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Forefoot Pain (aka Metatarsalgia)

Metatarsalgia forefoot pain - physiotherapy treatment torontoThe word metatarsalgia comes from metatarsal (long bones in feet) + algia (pain in Greek). It is a general term used for pain in the plantar (bottom of foot) forefoot area. Symptoms may occur in one or both feet and commonly affects the bones as well as the joints at the ball of the feet.

Symptoms of Metatarsalgia

Symptoms of metatarsalgia include all or some of the following:

  • Sharp, burning or aching pain in the ball of your foot, frequently occurring in one or more of the five metatarsal bones.
  • Sensation of having a pebble in your shoes
  • Symptoms that worsen as you spend more time in standing, running or walking, especially while barefoot, and eases with rest
  • Occasional burning, tingling or numb sensation in your toes
  • Often localized symptoms under the first metatarsal bone (big toe bone)
  • Another frequent site is pain between the first and second metatarsal bone

Causes and Risk Factors of Metatarsalgia

MetatarsalgiaThe common factor is excessive pressure transmitted through the affected area. One or more of the following causes can play a role in developing metatarsalgia:

  • Intense training/repetitive loading of forefoot
  • High impact activities where the athlete spends excessive time on balls of foot (i.e. runners, dancers, football players)
  • Wearing high heels puts increased pressure on ball of foot
  • Improper footwear especially shoes with a narrow toe box
  • Excess weight as extra pounds mean more pressure through the foot as you move
  • Certain foot shapes i.e. high arches, bunions, long second toes, hammer toes, excessive calluses may increase the risk of developing metatarsalgia
  • Connective tissue and tendons change over time and may increase the risk of developing metatarsalgia
  • Surgical procedures around the foot can cause a build-up of fibrous scar tissue causing joint stiffness in the area and limiting range of motion

How do I know I have Metatarsalgia?: Diagnosis

The diagnosis is made by a subjective history and detailed physical examination by an experienced physical therapist. Successful treatment must identify the underlying causes of metatarsalgia. Your therapist will gain a detailed understanding of the characteristics of your pain, your lifestyle, hobbies, occupation and previous history of musculoskeletal conditions in order to guide them to the root cause. The best physiotherapists will utilize this information along with your physical exam findings to develop an individualized treatment plan for your pain.

Differential Diagnoses: What Are Some Other Things That Could Be Confused for Metatarsalgia?

  • Rheumatoid arthritis or gout often presents itself as inflammation of the forefoot joints. Careful client history should reveal if any further tests are indicated to rule out rheumatoid arthritis.
  • Morton’s neuroma is a fibrous thickening of nerves that run along the metatarsal bones.
  • Fluid build up due to circulatory or metabolic dysfunction can put pressure on the structures of the forefoot
  • Stress fractures of the metatarsal bones may develop due to repetitive loading
  • Entrapments along the nerves originating from the low back area may also refer pain in this area.


If needed, imaging such as an X ray or CT scan can be performed to rule out stress fracture and/or joint degeneration. A blood test may determine if foot pain is being caused by a systemic inflammatory condition like rheumatoid arthritis or gout.

Treatment for Metatarsalgia

Acute self-management includes the use of ice, rest, non-steroidal anti-inflammatory medications, and reducing aggravating activities.

Physiotherapy Management:

If your self-management techniques do not provide results, we recommend seeking the expert care of a trusted physiotherapist. They will conduct an assessment and the best physios will provide an individualized, tailored program for you. This is sure to get you back on your feet (without pain) quickly. Your treatment will likely include one or all of the following techniques:

  • Exercise therapy including stretching certain foot and ankle muscles, strengthening foot intrinsic muscles and self-mobilizations exercises targeted at the joints of the foot and ankle.
  • Manual therapy in order to improve tissue mobility, range of motion and decrease pain
  • Education regarding proper footwear and training load management
  • If indicated prescription of orthotics or metatarsal pads
  • If indicated modalities like acupuncture, dry needling, IMS, cupping or taping

Sports Medicine Management:

Your physiotherapist may refer you to a sports medicine physician if your treatment is not responding as expected. You may also decide to see a sports doctor if you would like reassurance or require imaging or injection therapy. When you see a sports medicine physician this is what your care will look like:

  • You may require prescription for medical imaging or further diagnostic testing
  • You may require a referral to an orthopaedic specialist
  • Although this may be an unlikely route of care for metatarsalgia, your sports medicine physician may suggest injection therapy (such as corticosteroids) if pain is not managed well with other non-invasive therapies
  • Surgical management is necessary only if conservative management fails. In this case you may be referred to a surgeon.

If you think you have metatarsalgia and you are looking for an excellent physiotherapist in downtown Toronto, give us a call. We’d be happy to help as our physiotherapists, chiropractors and sports medicine physicians have a great deal of experience dealing with metatarsalgia and other foot and ankle conditions.


  1. Yoo W. Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion
  2. Exercise on Metatarsalgia with Morton’s Toe. Journal of Physical Therapy Science. 2014;26(12):1997-1998. doi:10.1589/jpts.26.1997.
  3. Männikkö K, Sahlman J. The Effect of Metatarsal Padding on Pain and Functional Ability in Metatarsalgia. Scandinavian Journal of Surgery. 2017;106(4):332-337. doi:10.1177/1457496916683090.
  4. Physio-pedia: https://www.physio-pedia.com/Metatarsalgia
  5. Morton’s Neuroma: https://www.mortonsneuroma.com/all-about-metatarsalgia/

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Rebalance Sports Medicine is a multidisciplinary clinic in downtown Toronto offering physiotherapy, chiropractic, registered massage therapy, sports medicine, naturopathy, Pilates and more.

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Yonge & AdelaideRebalance Clinic Yonge Adelaide
110 Yonge Street Suite 905
Toronto, ON M5C 1T4
T: (416) 777-9999
E: [email protected]
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155 University Avenue Suite 303
Toronto, ON M5H 3B7
T: (416) 306-1111
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