish what is normal for that patient. A positive drawer test changes management: plantar plate repair should be considered if surgery is pursued.

Grading the instability. A positive drawer is graded, and the grade drives the operation. The clinical metatarsophalangeal instability grade, from the drawer or "vertical Lachman" test:

• Grade 0: stable
• Grade 1: mild laxity, under half subluxation
• Grade 2: moderate, over half subluxation
• Grade 3: dislocatable joint
• Grade 4: fixed dislocation with rigid deformity

This maps onto the anatomic Nery-Coughlin plantar plate grading seen at surgery or on MRI:

• Grade 0: intact or attenuated
• Grade I: transverse distal tear involving less than half the plate
• Grade II: transverse tear of more than half
• Grade III: extensive tear, often with a longitudinal component
• Grade IV: complete tear or buttonhole with retraction, frequently with collateral involvement

The practical message is that a low grade may settle with a metatarsal pad and offloading, or with a Weil osteotomy that indirectly relaxes the plate, whereas the higher grades, with true subluxation or a crossover toe, need direct plantar plate repair combined with the Weil, and a fixed Grade 4 may need joint salvage rather than repair.

The first ray. Translate the first metatarsal dorsally on the medial cuneiform; excessive mobility, hypermobility, predisposes to transfer metatarsalgia. Look for hallux valgus at the same time.

The Achilles. The Silfverskiold test measures ankle dorsiflexion with the knee extended, and the gastrocnemius is tight if it is limited; repeat with the knee flexed, and if dorsiflexion improves the contracture is an isolated gastrocnemius one.

Range of motion. Assess metatarsophalangeal dorsiflexion and plantarflexion. Limited motion suggests arthropathy or Freiberg's disease.

Gait. Watch for an antalgic gait with a shortened stance phase, early heel-off that avoids toe-off on the painful forefoot, and toe-walking from an Achilles contracture. Toe-off is when load normally shifts to the forefoot, so painful toe-off confirms forefoot pathology.

Weight-bearing radiographs. The essential first investigation is an AP, lateral and oblique of the foot, and they must be weight-bearing. They are read for:

• Metatarsal length: is the second long (Greek foot)? Measure the relative lengths by the parabola method or by direct measurement
• Metatarsal alignment: elevation, depression or rotation
• Metatarsophalangeal joint space: arthropathy, erosions (rheumatoid arthritis), flattening (Freiberg's)
• First ray position: hallux valgus angle, first metatarsal elevation
• Sesamoid position: lateral displacement with hallux valgus

The second metatarsal is typically 1-2mm shorter than the first or equal to it; a second metatarsal more than 3mm longer than the first predisposes to overload. A calcaneal pitch angle greater than 30 degrees marks a cavus foot.

MRI. The gold standard for soft tissue, and the test to order when the drawer test is positive or the diagnosis is uncertain:

• Positive drawer test, to assess a plantar plate tear
• Suspected neuroma
• To rule out a stress fracture
• Freiberg's disease staging
• Preoperative planning

The protocol is a foot MRI with dedicated coils in sagittal, coronal and axial planes. The plantar plate is the key finding and is best seen on the sagittal and coronal images: a normal plate is a low signal structure on all sequences of uniform 1-2mm thickness; a partial tear shows high signal on T2 or STIR at the insertion, usually lateral, with thinning; a complete rupture shows discontinuity, high signal and metatarsophalangeal subluxation. Beyond the plate, a Morton's neuroma is low signal on T1 and T2 between the heads, a stress fracture shows bone marrow oedema with or without a fracture line, and Freiberg's disease shows head oedema, fragmentation and subchondral change.

Ultrasound. Dynamic, real-time, cheaper than MRI and without radiation, it detects Morton's neuroma as a hypoechoic mass between the heads, can show plantar plate tears (though it is less sensitive than MRI) and guides injections. It is operator-dependent and less detailed than MRI for the plantar plate, so MRI is preferred for a comprehensive assessment.

CT. A limited role, and not routinely required. It is for subtle metatarsal fractures not visible on the radiograph, Lisfranc injury and Freiberg's disease staging.

Laboratory studies. Generally not required for primary mechanical metatarsalgia; order them when a secondary cause is suspected:

• Rheumatoid factor and anti-CCP if there is bilateral metatarsophalangeal synovitis or systemic symptoms
• Uric acid for acute monoarticular metatarsophalangeal pain (gout)
• ESR and CRP if infection or an inflammatory arthropathy is suspected
• HbA1c in diabetic patients with neuropathy or an at-risk foot

The location of maximal tenderness is the most helpful discriminator: metatarsal head, web space or metatarsal shaft. The drawer test then separates plantar plate pathology from the rest, Mulder's click is pathognomonic for Morton's neuroma, and imaging confirms the diagnosis when the examination is unclear.

