Dr. Yi-Cheng Wu
中文

Why Does It Feel Like There's a Pebble Under Your Foot? Understanding Forefoot Pain

By Dr. Yi-Cheng Wu · Reviewed June 8, 2026

Forefoot pain is pain on the plantar side of the metatarsal heads, common in runners and people doing high-impact sports, and is often related to overuse, foot structure, and footwear.

Forefoot pain refers to a sharp, dull, or burning sensation on the plantar side of the metatarsal heads, at the front of the sole and behind the toes. It worsens with standing, running, or walking barefoot on hard ground and eases with rest, and some people feel as if there is a pebble in the shoe. It is a symptom rather than a single disease. The primary form is related to intrinsic factors such as an overly long metatarsal head or hallux valgus, while the secondary form is usually caused by trauma, overuse, or poor footwear. Long-distance running and jumping sports carry a higher risk because the forefoot bears about three times body weight. Early management may include icing, rest, suitable footwear, and metatarsal pads, and most cases do not require surgery.

Forefoot pain is usually felt at the front of the sole, in the area just behind the toes, as a sharp, dull, or burning sensation. It worsens with standing, running, bending the foot, or walking, especially when walking barefoot on hard ground, and eases with rest. Some people feel as if there is a small pebble inside the shoe.

Forefoot pain occurs on the plantar side of the metatarsal heads and can be regarded as a symptom rather than a specific disease. Primary forefoot pain arises from intrinsic factors such as an overly long metatarsal head, hallux valgus, or other congenital deformities. Secondary forefoot pain may be caused by trauma, overuse, or poor footwear.

The medial and lateral sides of the foot are maintained by these joints and by the small postural muscles of the foot. Beneath the joints lies a fat pad that cushions the impact of walking and running. Abnormal function of the medial longitudinal arch can affect lower-limb biomechanics, and abnormalities of the transverse arch and forefoot may also affect lower-limb biomechanics. Collapse of the transverse arch affects the propulsion phase of gait, the final 30% of the stance phase, when only the forefoot is in contact with the ground; abnormal forefoot biomechanics may in turn have a negative effect on the lower limb during propulsion.

Epidemiology

  • Intense training or activity. Long-distance runners face a risk of metatarsalgia, mainly because the front of the foot bears a considerable force during running. Anyone taking part in high-impact sports is at risk, especially if the shoes do not fit or are worn out.
  • Athletes in high-impact sports such as dance, running, and jumping transmit nearly three times body weight to the forefoot during running.

Cause

  • Repetitive or excessive stress combined with intrinsic and extrinsic factors.
  • The first metatarsal head normally bears about 30% of the load. A normal metatarsal arch maintains this balance by providing enough cushioning. Excessive pronation or splaying of the foot disrupts this balance, leading to abnormally high pressure on the second to fifth metatarsal heads. Over time, reactive tissue forms calluses around the metatarsal heads, worsening the pain.

Risk factors

  • Foot deformity: excessive pronation, flat feet, high arches, hallux valgus, prominent metatarsal heads, hammer toe deformity, Morton’s foot (a short first metatarsal with a relatively longer second metatarsal).
  • Excess weight: because most of the body weight shifts to the ball of the foot when moving, extra weight means more pressure placed on the bones.
  • Muscle imbalance or soft-tissue dysfunction: a tight Achilles tendon or toe extensors, weak toe flexors, or laxity of the Lisfranc ligament.
  • Other extrinsic factors: high heels, poorly fitting or worn-out shoes, or uneven force distribution caused by surgery.
  • Other intrinsic factors: skin problems such as warts, and atrophy or displacement of the fat pad.

Common conditions

  • Weakness of the intrinsic foot muscles
  • Warts
  • Hallux valgus or hallux rigidus
  • Hammer toe or claw toe
  • Morton’s syndrome (a long second metatarsal)
  • Freiberg’s disease (avascular necrosis of a metatarsal head, most commonly the second, seen in adolescent sprinters)

History

  • Patients typically describe pain over the medial metatarsophalangeal (MTP) joint prominence when wearing tight or stiff shoes.
  • Pain beneath the second metatarsal head accompanied by plantar keratosis.
  • During exercise there may be blisters, swelling, callus formation, or bursitis.
  • Patients may describe a widened forefoot or difficulty fitting into shoes, with concerns about the appearance of the foot and the comfort of footwear.
  • Numbness or tingling on the medial side of the big toe may be caused by compression of the medial cutaneous nerve.

