Ball of Foot Pain

What is it?

Ball of foot pain is pain under the front of your foot, usually around the second, third and fourth toes. The medical name is metatarsalgia. It happens near the rounded ends of the long bones in the front of your foot (the metatarsal heads).

It is a symptom, not a diagnosis. Several different conditions can cause it, so finding the cause is the key to treating it well.

The pain can be spread over a wide area or sit in one spot. It often feels burning or stabbing, and it is usually worse when you put weight on the foot. Some people say it feels like walking on a pebble. Tight, hard shoes tend to make it worse.

What can cause it?

The most common causes are changes in the soft tissues under the ball of your foot:

• Fat pad thinning (atrophy): the fatty cushion under the ball of your foot wears thin, so there is less padding.
• Capsulitis: irritation or injury of the tissue that wraps around a toe joint (the joint capsule).
• Intermetatarsal bursitis: irritation of a small fluid-filled cushion between the bones of the front of your foot.
• Plantar plate injury: a strain or tear in the strong tissue under the base of a toe.

Foot shape and loading are also common causes. Some people have a foot shape that puts extra pressure on the ball of the foot, either from birth or from changes over time. This often gives a wider, aching pain. Hard or cracked skin or a verruca (a wart on the foot) can also hurt. Running and other exercise, shoes that are too tight, bunions and hammer toes (toes that bend at the middle joint) can add to it.

Morton's neuroma is a trapped, thickened nerve between the toes. It most often causes sharp, burning or shooting pain between the third and fourth toes. It can feel like a pebble or lump is stuck under your foot, and it is worse in tight shoes. Sometimes it can also cause tingling.

Other causes are less common. A stress fracture (a small crack in a bone from overuse) can cause forefoot pain. So can arthritis and gout, infection, and avascular necrosis (when part of a bone loses its blood supply).

Who gets it?

Ball of foot pain is one of the most common complaints in people with foot problems. It is more common in older people and in people with diabetes.

Foot pain in general is common in middle and older age. About 24 per cent of adults aged 45 and over have frequent foot pain, and the toes and front of the foot are the most common places. That figure covers all foot pain, not only pain in the ball of the foot.

Things that can add to it include running and other impact exercise, tight or unsupportive shoes, arthritis and a foot shape that puts extra pressure on the ball of the foot.

How is the cause found?

Your podiatrist will usually work out the cause by asking questions and examining your feet and legs. They will ask when the pain started, what changed, how long it has lasted, and how it varies through the day. They will ask what makes it better or worse, and whether the foot swells or your toes have changed position. The timing of the pain as you walk can also give clues.

The examination often includes checking how well your ankle and toes move, and feeling for tender spots. Your podiatrist may press between the bones at the front of your foot, check for tight calf muscles, and gently test the toe joints. This test (the digital drawer test) checks the plantar plate and joint capsule. With a suspected Morton's neuroma, they may feel or hear a click as the nerve moves between the bones.

Imaging is used selectively. Some practitioners like an X-ray taken while you stand. Others only use X-rays when something looks unusual or surgery is being planned. Ultrasound or an MRI scan may be used when the cause is unclear. An MRI is best for showing how badly a plantar plate is injured, and a clear ultrasound makes a plantar plate injury unlikely. Blood tests are sometimes needed.

Symptoms overlap a lot between causes, so your podiatrist will put all the findings together before giving a diagnosis. It helps to bring the shoes you wear most often. It also helps to note where the pain is, what it feels like, and whether tight or hard shoes make it worse.

Treatment

Treatment depends on the cause. Most people start with simple steps at home.

Looking after it at home

• Shoes: wear shoes with plenty of room, especially a wide and deep toe box. Choose a low heel and a soft, cushioned sole that doesn't squash easily under the ball of your foot. A thick cushioned sole with a curved front (a rocker sole) can help. Avoid flat or slip-on shoes, and replace worn-out pairs.
• Insoles and pads: try soft insoles or pads in your shoes.
• Activity: avoid activities that make the pain worse. Swap running or jumping sports for low-impact activity such as cycling or swimming.
• Rest and ice: put your feet up when you can. Hold an ice pack wrapped in a towel on the sore area for up to 20 minutes every 2 to 3 hours.
• Stretching: try regular, gentle foot and ankle stretches.
• Weight: if you are overweight, losing weight takes pressure off your feet.
• Pain relief: paracetamol or ibuprofen gel can help. Ibuprofen tablets can be used if needed. Anti-inflammatory painkillers like ibuprofen aren't suitable for everyone. If you have other health conditions, check with a pharmacist or your GP first.

