Metatarsalgia is a common presenting symptom with an established list of differential diagnoses. The authors present a classification system and surgical treatment algorithm for chronic metatarsophalangeal pain due to metatarsophalangeal joint capsule tear. A series of 58 metatarsophalangeal joints with partial tear diagnosed by arthrogram and treated by surgical repair are reviewed. The authors propose a classification system based on preoperative arthrography and a surgical repair procedure for each type of three distinct patterns. A study was developed and funded to perform postoperative arthrograms on 15 patients who had undergone surgical repair using the procedures presented. The purpose of the study was to validate the utility of the arthrogram in the diagnosis and clarification of the nature of the capsular tear. The authors were also able to demonstrate that the arthrographic findings became normal postoperatively, and that surgical repair of a seemingly innocuous capsule tear relieves pain. Fifty-six patients in the series reported relief of their preoperative symptoms. Postoperative arthrograms in 15 patients demonstrated a normal pattern in 73%, 20% had decreased extravasation, and 7% were unchanged.