Metatarsalgia: Difference between revisions

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== Definition  ==
== Definition  ==
[[File:Metatarsalgia.jpg|435x435px|<ref>https://greenbayacupuncture.co/2017/05/17/metatarsalgia-forefoot-pain/</ref>|right|frameless]]
[[File:Metatarsal bone animation01.gif|right|frameless]]
Metatarsalgia is a general term for [[Pain Behaviours|pain]] in the area of the metatarsophalangeal joints.  This is often seen in clinical practice, the deformity and pain can deteriorate gait function and decrease quality of life<ref name=":5">Park CH, Chang MC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784640/ Forefoot disorders and conservative treatment.] Yeungnam University Journal of Medicine. 2019 May;36(2):92.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784640/ (last accessed 25.6.2020)</ref>. 


Metatarsalgia (also known as Metatarsophalageal joint synovitis) is a general term used to denote a painful foot condition in the metatarsal region (the area just proximal the toes, more commonly referred as the ball-of-the-foot). It is a common inflammatory condition occuring most frequently in the second, third and/or fourth metatarsophalangeal joints, or isolated in the first metatarsophalangeal joints<ref name=":0">Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.</ref>. This is a disorder that can affect the bones as well as joints at the plantar forefoot.  
Most common causes include:
* Interdigital nerve pain ([[Morton's Neuroma|Morton]] neuroma)
* Metatarsophalangeal joint pain
* [[Sesamoiditis]]
* Submetatarsal head fat pad atrophy typically associated with [[Older People - An Introduction|aging]]<ref name=":4">Mercks manual. [https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/foot-and-ankle-disorders/metatarsophalangeal-joint-pain MTP joint pain] Available from:https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/foot-and-ankle-disorders/metatarsophalangeal-joint-pain (last accessed 25.6.2020)</ref>
Metatarsalgies are often accompanied by excessive callus formation over a bony protrusion, with severe pain and pressure sensitivity around the callus.<ref>Doty, Jesse F., and Michael J. Coughlin. "Metatarsophalangeal joint instability of the lesser toes." The Journal of Foot and Ankle Surgery 53.4 (2014): 440-445.


Metatarsalgies are often accompanied by excessive callus formation over a bony protrusion, with severe pain and pressure sensitivity around the callus.[1,2]<br>
</ref><ref name=":1">Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review:
metatarsalgia." Foot &amp; ankle international 29.8 (2008) </ref>
[[File:Metatarsals .jpg|324x324px|Metatarsals of the Right foot|right|frameless]]


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The most important and relevant anatomy is the metatarsals. The metatarsals are proximally connected to the tarsal bones and distally to the the phalanges. The joints between the metatarsals and the repsective proximal phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and the ability yo move in these joints is very important for normal walking. Knowledge of the other foot bones and structures (muscles, tendons, ligaments…) is also necessary to distinguish the sctructures and pathologies.<ref>http://www.eorthopod.com/content/foot-anatomy</ref>
The most important and relevant anatomy is the forefoot and the metatarsal. The metatarsus of the [[Foot Anatomy|foot]] consists of five long [[Bone|bones]], which are called the metatarsals.  


More information about anatomy of the foot and ankle can be found [http://www.physio-pedia.com/Biomechanics_of_Foot_and_Ankle here].<br>  
Metatarsals:
* Comprised of: proximal base; shaft; distal head.
* Proximally connected to the tarsal bones and distally to the phalanges.
* Named I to V medially to laterally, from the dorsal surface of the foot.
* Convex on their dorsal surfaces but concave on their plantar surfaces
* Along with the tarsals, help form the [[Arches of the Foot|arches of the foot]], which are essential in both weight-bearing and walking.<ref name=":3">https://www.kenhub.com/en/library/anatomy/metatarsal-bones</ref>
The joints between the head of the metatarsals and the respective proximal phalanx are called the metatarsophalangeal joint (MTP).
* These joints form the ball of the foot, and the ability to move in these joints is very important for normal walking.
* In addition, the bases of the metatarsals articulate with each other to form intermetatarsal joints.<ref name=":3" />
== Etiology  ==
Common causes include:
* Overtraining
* Interdigital ([[Morton's Neuroma|Morton]]) neuroma
* Freiberg infraction
*[[File:Foot 1.jpg|right|frameless]]Stress fractures involving the foot
* Intermetatarsal bursitis
* Adventitial bursitis
* Inflammatory and degenerative arthritis
* Metatarsophalangeal joint synovitis/capsulitis
* Tendinosis/tenosynovitis
* Plantar plate disruption / plantar plate tears
* Schwannoma<ref>Radiopedia [https://radiopaedia.org/articles/metatarsalgia Metatarsalgia] Available from:https://radiopaedia.org/articles/metatarsalgia (last accessed 25.6.2020)</ref>
* [[Pes cavus]] or high arched foot
* Excessive pronation of the foot
* Clawing or hammer toes
* Tight extensor tendons of the toes
* Prominent metatarsal heads
* Morton’s foot—there is a shortened first metatarsal, which results in an abnormal subtalar joint, and increased weight going through the second metatarsophalangeal joint.<ref name=":0">Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.</ref>