Physical examination

  • Note the severity of hallux valgus (HV) and rotational deformity in standing and non-weight-bearing positions.
  • Assess the alignment of the arch and hindfoot.
  • Check the active and passive range of motion (ROM) of the first metatarsophalangeal (MTP) joint and the tarsometatarsal joints.
  • Assess sensation of the big toe.
  • Check the sesamoid bones of the big toe for pain and position.
  • Assess the tightness of the gastrocnemius of the calf.

Differential diagnosis

  • Hallux rigidus (degenerative arthritis of the first MTP joint with a dorsal bunion)
  • Trauma-induced tear of the medial joint capsule
  • Hallux interphalangeus (valgus at the interphalangeal joint rather than the MTP joint)
  • Gout and other inflammatory conditions
  • Osteoarthritis of the big-toe joint
  • Stress fracture

Diagnostic tools

  • Weight-bearing anteroposterior and lateral X-rays, along with sesamoid views of the foot, may help with diagnosis.
  • Ultrasound to rule out soft-tissue injury.
  • Medial digital nerve compression is usually a clinical diagnosis and does not necessarily require routine imaging.

Early treatment

  • Icing and rest, activity modification, and short-term use of NSAIDs for symptom control.
  • Wearing suitable athletic shoes.
  • Thinning the callus; seek a dermatologist or a related professional for treatment.
  • Placing a metatarsal pad proximal to the metatarsal heads to reduce pressure (avoid placing the pad directly under the metatarsal heads).
  • Stretching a tight Achilles tendon.

Long-term treatment

  • Insoles are beneficial for people with high arches and hallux valgus.
  • Wearing suitable shoes with arch support and a low heel day to day.
  • Shock-absorbing running shoes, considered for replacement every 350 miles or when they show early wear.
  • Maintaining flexibility of the gastrocnemius.
  • Exercise training to strengthen and correct postural or gait imbalances.
  • Avoiding hard surfaces and prolonged standing.

Surgery

  • If conservative treatment does not help or the condition does not improve, surgery may be considered. Most cases do not need it.
  • Weil osteotomy is a common surgical method used to reduce pressure on the metatarsal head, with good results. Percutaneous surgical techniques also show notable improvement in long-term outcomes and a lower rate of late forefoot pain.

Prognosis

  • If conservative treatment is started early, surgery may not be necessary.
  • Recovery time after surgery depends on the complexity and invasiveness of the procedure.

Complications

  • Back, knee, and hip pain caused by compensatory changes in gait.
  • Transfer forefoot pain after surgery, as pressure shifts to other areas.

References

Further reading

Frequently asked questions

Who needs to pay the most attention to this problem?

Long-distance runners and people who do high-impact sports such as dance and jumping are at higher risk, because during running the forefoot bears about three times body weight. Shoes that do not fit, are worn out, or are too heavy, as well as foot structure issues such as flat feet, high arches, hallux valgus, hammer toe, or Morton's foot, also make forefoot pain more likely.

What are the common treatments or management options?

Early management is usually conservative and includes icing, rest, activity modification, short-term use of anti-inflammatory pain medication to control symptoms, wearing suitable athletic shoes, and placing a metatarsal pad proximal to the metatarsal heads to reduce pressure. Over the longer term, options may include insoles, low-heeled shoes with arch support, maintaining calf flexibility, and exercise training to correct gait. Most cases do not need surgery, which is considered only when conservative treatment does not help.

When should you see a doctor for evaluation?

If the pain persists, affects walking or exercise, or is accompanied by blisters, swelling, calluses, bursitis, a widened forefoot that makes shoes hard to fit, or numbness and tingling on the inner side of the big toe, evaluation by a physician is advised. The physician may arrange investigations such as weight-bearing X-rays or ultrasound to rule out other causes such as stress fracture, gout, or arthritis.

This article is also available in the original Chinese, with the full reference list.

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