Anatomic and biomechanical aspects of the complex topic of metatarsalgia are reviewed. Cause is classified as structural, functional, and a combination of both. Evaluation of the lesion symptom complex is presented and light is shed on reasons for complications after metatarsal osteotomy. Ways to avoid complications are also discussed. The oblique osteotomy with rigid fixation performed at the distal surgical neck or the proximal metaphysis is recommended.