Burning in the ball of the foot: neuroma or metatarsalgia?

Pain under the ball of the foot has a long list of possible causes, and two of the most common look surprisingly alike. One is a thickened nerve between the toes. The other is an injury to the ligament-like plate under the joint at the base of a toe. The right treatment depends on which one you have, so it is worth understanding how they are told apart.

What “metatarsalgia” means

Lesser (or central) metatarsalgia is pain in the forefoot under or around the lesser metatarsals and their joints with the toes. Two common causes are Morton’s neuroma and plantar plate injury. Because the clinical and imaging features of the two overlap, working out the right diagnosis can be challenging.^[1]

What a Morton’s neuroma feels like

Morton’s neuroma is a thickening of the tissue around a small nerve between the long bones of the forefoot. It is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate into the affected toes, commonly the third and fourth.^[3] Despite the name it is not a true neuroma. It is fibrosis of the nerve, caused by pressure or repetitive irritation.^[5]

How much do the usual symptoms tell us?

A 2024 systematic review pooled nine studies on how well symptoms and bedside tests identify a Morton’s neuroma. Its findings are useful, and a little surprising:^[2]

• A click you feel between your toes was highly specific (0.96), which means that if you feel it, a neuroma becomes considerably more likely.
• Tenderness when the space between the toes is squeezed (the modified webspace tenderness test) was highly sensitive (0.96), so a negative result makes a neuroma unlikely.
• The “walking on a pebble” feeling and “burning pain” were reported by roughly half of people with a neuroma (sensitivities of 43% to 53% and 54% to 57%), and their specificities were only about 50%. They fit with a neuroma, but they don’t separate it from other causes.

The review also cautions that only one included study had a low risk of bias, so these are useful guides, not proof.^[2]

Clues that point elsewhere

Other problems can cause pain in the same spot. Your examination will consider irritation of the joints at the base of the toes, a plantar plate injury, metatarsal stress fractures, arthritis of the toe joints and nerve problems elsewhere, such as peripheral neuropathy or tarsal tunnel syndrome. Numbness that spreads beyond two toes, or that appears in both feet, should make you and your clinician think of something other than a single neuroma.

When imaging helps

X-rays don’t show a neuroma, but they help rule out problems in the bones and joints. When more information is needed, a meta-analysis of 14 studies found that ultrasound and MRI were about equally sensitive for detecting a Morton’s neuroma (0.91 and 0.90), using surgery as the reference.^[4] A review of metatarsalgia stresses that imaging has a pivotal role in separating a neuroma from a plantar plate injury, and that each imaging method has its own strengths and pitfalls.^[1] Imaging is always read together with your symptoms and examination, and it is arranged through an imaging provider when it would change the plan.

What helps while you find out

Whichever it turns out to be, reducing pressure on the ball of the foot is a sound first step. First-line treatment for Morton’s neuroma is reducing activities that cause pain, orthotics, and an injection.^[3] Our guides to shoes for Morton’s neuroma and Morton’s neuroma injections cover those options. For the full picture, see Morton’s neuroma and numbness, tingling and burning in the foot.

When to see a specialist

Get an evaluation if burning or aching under the ball of your foot has gone on for more than a few weeks, is limiting how far you can walk or what you can wear, or is spreading numbness beyond two toes.