Forefoot pain (metatarsalgia): causes, assessment and offloading

Metatarsalgia is a symptom diagnosis. It describes pain in the front part of the foot, under the heads of the metatarsal bones [1]. NHI describes the condition as pain in the metatarsal bones [2].

The pain often develops gradually over months [1]. A distinction is made between metatarsalgia with no known underlying cause and secondary metatarsalgia, where the pain is related to, for example, a foot deformity or a previous operation [1]. The distinction matters for the choice of treatment and for whether referral is relevant [1].

With metatarsalgia, the pressure under the forefoot is often unevenly distributed, with increased load under the middle of the metatarsal bones. This can lead to thickened, hard skin [1]. With a fallen transverse arch, metatarsal bones number 2 to 4 sit deeper than normal, and the toes can develop a hammer toe position [2].

Other conditions that can lie behind it are hammer toe, hallux valgus, a tight Achilles tendon, ankle osteoarthritis and age-related weakening of the tissue under the forefoot [1].

The main symptom is pain in the forefoot when loaded [1][2]. The character and location of the pain vary with the underlying cause [1]. On examination there may be tenderness to pressure and hard skin in the area [1].

Burning or shooting pain that spreads towards the toes, especially between the third and fourth toe, may instead point to Morton's neuroma. This is a thickened nerve between the metatarsal bones [1][3]. The condition is described on the page about Morton's neuroma.

The diagnosis is made from the history and a clinical examination of the foot [1]. The examiner looks for tenderness, hard skin and any deformities that contribute to the problem [1]. An X-ray taken while standing can be used, especially before a possible operation, and shows joint changes and changes in the skeleton [1].

Conditions that must be distinguished from metatarsalgia are stress fracture in the metatarsal bones, which can cause similar pain, and Morton's neuroma [1]. Stress fractures often require long immobilisation [1].

Treatment aims to relieve pain [1]. The first step is to offload the area under pressure. This can be done with a self-adhesive pad, a metatarsal pad, placed just behind the heads of the metatarsal bones in your own shoes, or with ready-made or custom insoles with a pad [1]. NHI mentions short-term offloading and insoles that lift the transverse arch of the foot [2].

Footwear should fit well, have enough room at the front and have a soft, shock-absorbing sole [1]. Surgery is not relevant for metatarsalgia with no known cause, but can be considered for certain deformities or arthritis [1].

Most people get relief with adapted footwear and offloading insoles [1]. In some, relief fails to appear or the symptoms temporarily get worse. Offloading is then tried in a different way [1]. With secondary metatarsalgia, or when treatment without surgery does not give relief, referral to an orthopaedic surgeon can be relevant [1].

Persistent pain, or little effect of self-care, should be assessed by a healthcare professional [2]. The same applies if another cause than metatarsalgia is suspected, for example a stress fracture [1].

A chiropractor can examine the foot, assess where the pressure is greatest and what may contribute to the problem, and talk with you about offloading and footwear. If insoles are relevant, you can read about insoles adapted to your foot. You do not need a referral from a doctor to book an appointment.

What is metatarsalgia?

Pain under the front of the foot, around the metatarsal bones, that typically comes when walking or running. It is a symptom diagnosis and not one specific disease [1][2].

What is the difference between metatarsalgia and Morton's neuroma?

Metatarsalgia is caused by overload of the soft tissue under the heads of the metatarsal bones. Morton's neuroma is a thickened nerve between the metatarsal bones, most often between the third and fourth toe, with burning pain that spreads towards the toes [1][3][4].

What do the sources say you can do about pain under the forefoot?

The first step is to offload the area under pressure with a pad or insoles and to use footwear with enough room and a soft sole [1][2].

Is surgery needed for metatarsalgia?

Surgery is not relevant for metatarsalgia with no known cause. It can be considered for certain deformities or arthritis, or when other treatment does not give relief [1].

The page about Morton's neuroma describes forefoot pain caused by a thickened nerve. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Baas J. Metatarsalgi (nedsunken forfod). Lægehåndbogen, sundhed.dk. Professionally updated 21 May 2025. Link

2. Hæl- og fotsmerter, hva kan årsaken være (Heel and foot pain, what can the cause be). NHI.no. Last updated 2 October 2020. Link

3. Mortons metatarsalgi (Morton's metatarsalgia). NHI.no. Last updated 8 April 2026. Link

4. Hansen TB. Mortons metatarsalgi (Morton's metatarsalgia). Lægehåndbogen, sundhed.dk. Professionally updated 10 January 2022. Link