Treatment from your podiatrist

Your podiatrist will look at your shoes, activities and foot shape. They can advise on footwear and give you an exercise plan, including calf and foot stretches. They may suggest insoles or heel raises of 5 to 10 mm, along with pads that take pressure off the sore spot. It isn't yet known which of these steps works best for each cause.

For Morton's neuroma, wider shoes and padding worked for about 32 per cent of people after an average of 4.5 months. No unwanted effects were reported with this approach.

Other options

If simple steps aren't enough, ask your GP, podiatrist or a foot specialist about other options. They will also check again for warning signs.

For Morton's neuroma, a corticosteroid injection (a steroid medicine injected near the nerve) gave better results at 6 months than wider shoes and padding. Possible downsides include lighter skin colour over the area, thinning skin and thinning of the fat pad under the foot. Gentle manual therapy (manipulation or mobilisation of the foot) also reduced pain more than no treatment at 6 weeks. No single best non-surgical treatment has been shown yet.

If these don't help, surgery is sometimes considered. Two operations that adjust the metatarsal bones, Weil's osteotomy and distal metatarsal metaphyseal osteotomy, are equally safe and effective for metatarsalgia.

Will it get better?

How long ball of foot pain lasts depends on the cause, and it isn't yet clear how long it usually takes to settle or how often it comes back. What matters most is working out the cause and dealing with it. Many people start with changes to shoes and activity, and these are worth trying consistently.

If the pain isn't settling, don't just put up with it. Treatment can be adjusted, and there are more options to try.

Preventing it

The steps that help treat ball of foot pain are also the sensible ones to keep going. Whether they stop it coming back isn't yet clear.

Choose roomy, low-heeled, cushioned shoes and wear them regularly, indoors too. Replace them when they wear out. If running or jumping brings the pain on, mix in low-impact activity such as cycling or swimming. Keep up gentle foot and calf stretching, and work towards a healthy weight through diet and regular low-impact exercise if you are overweight.

When to see a podiatrist

Book an appointment if

Your pain hasn't improved after 2 weeks of looking after it at home, or it is getting in the way of your usual activities. Book an appointment with your podiatrist. You can also see your GP.

Seek prompt assessment if

Call your local emergency number if you have an infection or a foot problem and you also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine. This could be sepsis. Call your local emergency number as well if you suddenly become short of breath, have chest pain, or cough up blood.

Go to the nearest emergency department if your foot is at an odd angle or has suddenly changed shape after an injury.

See your GP or another doctor today if any of these happen:

• You have sudden, severe pain in one joint, with swelling, skin colour change around the joint, and you feel generally unwell with a high temperature or the shivers. A joint infection can cause this.
• You have sudden, very severe foot pain, or a foot that has changed shape without a clear cause.
• Your foot is red, hot and swollen, especially if you have numbness or diabetes.
• You have a fever or feel unwell along with foot pain.
• Your calf is painful, swollen, warm or red.
• You think you may have broken your foot. Don't try to treat it yourself.
• You have diabetes and a new foot wound or spreading redness.

If your GP can't see you today, go to an urgent care clinic or an after-hours GP.

See your GP soon if:

• You have tingling, weakness or numbness in your foot.
• You have diabetes and foot pain.
• The pain wakes you at night or stops you sleeping, or keeps getting worse.
• You have foot pain with no injury and you have lost weight without trying, or you've had cancer in the past.
• You have a lump or swelling that is unusual or growing.
• A joint stays swollen for no clear reason.

Frequently asked questions

Is ball of foot pain the same as Morton's neuroma?

No. Ball of foot pain (metatarsalgia) is a symptom with many possible causes. Morton's neuroma, a trapped nerve between the toes, is just one of them. It most often causes sharp, burning or shooting pain between the third and fourth toes. Your podiatrist can tell which cause fits your pain.

Could my ball of foot pain be a stress fracture?

It could be, but a stress fracture is only one of several possible causes, and the symptoms overlap with others. An examination, and sometimes imaging, is needed to tell them apart.

Further reading

• Foot pain NHS
• Foot pain: MedlinePlus Medical Encyclopedia MedlinePlus
• Metatarsalgia - My Joint Health Hub NHS
• Morton's neuroma NHS
• Pain in your toe or the ball of your foot - Morton's neuroma - Bradford District Care NHS Foundation Trust NHS