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1 · SNAPSHOT

Metatarsalgia body chart — Illustrative, not diagnostic. Canva body chart for Metatarsalgia.

Who: Load or footwear change, high heels, runners, and anyone with a stiff first MTP or a tight calf shifting pressure laterally.
What: Pressure overload under the lesser metatarsal heads — or something specific underneath it.
How it behaves: Aching or burning under the metatarsal heads, commonly 2nd–3rd. "Like walking on pebbles." Worse with walking, running and high heels. Eased by rest and cushioned footwear.

The one thing to take from this page:

Metatarsalgia names a location and a sensation. It is where you start, not where you finish.

What it hides

Driver	Its one discriminator
Mechanical overload	Callus at the pressure zone, no radiation, no sensory change
Plantar plate injury / lesser MTP instability	Toe drift, swelling, positive dorsal drawer
Morton's neuroma	Radiation into the toes, sensory change, webspace
Intermetatarsal bursitis	Webspace pain — mimics neuroma closely
Metatarsal stress fracture	Focal bony tenderness, load history, pain on percussion or hop
Freiberg's disease	Dorsal MT head pain, ↓ MTP range, young active patient

And off the mechanical list entirely: inflammatory arthropathy, and referred pain.

⚠️ No guideline exists — and none should be expected. You cannot write a guideline for a symptom. The pressure-redistribution evidence is decent; the diagnostic work is yours.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order.

MAIN PROBLEM

"It feels like I'm walking on a pebble."
"There's a burning under the ball of my foot by the end of the day."
"It started when I changed shoes."

BODY CHART

Mark which rays. 2nd and 3rd is the common mechanical pattern; the webspace is a different question.
Does it radiate into the toes? Draw it if it does — that is the neuroma question, and it changes everything.
Mark callus and pressure zones as areas.
Note any toe drift or deformity and date the observation.

BEHAVIOUR

	Fits mechanical metatarsalgia	Points elsewhere
Aggs	Walking distance, running, high heels, hard surfaces	Sudden spike with focal pain → stress fracture
Eases	Rest, cushioned footwear, taking shoes off	Taking shoes off gives dramatic relief → neuroma
Severity	VAS 0–10 at best / at worst / right now	—
Quality	Ache, burning under the heads	Sharp, electric, into the toes → neuroma
Sensory	Normal	Numb or tingling → neuroma

HISTORY

Load and footwear change. A new shoe, a new distance, a new surface, a new job on hard floors. This is usually the whole story.
Bone health and load history — the stress fracture screen.
Toe changes over time — has the second toe started to drift?

SPECIAL / SCREENING QUESTIONS

Morning stiffness >30 min (In), other joints, systemic features — inflammatory arthropathy.
Night pain, rest pain, or a pain that doesn't behave mechanically — off this page.
Diabetes or neuropathy — changes the whole risk profile of a pressure lesion.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Morton's neuroma	Sharp burning radiating into the toes, "pebble in shoe", positive Mulder's click, sensory change in the webspace.
Sesamoiditis	Localised plantar 1st MTP pain on push-off, pain with resisted hallux flexion.
Freiberg's disease	Dorsal 2nd MT head pain with swelling and reduced MTP range, in an adolescent or young active patient.

The three the table doesn't carry

Plantar plate injury and lesser MTP instability — toe drift, swelling, plantar plate tenderness, positive dorsal drawer (Kinter & Hodgkins 2020; Maas et al. 2016; Park et al. 2025).
Intermetatarsal bursitis — which mimics neuroma closely enough that it should be considered before anyone injects or refers for neuroma surgery (Larsen et al. 2023).
Metatarsal stress fracture — focal bony tenderness, a load history, and pain on percussion or hop.

And the escalation: pain that is focal, dorsal, traumatic, neurological, inflammatory, or simply not behaving mechanically belongs off this page.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Focal bony tenderness + load spike, pain on hop or percussion — in a distance runner or recruit the second or third MT is a common site, the same rays mechanical metatarsalgia favours (Sun et al. 2024) [21]	Metatarsal stress fracture	Offload and image
Night or rest pain, not mechanical	Bone stress, infection, tumour	Medical referral
Hot, red, swollen ± fever, or a diabetic foot with skin breach	Infection	🚑 See the infection page
Morning stiffness >30 min (In), multiple joints, systemic features	Inflammatory arthropathy	GP referral
Progressive toe drift or deformity	Plantar plate failure	Protect the toe, refer if progressing
Numbness, or a foot with neuropathy and a pressure lesion	Neuropathic risk	See the diabetic foot pathway

The rule: pressure pain that responds to offloading is yours. Focal bone pain, systemic features, or a numb foot with a pressure lesion is not.

Cross-links: Morton's neuroma · Stress fracture — metatarsal, navicular, calcaneal · Infection / osteomyelitis / ulcer

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Guideline anchor

No guideline exists for metatarsalgia, in Australia or anywhere — which is unsurprising, because it is a symptom label rather than a diagnosis.