The principle. Treat the mechanical cause, not the symptom alone. The diagnosis is clinical, weight-bearing radiographs establish the metatarsal lengths and alignment, and almost everyone then has a 3-6 month conservative trial. Symptoms that persist despite a compliant trial are imaged with MRI or ultrasound to pin down the structural driver, and surgery is reserved for a function-limiting lesion and matched to the pathology found.

Algorithm

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Floating toe. The toe loses contact with the ground during walking. The causes are excessive metatarsal shortening, weak plantar structures and extensor overpull, and it is usually a cosmetic concern rather than a functional problem. The same pooled review that reported 7% transfer reported floating toe as the most common complication, in 36%, against the 15-30% in the table. It is prevented by limiting the shortening, repairing the plantar plate when torn, repairing the capsule at closure and strapping the toe in plantarflexion postoperatively; treatment is toe taping, with revision rarely if it is significantly symptomatic.

Metatarsophalangeal stiffness. A loss of dorsiflexion, typically 10-20 degrees compared with the preoperative range, from capsular adhesions, prolonged immobilisation or an aggressive osteotomy. Early range of motion, physiotherapy and minimal soft tissue disruption prevent it. It is usually well tolerated; severe stiffness gets aggressive physiotherapy, and manipulation under anaesthesia is rarely needed.

Recurrent pain. Inadequate shortening, a plantar plate that was not addressed, the wrong diagnosis or progression of an arthropathy. Review the imaging, look for an alternative diagnosis, and check fixation and union. Management is conservative first, with revision rarely, and only if a clear structural issue is identified.

Intraoperative complications. Neurovascular injury, to the digital nerve or vessel during dissection, is prevented by careful dissection and identifying the structures. Malposition of the osteotomy at the wrong angle causes a dorsal or plantar step-off, and is prevented by cutting parallel to the weight-bearing surface. Excessive shortening beyond 4mm raises the transfer risk, and is prevented by measuring and planning; inadequate fixation, a stripped screw or a bent K-wire, by proper technique and appropriately sized implants.

Early postoperative complications, within 6 weeks:

• Infection in under 2%, typically superficial, managed with antibiotics and wound care
• Haematoma, a collection causing painful swelling, which usually resolves and is aspirated if large
• Wound dehiscence from poor healing (diabetes, smoking), managed with local wound care and rarely revision
• Fixation failure, screw loosening or displacement, which may need revision fixation if symptomatic

Late complications, after 6 weeks:

• Delayed union, visible on the radiograph at 3-6 months, usually asymptomatic and progressing to union
• Nonunion, a persistent gap with no bridging callus, which may need revision if painful
• Malunion, healing in an abnormal position, which can cause persistent pain or deformity
• Hardware prominence, a palpable screw head, which may need removal if symptomatic
• Complex regional pain syndrome, rare: disproportionate pain, swelling and vasomotor changes

The complications of any foot operation. Digital paraesthesia, temporary or permanent, affects under 10%, usually the medial or lateral aspect of the toe; most resolve over 3-6 months, and desensitisation techniques help if it is permanent. Scars can be hypertrophic or adherent, and keloid is rare; massage, silicone gel and rarely revision. Hammer toe and claw toe can develop or worsen and may need soft tissue balancing, and first ray hypermobility or hallux valgus that was not addressed may progress and cause recurrent symptoms. Some patients are dissatisfied despite a technically successful operation, because of stiffness, residual pain or unrealistic expectations, which is why the preoperative counselling matters.

Metatarsalgia is a worldwide forefoot complaint with no single dedicated national-society guideline; practice is driven by foot-and-ankle literature and the closely related conditions of hallux valgus and lesser-toe instability. The principles below are consistent across UK (BOFAS/BOA), US (AAOS/AOFAS), European (EFAS/EFORT) and AO Foundation teaching.

Global Epidemiology

Guidance and Consensus, Side by Side

Registry & Pooled Evidence

No national joint registry captures lesser-metatarsal osteotomy (registries focus on arthroplasty). The best population-level evidence is therefore pooled review data: across 1131 Weil osteotomies, floating toe occurred in 36%, recurrence in 15%, transfer metatarsalgia in 7%, and delayed/non-/malunion in 3% (Highlander 2011, PMID 21490179). These figures should frame consent worldwide.

Practice Variation

Consent and Documentation (Universal Principles)