== Epidemiology/Etiology ==
== Causes ==
[[File:Hallux valgus anatomy.jpg|right|frameless]]There can be multiple causative factors. Often localized to the first metatarsal head.Next most frequent site of metatarsal head pain is under the second metatarsal.<ref name=":1" /><ref name=":2">G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to
biomechanical disorders”. Physical Therapy 66(6): 970-2; July 1986 </ref><ref>Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia&nbsp;: Diagnosis
and Manangement, Etiologies and Differential diagnoses”. Podiatry Management </ref>


There can be multiple causative factors that lead to the development of metatarsalgia, but the majority seem to be related to foot and ankle deformity. This can lead to a fundamental etiological component of metatarsalgia, that being the repetitive loading of a locally concentrated force in the forefoot during gait.
Factors that can cause excessive pressure are:


Metatarsalgia is most often localized to the first metatarsal head. The next most frequent site of metatarsal head pain is under the second metatarsal. This can be due to either a short first metatarsal bone or a hypermobility of the first ray (metatarsal bone and the medial cuneiform behind it), both of which result in excess pressure being transmitted into the second metatarsal head.[2,3,4]
*Participating in high impact activities without proper footwear and/or [[Introduction to Orthotics|orthotics]]
 
*[[Older People - An Introduction|Older age]] as the pad in the foot tends to thin out making it much more susceptible pressue and pain  
One or more of the metatarsal heads become painful and/or inflamed, usually due to excessive pressure. It’s common to experience acute, recurrent, or chronic pain with metatarsalgia. The pain is often caused from poorly fitted footwear, most frequently by high heel shoes and other restrictive footwear (Figure 1: Over-compression around the metatarsal heads can be related to metatarsalgia) [6]. Footwear with a narrow toe area forces the ball-of-foot area to be forced into a minimal amount of space (latero-medial over-compression). This can hamper the walking process and lead to extreme discomfort in the forefoot. [5,9]
 
Other factors that can cause excessive pressure are:
 
*Participating in high impact activities without proper footwear and/or orthotics  
*Older age as the pad in the foot tends to thin out making it much more susceptible pressue and pain  
*An imbalance in the length of the metatarsals  
*An imbalance in the length of the metatarsals  
*Disturbances in gait  
*Majority seem to be related to foot and [[Ankle & Foot|ankle]] deformity
*Disturbances in [[gait]]
*Morphology of the foot (e.g. increased bone length that protrudes into the bottom of the foot)  
*Morphology of the foot (e.g. increased bone length that protrudes into the bottom of the foot)  
*A shortened [http://www.physio-pedia.com/index.php5?title=Achilles_tendon_repair Achilles tendon]
*A shortened [http://www.physio-pedia.com/index.php5?title=Achilles_tendon_repair Achilles tendon]