Anchored for management to the conservative treatment review of forefoot disorders (Park & Chang 2019, PMID 31620619) and the orthotic systematic reviews (Arias-Martin et al. 2018, PMID 29423640; Ruiz-Ramos et al. 2025, PMID 39399760), and for the differential to Afonso et al. 2023 (PMID 37230133).

PubMed Source

No guideline exists and none should be expected, because metatarsalgia names a location and a sensation rather than a pathology. The management evidence here is about pressure redistribution, which is well studied; the diagnostic work of finding what is actually driving it is not guideline territory at all.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 21

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2006Kang et al. (2006). Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC musculoskeletal disorders, 7, 95. https://doi.org/10.1186/1471-2474-7-95
2014DiPreta (2014). Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. The Medical clinics of North America, 98(2), 233-51. https://doi.org/10.1016/j.mcna.2013.10.003
2014Schuh et al. (2014). Comparison of plantar-pressure distribution and clinical impact of anatomically shaped sandals, off-the-shelf sandals and normal walking shoes in patients with central metatarsalgia. International orthopaedics, 38(11), 2281-8. https://doi.org/10.1007/s00264-014-2508-6
2016Maas et al. (2016). Metatarsophalangeal joint stability: a systematic review on the plantar plate of the lesser toes. Journal of foot and ankle research, 9, 32. https://doi.org/10.1186/s13047-016-0165-2
2016Hähni et al. (2016). The effect of foot orthoses with forefoot cushioning or metatarsal pad on forefoot peak plantar pressure in running. Journal of foot and ankle research, 9, 44. https://doi.org/10.1186/s13047-016-0176-z
2017Duan et al. (2017). Role of magnetic resonance imaging versus ultrasound for detection of plantar plate tear. Journal of orthopaedic surgery and research, 12(1), 14. https://doi.org/10.1186/s13018-016-0507-6
2018Federer et al. (2018). Conservative Management of Metatarsalgia and Lesser Toe Deformities. Foot and ankle clinics, 23(1), 9-20. https://doi.org/10.1016/j.fcl.2017.09.003
2018Arias-Martín et al. (2018). Effectiveness of custom-made foot orthoses for treating forefoot pain: a systematic review. International orthopaedics, 42(8), 1865-1875. https://doi.org/10.1007/s00264-018-3817-y
2019Gougoulias et al. (2019). Morton's interdigital neuroma: instructional review. EFORT open reviews, 4(1), 14-24. https://doi.org/10.1302/2058-5241.4.180025
2019Park & Chang (2019). Forefoot disorders and conservative treatment. Yeungnam University journal of medicine, 36(2), 92-98. https://doi.org/10.12701/yujm.2019.00185
2020Kinter & Hodgkins (2020). Lesser Metatarsophalangeal Instability: Diagnosis and Conservative Management of a Common Cause of Metatarsalgia. Sports health, 12(4), 390-394. https://doi.org/10.1177/1941738120904944
2021Albano et al. (2021). Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses. La Radiologia medica, 126(7), 963-970. https://doi.org/10.1007/s11547-021-01354-8
2022Carroll et al. (2022). Forefoot Injuries in Athletes: Integration of the Movement System. International journal of sports physical therapy, 17(1), 81-89. https://doi.org/10.26603/001c.30021
2022Baker et al. (2022). Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 61(5), 1114-1118. https://doi.org/10.1053/j.jfas.2022.02.002
2022Yi et al. (2022). Comparison of the Forefoot Pressure-Relieving Effects of Foot Orthoses. Yonsei medical journal, 63(9), 864-872. https://doi.org/10.3349/ymj.2022.63.9.864
2023Larsen et al. (2023). Diagnostic Considerations of Intermetatarsal Bursitis: A Systematic Review. Diagnostics (Basel, Switzerland), 13(2). https://doi.org/10.3390/diagnostics13020211
2023Afonso et al. (2023). Differential Diagnosis of Metatarsalgia. Seminars in musculoskeletal radiology, 27(3), 337-350. https://doi.org/10.1055/s-0043-1764388
2025Ruiz-Ramos et al. (2025). Effectiveness of bespoke or customised orthotic treatment in plantar pressure reduction of the central metatarsals: A systematic review and meta-analysis. Journal of orthopaedics, 59, 111-118. https://doi.org/10.1016/j.jor.2023.12.006
2025Palka et al. (2025). Radiological approach to metatarsalgia in current practice: an educational review. Insights into imaging, 16(1), 94. https://doi.org/10.1186/s13244-025-01945-3
2025Park et al. (2025). Diagnosing Plantar Plate Injuries: A Narrative Review of Clinical and Imaging Approaches. Diagnostics (Basel, Switzerland), 15(17). https://doi.org/10.3390/diagnostics15172188
2024Sun et al. (2024). Risk factors of metatarsal stress fracture associated with repetitive sports activities: a systematic review. Frontiers in bioengineering and biotechnology, 12, 1435807. https://doi.org/10.3389/fbioe.2024.1435807

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