Running Injuries Foot Pain & Running Injuries: Torn Metatarsal Ligament vs. Metatarsalgia and Stress Fractures

Foot Pain & Running Injuries: Torn Metatarsal Ligament vs. Metatarsalgia and Stress Fractures

Metatarsal stress fractures are common running injuries that are often confused with metatarsalgia or plantar plate tears. This video and article will help you differentiate between these three conditions.

4 Minute Video: Torn Metatarsal Ligament, Metatarsalgia, or Stress Fracture?

Common Running Injuries – Foot Pain

Foot pain and injuries are common in the running community.  The most common conditions we treat are plantar fasciitis and heel pain syndrome.  Less common injuries also appear in the foot and are often overlooked or misdiagnosed by most physicians.  Pain in the ball of the foot can be a number of different conditions:

  1. Pain under the big toe can be sesamoiditis or a fractured sesamoid bone
  2. Pain under the 2nd -4th metatarsal can be metatarsalgia, stress fracture or a torn transverse metatarsal ligament.
  3. Pain near the heel that goes slightly into the arch can be heel spurs, heel pain syndrome or plantar fasciitis.

These are the most common foot conditions seen and treated by the San Diego Running Institutes Sports Medicine Clinic.  Let’s look at the diagnoses of metatarsalgia, stress fractures, and torn transverse metatarsal ligaments. In the early stages there is no real way to tell the difference between metatarsalgia, stress fracture and a torn metatarsal ligament.  It is in the later stages it may become obvious.


The first signs and symptoms are pain beneath the 2nd, 3rd or 4th metatarsals.  Early on this condition can be treated with manipulation of the metatarsal heads, placement of a metatarsal pad and 1-2 weeks of rest from impact activity.  Sometimes a walking boot is required.

Stress Fractures

Stress fractures of the metatarsal heads are a progression of Metatarsalgia.  Once the ligaments of the metatarsals are bruised they weaken.  This makes the bone susceptible to fracture. Before the bone actually fractures the marrow inside the bone cavity swells, resulting in bone marrow edema. This will then progress to the bone fracturing from the inside out resulting in stress fracture.

Stress Fracture Symptoms

Signs and symptoms of bone marrow edema and stress fracture are slight discomfort while running but increased pain and LIMPING after running!  It is an interesting fact that many with this condition seem to fool themselves into thinking it does not hurt when they run.  The tell tale sign however is found AFTER THEY RUN.  If the runner has pain and a limp post run they most likely have a stress fracture.

Stress Fracture Treatment & Diagnosis

Once bone marrow edema or stress fracture is achieved the patient needs to have complete rest from impact activity and give the injury 4-6 weeks to repair before returning to running. X-rays or MRI may help confirm the diagnosis but are not necessary as they do not change the symptom and sometimes are not sensitive enough to find the exact site of the break.

Torn Plantar Plate/Metatarsal Ligament

Detecting a torn metatarsal ligament can be challenging.  The pain may be present following 6 weeks of complete rest.  While bone typically heals in 6 weeks ligaments can take up to a full year to completely repair.

Torn Metatarsal Ligament Symptoms

You may notice the toes splaying away from the pain.  Most common is to see the second toe splay towards the big toe.  This indicates ligament tearing and subluxation of the metatarsal-phalangeal joint.

Torn Metatarsal Ligament Treatment

Once a diagnosis of a torn metatarsal ligament is given the patient is placed in a walking boot and restricted from any weight bearing activity for 6 weeks.  Custom orthotics with extra forefoot padding and metatarsal pads are prescribed.  After 6 weeks the patient is allowed to begin non-impact activities like stair climbing or elliptical.  If there is no pain with those activities after 2 weeks the patient can begin walking and hiking.  After a week if there is still no pain the patient can begin light running (1-2 miles) for the next 2 weeks.  If there is still no pain a prudent and progressive training program can be undertaken.

Help with Running Foot Injuries

If you would like help in resolving any of these conditions, the San Diego Running Institute recommends Dr. Victor Runco. Dr. Runco is a running injury specialist as well as a marathon runner. He has helped hundreds of runners and non-runners with painful conditions. If you would like to make an appointment call (858) 268-8525.

Read the comments on this post to see questions asked by real patients with running injuries and foot pain. Dr. Runco personally responds to each question and provides valuable information for anyone suffering from stress fractures, metatarsalgia, or torn metatarsal ligaments.

About Victor Runco

Dr. Runco is a U.S. Navy and Gulf War Veteran. Graduating as a Doctor of Chiropractic he began private practice in San Diego in 2000. He has been a professor of Anatomy, Physiology, and Biomechanics at various colleges and continues to teach continuing education in the fields of rehabilitation, custom orthotics and athletic taping. He is also a member of the American College of Sports Medicine, National Strength and Conditioning Association and is a Certified Strength and Conditioning Specialist. He has completed over 15 Marathons in 15 states and has run 9 50 mile Ultramarathons.


Nj 15-02-2015, 21:48


I run regularly, about 10km most nights on road. I have a sever hallux valgus left foot. Insidious onset left foot pain over dorsal surface, around head of met 2/3 possible into tarsal bones too. Nothing visible to see. Hurts when running but I can run through it (particularly on foot strike and push off). I get a severe limp after running and can hardly weight bear for up to 24 hours. Then eases with rest. I had a week off it felt better and then one run back to square one. XR showed nothing. Help!

Dr. Runco 16-02-2015, 15:14

It appears that you are suffering from a transfer injury due to compensation while running brought on by your “severe Hallux Valgus left toe”. Hallux Valgus is another way of describing a bunion. When this occurs a runner may transfer some of their weight or all of it away from the first toe and onto the second during toe-off. The second metatarsal is not designed to handle this repetitive load and over time will result in injury. The specific type of injury to the second metatarsal can be
1. Stress fractures. They usually do not show themselves on x-ray.
2. Bone marrow edema. Is also known as a “pre-stress” fracture
3. Plantar Plate tear/sprain. Can be anything from a less sever grade 1 tear to a more severe grade 3 tear.
4. Joint capsule tear. Also referred to as capsulitis.
5. Tendonitis or Tenosynovitis. Is a torn flexor tendon and can be less severe to more severe.
I would suggest that your injury is going from less severe to more severe at this moment. The fact that you get a severe limp and can not weight bear for 24 hours suggests it is worsening and you are headed down a road you would rather not go down. I recommend you call my office at 858-268-8525 and schedule a phone consultation. The cost is $125. Afterwards you will be provided with a specific treatment plan and guidelines so that you will have all the tools necessary to properly and successfully recover from this condition and prevent future recurrences.
If you would like to do this please follow these directions beforehand
1. When you call my office leave your full name and a number and time(s) you will answer so my office can call you back to schedule the phone consult
2. Take pictures and email them to me of your feet while sitting and then standing
3. Take pictures of the bottoms of your shoes and email them to me
4. Pictures of any insoles you may wear…tops and bottoms and email them to me

Jess Brown 29-08-2015, 03:47

Hi, I have just recently had a stress fracture and have been in a boot for 6 weeks. Ct showed the other day that all is healed. My running coach told me to take it very slow in terms of getting back into sport. I played hockey the other day for around 15 mins and now the top of my foot is painful. I had the stress fracture in the fourth metatarsal but the pain I feel now is in the second metatarsal. What do you think it could be? Could it be another stress fracture? Many thanks Jess

Dr. Runco 31-08-2015, 12:05

it is hard to imagine another stress fracture that quickly. See if it happens again. If it persists you will want another film. If it is another fracture you need to consider why you keep breaking. Maybe there is an underlying cause

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