The Metatarsophalageal joints become inflamed, usually due to excessive pressure over a prolonged period. It is often related to'
=== Subtypes ===
* pes cavus or high arched foot
*'''Primary metatarsalgia''' refers to symptoms arising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal.&nbsp;<ref name="p2">Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8 (2008)</ref>  
* excessive pronation of the foot
*'''Secondairy metatarsalgia''' can be caused by systemic conditions such as [[arthritis]] of the MTP joint.  
* clawing or hammer toes
*'''Iatrogenic metatarsalgia''' can occur after (failed) reconstructive surgery.
* tight extensor tendons of the toes
* prominent metatarsal heads
* Morton’s foot—there is a shortened first metatarsal, which results in an abnormal subtalar joint, and increased weight going through the second metatarsophalangeal joint.<ref name=":0" />
 
Forefoot pain may also be caused by conditions of the lesser toes, such as hammertoes, mallet toes, and claw toes. The pathophysiology of lesser toe deformities is complex and is affected by the function of intrinsic and extrinsic muscle units. In addition to lesser toe and metatarsal abnormality, forefoot pain can be attributed to interdigital neuritis, disorders of the plantar skin, and gastrocsoleus contracture.<ref>W Yoo, Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion Exercise on Metatarsalgia with Morton’s Toe, 2014, Pubmed</ref>
 
<br> Norman Espinosa divided metatarsalgia into three categories in his review. He listed the various conditions associated with each subtype.
 
*'''Primary metatarsalgia''' refers to symptoms arising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal. According to Jesse F. Doty, metatarsophalangeal joint instability of the lesser toes (mainly due to plantar plate insufficiency) is also a common cause of metatarsalgia.&nbsp;<ref name="p2">Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8 (2008)</ref>  
*'''Secondairy metatarsalgia''' can be caused by systemic conditions such as arthritis of the MTP joint.  
*'''Iatrogenic metatarsalgia''' can occur after (failed) reconstructive surgery.<br>


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
 
# Metatarsalgia most commonly results from misalignment of the joint surfaces with altered foot biomechanics, may cause
Metatarsalgia typically affects the bottom of the second metatarsophalangeal joint. However, any of the other metatarsals can be affected. In more unusual cases, more than one metatarsal can be affected on one foot. When metatarsalgia affects the second metatarsophalangeal joint, it also sometimes referred to as “second metatarsophalangeal stress syndrome”.
#* Joint subluxations,
 
#* Flexor plate tears (a fibrocartilaginous structure that lies directly plantar to the lesser metatarsal heads and acts as a sesamoid-like mechanism for each lesser joint (MPJ) of the foot<ref>Podiatry today [https://www.podiatrytoday.com/understanding-biomechanics-plantar-plate-injuries Understanding PP injuries] Available from:https://www.podiatrytoday.com/understanding-biomechanics-plantar-plate-injuries (last accessed 25.6.2020)</ref>)
Metatarsalgia is defined as pain in the anterior segment of the foot. Viladot stated that it is one of the most common types of pain. Symptoms of metatarsalgia include:  
#* Increased pain during the mid-stance and propulsion phases of walking as body weight is shifted forward onto the forefoot.<ref>G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders”.  Physical Therapy 66(6): 970-2; July 1986</ref>
 
#* Capsular impingement
*Pain and tenderness of the plantar surface of the heads of the metatarsal bones or of the metatarsophalangeal joint
#* Joint [[cartilage]] destruction (osteoarthrosis).
*Development of callus under the prominent metatarsal heads
#* Misaligned joints synovial impingement, with minimal if any heat and swelling (osteoarthritic synovitis).
*Increased pain during the mid-stance and propulsion phases of walking as body weight is shifted forward onto the forefoot.<ref>G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders”.  Physical Therapy 66(6): 970-2; July 1986</ref>
#* Metatarsophalangeal joint subluxation - May occur as a result of chronic inflammatory arthropathy, particularly [[Rheumatoid Arthritis|rheumatoid arthritis]] (RA)
 
#* Metatarsophalangeal joint pain  - weight bearing and a sense of stiffness in the morning.  
<br> The pain is typically described as a deep bruise. Sometimes, it will feel like there is a rock under the ball of the foot. These symptoms are usually worsened when walking or standing barefoot on a hard surface or poorly cushioned shoe, and better when in well-cushioned shoes. At the end of a day, with substantial standing and/or walking, the area can throb.  
#* Loss of metatarsal fat pad (usually cushions the stress between the metatarsals and interdigital nerves during walking) tends to move distally under the toes, causing interdigital neuralgia/Morton neuroma.  
 
