The causes of metatarsalgia are classified as primary, secondary, and iatrogenic. Anatomical and biomechanical considerations separate “static” from “propulsive” forms of metatarsalgia. The physical examination should be combined with an assessment of weight-bearing radiographs and, if needed, of ultrasound or magnetic resonance imaging scans. The first-line treatment is conservative (stretching exercises, footwear modification, insoles, and lesion debridement). Soft-tissue surgical procedures (gastrocnemius muscle recession, tendon transfer, and plantar plate repair) should also be considered. Among the various types of metatarsal osteotomy, the Weil procedure is reliable. Percutaneous methods are being developed but require evaluation. A treatment algorithm can be developed based on whether the hallux is normal or abnormal. Metatarsalgia due to inflammatory disease requires a specific treatment strategy.