Ball of foot pain (metatarsalgia)

The ball of the foot is the padded area under the ends of the long metatarsal bones, where the toes join the foot. It takes much of your weight as you push off, and too much load there hurts. People describe an ache, a bruised feeling, or the sense of walking on a pebble. We see patients with ball-of-foot pain at our offices in Lyndhurst, Paramus and Millburn, NJ. For other kinds of foot pain, see our foot pain guide.

Where exactly it hurts

Where it hurts	What it often feels like	Common causes
Under the big toe joint	Pain when you push off or bend the big toe	Sesamoiditis, a sesamoid fracture, turf toe
Under the second or third toe	A deep ache or bruised feeling, sometimes swelling at the base of the toe	Overload, an inflamed toe joint, a plantar plate injury, a stress fracture
Between the third and fourth toes	Burning or sharp pain, tingling or numbness into the toes	Morton’s neuroma

Under the big toe joint. Two small bones, the sesamoids, sit in the tendons under the big toe joint. Irritation around them (sesamoiditis) often builds gradually and is common in dancers and runners; a sesamoid can also break, from overuse or when the toe is bent backward.^[3] Turf toe is a sprain of the big toe joint from forceful bending back of the toe, common in football, soccer, basketball and dance.^[4] Pain on top of the joint, stiffness or a red, hot joint points elsewhere; see big toe pain.

Under the second and third toes. This is the classic spot for metatarsalgia, and it often comes with a bunion or bent toes.^[2] If the base of a toe is swollen and the toe feels unstable or is moving out of line, the plantar plate, a strong ligament under the toe joint, may be injured. These injuries are easily missed because they feel like other forefoot problems.^[5] A stress reaction or stress fracture of a metatarsal is another common cause,^[9] most often in the second or third metatarsal. It usually builds gradually with activity, the bone is tender to press, and there may be swelling on the top of the foot.^[10] See top of foot pain.

Between the third and fourth toes, with burning. A Morton’s neuroma is a thickening of the tissue around a small nerve between the toes. It causes burning or sharp pain in the ball of the foot that can spread into the toes, sometimes with numbness or tingling.^[6]

Why it happens

• Shoes. Narrow shoes and high heels are worth avoiding while the front of your foot hurts.^[11,6] In one small hospital study of people treated for metatarsalgia (25 were interviewed, and there was no comparison group), 40% wore high heels every day and about two thirds had done standing work for years.^[8] See high heels and foot pain.
• Foot shape. High arches concentrate pressure under the heel and the ball of the foot, and the higher the pressure, the more likely the pain.^[12] See high-arched feet.
• A tight calf, which makes the heel lift early as you walk and puts more pressure on the ball of the foot.^[13]
• Bunions, claw toes and unstable toe joints, which can all lead to pain under the ball of the foot.^[14,11] See bunions and hammertoes.
• Calluses, a sign of too much pressure that adds pain of its own. See corns and calluses.

A thinning fat pad is often blamed. In one small MRI study, though, people with metatarsalgia didn’t have thinner fat pads than people with foot or ankle arthritis, and pad thickness didn’t track with their pain,^[15] so we also look for the load problem behind it. Metatarsalgia from an inflammatory arthritis, such as rheumatoid arthritis, needs its own treatment plan.^[7]

Home care and padding

• Ease the load for a while: less running, jumping and standing in thin-soled shoes.
• Wear a low heel, a roomy toe box, and a cushioned or rocker sole.^[11]
• Try a metatarsal pad. It sits just behind the sore spot, toward the heel, not directly on it. Placed there, a pad cut peak pressures by a third in one study,^[11] and custom-made insoles with a metatarsal pad lowered pain by about 3 points out of 10 in a small hospital study without a comparison group.^[8]
• Use inserts that spread pressure across the forefoot.^[16]
• Stretch your calves every day, especially if they feel tight.^[7,13]

If you have diabetes, neuropathy or poor circulation, don’t trim calluses or use medicated corn pads yourself: with nerve damage, a callus can turn into an ulcer, so let us treat it early.^[17,18] See diabetic foot care.

How we evaluate it

We press on each joint and the spaces between the toes, check whether a toe joint is unstable, test how far your ankle bends, and look at your shoes and walking. Standing X-rays at the practice show the bones; ultrasound or MRI is added when a plantar plate tear or a neuroma needs confirming.^[7,5] An early stress fracture may not show on X-ray for a few weeks, so we protect the foot and re-check it if one is suspected.^[10]

Treatment at the practice

Treatment depends on the cause, and nonsurgical care is usually enough.^[2]

• Padding shaped to take pressure off the sore spot or a painful sesamoid.^[3]
• Custom orthotics made from a 3D scan of your feet, with a metatarsal pad built in. In one small study, custom insoles with a metatarsal pad eased metatarsalgia pain.^[8] See custom orthotics.
• Taping the big toe for sesamoiditis, and protection in a stiff-soled shoe or removable boot for a stress fracture or a sesamoid that won’t settle.^[3,10]
• Calf stretching and callus care, and treating a bunion or hammertoe that adds to the load.^[7]
• Injections, used selectively. Injections are one of the nonsurgical options for metatarsalgia.^[1] In a review of the few published cases of sesamoiditis (59 people), steroid injections and orthotics appeared to help, but the pain often came back and some people didn’t fully recover.^[19] Our article on cortisone shots in the foot explains the trade-offs.

When surgery is considered

Surgery is considered when pain continues despite a thorough trial of these measures.^[1] Because ball-of-foot pain often has more than one cause, every problem that adds to the pain needs correcting.^[2] Options include plantar plate repair, calf lengthening, tendon transfer and shortening an overloaded metatarsal, often with treatment of a bunion.^[7] Most sesamoid problems settle without surgery; when one doesn’t, part or all of the sesamoid can be removed.^[3]

Common questions

Why does it feel like I’m walking on a pebble?

That feeling is common with a Morton’s neuroma, but it isn’t specific to it. In a systematic review, about half of people with a neuroma described it, and so did nearly half of those whose pain had another cause.^[20] An inflamed toe joint or a plantar plate injury can feel much the same.^[5]

How long does metatarsalgia last?

It depends on the cause, and its natural course hasn’t been well studied.^[8] Most people improve with nonsurgical care.^[2] Sesamoid problems can take weeks to months, because every step loads those small bones.^[3]

Is it the same as plantar fasciitis?

No. Plantar fasciitis hurts under the heel; metatarsalgia is behind the toes. A tight calf can contribute to both.^[13] See heel pain.

Do I need custom orthotics?

Not always. Store-bought inserts that spread pressure across the forefoot are a common first step,^[16] and a well-placed metatarsal pad lowers pressure under the sore spot.^[11] Custom orthotics make most sense when a store-bought insert hasn’t helped or pressure needs moving precisely off one spot. See custom vs. store-bought orthotics.

When to seek care

Book an evaluation for ball-of-foot pain that hasn’t improved after two or three weeks of better shoes and padding, a toe that is starting to drift, or pain that changes how you walk.