#* To compensate for the loss of cushioning, adventitial calluses and bursae may develop.  
When a patient reports forefoot pain, the first thing is to observe whether a callus is present. There may be tenderness over the plantar surface of the metatarsals, as well as the possibility of a depression on the dorsum over the head of the metatarsal bone. There may also be a decreased passive range of motion of the involved metatarsophalangeal joint. <ref>Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia : Diagnosis and Manangement, Etiologies and Differential diagnoses”. Podiatry Management</ref>  
#* Coexisting rheumatoid nodules beneath or near the plantarflexed metatarsal heads may increase pain.<br>The 2nd metatarsophalangeal joint is most commonly affected.  
 
#* Usually, inadequate 1st ray (1st cuneiform and 1st metatarsal) function results from excessive pronation (the foot rolling inward and the hindfoot turning outward or everted), often leading to capsulitis and hammer toe deformities.  
It is not uncommon to have a callus located under the affected metatarsal. Pain usually is first noticed at the bottom of the ball of the foot and there is no swelling. With progression, swelling can appear, along with tenderness at the top side of the joint. In some cases, bursitis will form adjacent to the metatarsal. In even more advanced cases, the joint capsule and ligaments on the bottom of the joint can wear-out and rupture, leading to the progressive development of a hammertoe. <ref>Department of Foot and Ankle Surgery, Kaiser Medical Center, Santa Rosa; metatarsalgia http://www.permanente.net/homepage/kaiser/pdf/33070.pdf</ref> Prof. Espinosa found that claw-toes with synovitis or even subluxation of the MTP joints were a common finding.<ref>Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8 (2008)</ref>  
#* Overactivity of the anterior shin muscles in patients with [[pes cavus]] (high arch) and ankle equinus (shortened Achilles tendon that restricts ankle dorsiflexion) deformities tends to cause dorsal joint subluxations with retracted (clawed) digits and retrograde, increased submetatarsal head pressure and pain<ref name=":4" />.[[File:Hallux rigidus XR.jpg|right|frameless]]
#Metatarsophalangeal joint pain may also result from functional [[Hallux Rigidus|hallux limitus]] (see xray R)
#* Limits passive and active joint motion at the 1st metatarsophalangeal joint.  
#* Patients usually have foot pronation disorders that result in elevation of the 1st ray with lowering of the medial longitudinal arch during weight bearing.
#* As a result of the 1st ray elevation, the proximal phalanx of the great toe cannot freely extend on the 1st metatarsal head; the result is jamming at the dorsal joint leading to osteoarthritic changes and loss of joint motion (with time, pain may develop).  
#Another cause of 1st metatarsophalangeal joint pain due to limited motion is direct trauma with stenosis of the flexor hallucis brevis, usually occurring within the tarsal tunnel. If pain is chronic, the joint may become less mobile with an arthrosis (hallux rigidus), which can be debilitating.
#Acute arthritis can occur secondary to systemic arthritides such as [[gout]], RA, and [[Spondyloarthropathy--AS|spondyloarthropathy]].<ref name=":4" />


== Differential Diagnosis  ==
== Differential Diagnosis  ==
A study by Scranton (1980) of metatarsalgia in 98 patients revealed 23 distinct diagnoses. These diagnoses were grouped in three main headings: primary metatarsalgia, secondary metatarsalgia, and pain under the forefoot. The following table shows the different diagnoses divided under the three main catogories. <ref>J Bone Joint Surg Am. 1980 Jul;62(5):723-32. Scranton PE Jr; Metatarsalgia: diagnosis and treatment.</ref>
[[Image:Forefoot Pain Dx Table.png|center|Forefoot Pain Diagnoses]]
Four of these diagnoses are mentioned below. Scranton divided metatarsalgia into structural, systemic, and miscellaneous forefoot pain categories. Structural and postoperative etiologies were the most common causes of forefoot pain; however, rheumatoid arthritis, Morton’s neuroma, and sesamoiditis were also relatively common. Although the greatest percentage of pain in the forefoot, especially under metatarsal heads, is caused by callosities, the most common of these diagnoses will be considered. <ref>Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia : Diagnosis and Manangement, Etiologies and Differential diagnoses”. Podiatry Management</ref>
#[http://www.physio-pedia.com/Plantarfasciitis Plantar fasciitis]  
#[http://www.physio-pedia.com/Plantarfasciitis Plantar fasciitis]  
#[http://www.physio-pedia.com/Morton's_Neuroma Morton's Neuroma]
#[http://www.physio-pedia.com/Morton's_Toe Morton's toe]  
#[http://www.physio-pedia.com/Morton's_Toe Morton's toe]  
#[http://www.physio-pedia.com/RA_(Rheumatoid_Arthritis) Systemic Arthtritis]
#[http://www.physio-pedia.com/RA_(Rheumatoid_Arthritis) Systemic Arthtritis]


