Metatarsalgia

In brief

Metatarsalgia is pain in the front part of the sole of the foot, just beneath the heads of the metatarsals. In children and adolescents it can be caused by sports overload, differences in foot shape, unsuitable footwear or certain bone and joint injuries. Treatment depends on the cause and usually starts with conservative measures.

Typical age

Any age; causes vary during growth

Also known as

Forefoot pain · Pain under the metatarsals

What is it?

Metatarsalgia is a term that describes pain in the front of the sole of the foot, especially in the area just behind the toes. The metatarsals are the bones that connect the midfoot to the toes. This area bears a large part of the body’s weight when walking, running and jumping. When the load is concentrated too much on one or more metatarsals, discomfort can appear that makes daily or sports activity difficult.

In children and adolescents, the pain may be related to increased physical activity, repetitive training, narrow or unsuitable shoes and certain features of the shape of the foot. It can also be caused by differences in the length or position of the metatarsals, toe deformities or specific bone and joint injuries. During growth, it is important to distinguish these causes from simple overload.

There is no single cause or frequency figure that applies to all children, because metatarsalgia is a symptom rather than a specific diagnosis. The exact location of the pain, when it appears and the activities that trigger it help guide the assessment.

Although it often improves with simple measures, persistent or recurrent pain deserves a medical assessment to identify its origin and prevent it from limiting walking, sport or everyday activities.

Signs parents may notice

The most common signs are:

• Pain in the ball of the foot: the child points to the area behind the toes, especially when walking or running.
• Discomfort during sport: the pain appears when jumping, running or training and may improve with rest.
• Limping or changes in walking: they may put more weight on the heel or the outer edge of the foot to avoid the painful area.
• Difficulty walking barefoot: direct contact with the floor can increase the discomfort.
• Calluses or hardened skin: can appear when pressure on the forefoot is unevenly distributed.
• Redness or swelling: may accompany some overload injuries or trauma.
• Lower exercise tolerance: the child needs to rest more often or stops doing activities they used to do easily.

The absence of visible signs does not rule out a problem. Some bone or joint injuries cause pain without swelling or obvious skin changes.

When to see a specialist

A medical assessment is advisable if:

• The pain recurs over several training sessions or persists despite relative rest.
• The child limps or has difficulty walking normally.
• The pain always appears at the same spot.
• There are toe deformities or progressive changes in the shape of the foot.
• The discomfort interferes with school, physical activity or wearing ordinary shoes.
• The pain gradually increases or returns when sport is resumed.

When is it urgent?

An urgent assessment is needed if the child cannot put weight on the foot, has severe pain after an injury, has marked swelling or a sudden deformity, or if the foot is red and warm and there is fever. A stress injury should also be ruled out when there is localised bone pain that increases with weight-bearing.

How is it diagnosed?

The diagnosis starts with a clinical interview and physical examination. The specialist will ask when the pain started, whether it coincided with increased training, what shoes the child wears and whether there has been any injury.

The examination pinpoints the exact site of the pain and assesses the shape of the foot, the length and position of the toes, joint movement and how load is distributed when walking. Ankle movement and calf muscle tightness may also need to be assessed.

Imaging is requested according to the clinical suspicion:

• X-rays: show the alignment and length of the metatarsals and can detect certain bone changes. In some cases they are taken standing up.
• MRI: can be useful if a stress injury, an osteochondral lesion or another problem not visible on X-rays is suspected.
• Ultrasound: can help assess certain soft-tissue injuries when indicated.

Not every child needs imaging. The choice depends on the symptoms, the examination and how the pain progresses.

Treatment

Treatment should target the cause of the metatarsalgia. In most cases it starts with conservative measures, but a bone injury or a specific structural problem may need a different approach.

Conservative treatment

The main measures include:

• Temporarily adjusting activity: reducing running, jumping or training that causes pain for a while. The return to activity should be gradual.
• Suitable footwear: comfortable shoes with enough room for the toes and a sole suited to the foot’s needs.
• Insoles or metatarsal pads: can help redistribute pressure and relieve load on the painful area. Their placement must be individualised to avoid increasing pressure right on the affected spot.
• Local cold: can temporarily relieve discomfort after activity.
• Physiotherapy: can help restore movement, improve function and address associated biomechanical factors when present.
• Pain relief: painkillers should be used as directed by a health professional and taking the child’s age into account.

If there is a stress injury or another bone injury, it may be necessary to limit weight-bearing, use crutches or temporarily immobilise the foot. These measures must be tailored to the diagnosis and are not routinely used for all cases of metatarsalgia.

Surgical treatment

Surgery is uncommon and is not usually needed when the pain is simply due to overload that improves with conservative treatment.

It may be considered when there is a clearly identified structural cause, such as a bone deformity that concentrates too much load, a significant abnormality in the position of the metatarsals or certain joint injuries, and symptoms persist despite appropriate treatment.

The technique depends on the specific problem. In selected cases, the position or length of a metatarsal may need to be corrected with an osteotomy, a controlled cut in the bone to change its alignment. Other injuries require specific procedures, so there is no single operation for metatarsalgia.

The operation may be done under general or regional anaesthesia. Some procedures allow discharge on the same day, although the need for a hospital stay, immobilisation and limited weight-bearing depends on the technique and the patient.

In children and adolescents it is especially important to take bone growth into account and to avoid surgical correction if the cause of the pain has not been clearly identified.

Outlook and recovery

Recovery depends on the cause of the metatarsalgia and the treatment needed.

• Overload without significant structural injury: improvement may occur within days or a few weeks by adjusting activity and footwear.
• Bone stress injuries: may need several weeks of protection and a gradual return to weight-bearing, depending on the location and severity.
• After surgery: timescales depend on the technique, bone healing and the need to protect the operated area.
• School: a return is usually possible before a return to sport, as long as the pain is under control and getting around is safe.
• Return to sport: should be gradual once the child can walk without pain, has regained function and the underlying injury allows impact to resume.

Not every patient needs a cast or has to stop putting weight on the foot. The specialist will advise whether crutches, a post-operative shoe or immobilisation are needed and when activities can be resumed.

Check-ups are used to monitor progress and adjust treatment if the pain persists or returns.

Frequently asked questions

Is metatarsalgia common in children?

It can appear during childhood and adolescence, especially in connection with physical activity, but how common it is depends on the cause. There is no single figure covering all types of forefoot pain in children.

Can it be caused by sport?

Yes. Repetitive training, jumping and sudden increases in activity can overload the forefoot. However, persistent or very localised pain requires ruling out a bone injury or another specific cause.

Can insoles fix it?

They can relieve pain in some cases by redistributing pressure, but how well they work depends on the cause. They do not correct all deformities and do not replace treatment of a bone injury.

When can my child return to sport?

It depends on the cause of the pain. For mild overload, the return can be fairly quick and gradual. If there is a stress injury or surgery has been performed, it may be necessary to wait several weeks or months.

This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.