Ball of foot pain

What is ball of foot pain?

Ball of foot pain is called metatarsalgia (pain under the front of the foot, around the long bones behind your toes)¹. It's usually felt behind the second to fourth toes².

The pain tends to come on with standing, walking or running. It's often burning or stabbing, and some people say it feels like walking on a pebble. Tight, hard shoes make it worse³.

Metatarsalgia isn't a diagnosis in itself. It's a name for the pain, and several different problems can cause it⁴. It's one of the most common complaints in people with foot problems², and it's more common in older people and people with diabetes¹.

What causes it?

The most common causes are thinning of the fatty cushion under the ball of the foot (fat pad atrophy), an inflamed joint capsule at the base of a toe (capsulitis), inflamed fluid sacs between the bones (intermetatarsal bursitis) and an injured plantar plate (the tough band of tissue under the toe joint)⁵.

Running and other exercise, tight shoes and arthritis are common triggers. A foot shape that puts extra pressure on the ball of the foot, hard or cracked skin, or a verruca can also hurt⁶. Gout, bunions, hammer toes and stress fractures can be behind it too¹.

Morton's neuroma (a trapped nerve between the toes) often causes a shooting, stabbing or burning pain between the 3rd and 4th toes, and a feeling of a pebble or lump under the foot⁷.

Symptoms overlap a lot, so where the pain is and what it feels like are clues rather than proof.

How is the cause found?

A podiatrist works it out mainly by asking questions and examining your foot and lower leg⁸. They may ask when the pain started, how it has changed, whether the foot swells, and whether your toes have changed position⁹. They may press on the foot, check movement and calf tightness, and test how stable your toe joints are⁹.

Blood tests or an ultrasound are sometimes needed⁸. An X-ray may be used if something looks unusual or surgery is being planned¹⁰.

Before your visit, note when the pain started, what changed, and how it varies through the day. Bring the shoes you wear most often.

What can I do at home first?

Self-care is the place to start. Try:

• Roomier shoes with a low heel and a soft sole, and plenty of room for your toes⁶. A wider, deeper toe box can help⁹.
• Soft insoles or pads in your shoes⁶.
• Easing off what brings it on. Low-impact activity such as cycling or swimming can replace running or jumping¹.
• Rest and ice. Put your foot up when you can, and use an ice pack wrapped in a towel for up to 20 minutes every 2 to 3 hours⁶.
• Gentle foot and ankle stretching, and working towards a healthy weight if you're overweight⁶.
• Pain relief. A pharmacist can advise on options such as paracetamol. Anti-inflammatory medicines such as ibuprofen aren't suitable for everyone, so check with a pharmacist or GP if you have other health conditions.

Most of this advice is general guidance rather than trial results. For Morton's neuroma, roomier shoes with padding helped some people, and no harms were reported¹¹.

What if self-care isn't enough?

Ask your GP or podiatrist about the options. Which one suits you depends on the cause.

The best-supported options are for Morton's neuroma. A corticosteroid injection worked better than footwear and padding in one trial, and hands-on foot manipulation or mobilisation (gentle movement of the foot joints) eased pain¹¹. No single non-surgical treatment has been shown to be best, and the evidence is limited¹¹. For other causes, it isn't clear yet which next step works best.

Two operations on the metatarsal bones used for metatarsalgia seem to be equally safe and effective, though better studies are needed¹².

Will it get better, and how do I stop it coming back?

It isn't clear yet how long ball of foot pain usually lasts or how often it comes back, and no step has been shown to prevent it. What follows is general guidance.

Footwear is the most consistent advice. A shoe with a thick, cushioned sole that doesn't squash under the ball of the foot, and a curved front (rocker), can help forefoot symptoms¹³. Wear supportive shoes regularly, indoors too, and replace them when they're worn out¹. Keep up the stretching and low-impact activity that suit you.