Metatarsalgia is a clinical syndrome rather than a single diagnosis, describing pain located beneath the metatarsal heads of the forefoot. Primary metatarsalgia arises from intrinsic anatomic factors such as long second metatarsal (Morton foot), elevated first ray (cavovarus foot), pes cavus, or hallux valgus that shifts weight to lesser metatarsals. Secondary metatarsalgia results from systemic disease (rheumatoid arthritis, gout), iatrogenic injury, or focal pathology including plantar plate tear, Morton neuroma, Freiberg infraction, sesamoiditis, stress fracture, or fat pad atrophy. Iatrogenic metatarsalgia follows transfer overload after first ray surgery.
Patients describe burning, aching, or sharp pain over the metatarsal heads aggravated by walking and high-heeled shoes. Examination shows tenderness over specific metatarsal heads, callus formation under the pressure points, plantar plate instability with the Lachman test of the MTP joint, Mulder click for Morton neuroma, hammer toe deformity, or fat pad thinning. Imaging includes weight-bearing radiographs (metatarsal length pattern, joint changes, sesamoid position), ultrasound for plantar plate and neuroma, and MRI for stress fracture or Freiberg infraction.
Treatment begins with footwear modification (wide toe box, low heel, rocker-bottom sole), metatarsal pads placed proximal to the painful metatarsal head, custom orthotics with metatarsal dome, NSAIDs, and intrinsic foot muscle strengthening. Plantar plate tears may benefit from taping, cortisone-sparing injections, or surgical repair (often combined with Weil osteotomy). Morton neuroma responds to corticosteroid or alcohol injections and surgical resection if persistent. Structural correction (hallux valgus repair, Weil osteotomy, fat pad augmentation) addresses the biomechanical cause. Weight reduction and avoidance of high heels are essential.