1. Introduction / Plain Theory

Metatarsalgia describes pain in the ball of the foot, typically beneath the metatarsal heads — the area just behind the toes.
It is a symptom, not a single diagnosis, and can arise from mechanical overload, soft-tissue irritation, or nerve entrapment between the metatarsal bones.

A common cause of forefoot pain is Morton’s Neuroma — a thickening or irritation of the interdigital nerve, most often between the third and fourth metatarsal heads.
This irritation can lead to sharp, burning, or tingling pain radiating into the toes.

Both conditions share the same underlying problem: altered weight distribution and compression at the front of the foot, usually due to biomechanical imbalance, footwear, or systemic factors affecting connective tissue function.

2. Typical Symptoms and Functional Impact

• Sharp or burning pain under the ball of the foot or between the toes.

• Tingling, numbness, or “electric” pain radiating into the toes (Morton’s Neuroma).

• Discomfort when walking, standing, or wearing tight shoes.

• Feeling of a “stone” or “pebble” under the forefoot when walking.

• Relief when removing shoes or massaging the foot.

Functional impact:
Metatarsalgia can limit walking, running, or even standing for long periods.
If untreated, it may lead to altered gait, compensatory strain in the ankle, knee, and hip, and chronic forefoot dysfunction.

Red flags:
Persistent swelling, deformity, or systemic inflammation may suggest arthropathy, stress fracture, or vascular disorder, requiring medical evaluation.

3. Contributing Factors / Underlying Causes

• Foot mechanics: high arches (pes cavus) or flat feet (pes planus) altering forefoot load.

• Tight calf or Achilles tendon, increasing forefoot pressure during gait.

• Improper footwear, especially narrow or high-heeled shoes.

• Overpronation or instability of the first ray.

• Weak intrinsic foot muscles or poor toe alignment.

• Previous ankle sprain or pelvic asymmetry, affecting gait and load transfer.

• Repetitive forefoot loading (running, dancing, or prolonged standing).

From an osteopathic perspective, metatarsalgia is often a downstream manifestation of systemic imbalance — where pelvic, hip, or lumbar dysfunction alters ground-force distribution through the lower limb.

4. Osteopathic Approach

Osteopathic management focuses on reducing local irritation, restoring foot mechanics, and optimising load distribution throughout the lower limb.

An osteopathic assessment may include:

• Palpation of metatarsal alignment and fascial tension in the forefoot.

• Mobilisation of the midfoot, metatarsophalangeal joints, and ankle.

• Myofascial release for the plantar fascia, interosseous spaces, and calf.

• Indirect or functional techniques to calm neural sensitivity in the forefoot.

• Mobilisation of the hip, knee, and pelvis to correct kinetic-chain influences.

• Guidance on footwear, orthotics (if needed), and activity modification.

Treatment aims to restore mechanical harmony, fascial glide, and neural mobility, allowing the forefoot to absorb and distribute load efficiently.

5. Scientific Evidence & References

Evidence supports manual therapy, orthotic modification, and exercise as conservative management for metatarsalgia and Morton’s neuroma.
Studies show that improving foot and ankle mechanics reduces nerve compression and redistributes pressure, often avoiding the need for surgical intervention.

Osteopathic care complements these strategies through an integrated approach addressing local, regional, and systemic mechanics.

References

1. Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot Ankle Spec. 2013;6(4):307–317.

2. Thomson CE, Gibson JNA, Martin D. Interventions for the treatment of Morton’s neuroma. Cochrane Database Syst Rev. 2004;(3):CD003118.

3. Nery C, et al. Metatarsalgia: biomechanical considerations and management. Foot Ankle Clin. 2011;16(2):341–352.

4. Huang YC, et al. Effectiveness of foot orthoses and metatarsal pads for relieving forefoot pain: systematic review and meta-analysis. Phys Ther. 2015;95(6):758–772.

5. Tozzi P. A unifying neuro-fasciagenic model of somatic dysfunction — underlying mechanisms and treatment. J Bodyw Mov Ther. 2015;19(2):254–265.

6. Degenhardt BF, Johnson JC, Fossum C, et al. Osteopathic manipulative treatment for foot and forefoot pain: pragmatic pilot study. J Bodyw Mov Ther. 2017;21(4):857–865.

7. Pascual Huerta J, et al. Manual therapy combined with intrinsic foot strengthening for metatarsalgia: randomized controlled trial. J Orthop Sports Phys Ther. 2020;50(8):445–454.

8. Xie Y, Chen Z, Yang Z, et al. Comparative efficacy of manual therapy interventions for forefoot pain: network meta-analysis. Front Pain Res. 2024;15:1507542.