== Investigations  ==
=== Diagnostic Procedures  ===
X-rays should be performed to assess the degree of degeneration of the joint. <ref name=":0" />
* Mainly clinical evaluation
 
* Exclusion of infection or arthropathy if signs of inflammation
== Diagnostic Procedures  ==
* To differentiate one diagnosis from another, the use of the patient’s history, physical exam, roentgenograms, cholesterol-crystal force-plate analysis, intra-articular/digital injections, and additional laboratory studies (electromyography, arteriograms, venograms,..) can be used.<ref>J Bone Joint Surg Am. 1980 Jul;62(5):723-32. Scranton PE Jr; Metatarsalgia: diagnosis and treatment</ref>
 
* Investigations - [[X-Rays|X-rays]] can be performed to assess the degree of degeneration of the joint.
To differentiate one diagnosis from another, the use of the patient’s history, physical exam, roentgenograms, cholesterol-crystal force-plate analysis, intra-articular/digital injections and additional laboratory studies (electromyography, arteriograms, venograms,..) can be used.<ref>J Bone Joint Surg Am. 1980 Jul;62(5):723-32. Scranton PE Jr; Metatarsalgia: diagnosis and treatment</ref><br>


== Outcome Measures  ==
== Outcome Measures  ==


*[http://www.physio-pedia.com/Foot_Function_Index_(FFI) Foot Function Index (FFI)] - The Brazilian-Portuguese version of the FFI questionnaire was found to be a valid and reliable instrument for foot function evaluation, and can be used both in scientific settings and in clinical practice. → Level of evidence: 2B<ref name="Martinez 2016">Martinez, Bruna Reclusa, et al. Validity and reliability of the Foot Function Index (FFI) questionnaire Brazilian-Portuguese version. 2016.</ref>
*[http://www.physio-pedia.com/Foot_Function_Index_(FFI) Foot Function Index (FFI)] - The Brazilian-Portuguese version of the FFI questionnaire was found to be a valid and reliable instrument for foot function evaluation, and can be used both in scientific settings and in clinical practice.<ref name="Martinez 2016">Martinez, Bruna Reclusa, et al. Validity and reliability of the Foot Function Index (FFI) questionnaire Brazilian-Portuguese version. 2016.</ref>
 
*Foot Posture Index (FP1-6) - No scientific evidence found correlated to metarsalgia
 
*[http://www.physio-pedia.com/Manchester%E2%80%93Oxford_Foot_Questionnaire Manchester-Oxford foot questionnaire (MOxFQ)] → Level of evidence: 4<ref name="Haque 2015">Haque, Syed, et al. Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia. Foot &amp; Ankle International. 2015.</ref><br>
 
== Examination  ==
 
Look for evidence of systemic disease especially:
*diabetic neuropathy
*inflammatory arthropathy
*neurological disease
*vascular disease


Examination must begin proximally:
*[[Foot Posture Index (FP1-6)|Foot Posture Index]] (FP1-6) - No scientific evidence found correlated to metarsalgia<ref name="Haque 2015">Haque, Syed, et al. Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia. Foot &amp; Ankle International. 2015.</ref>
*any stiffness or deformity (including length discrepancy) which might alter pressures on the forefoot?
*tight Achilles tendon or reduced ankle dorsiflexion, especially if there is fixed equinus (remember to examine in subtalar neutral position)
*pes cavus <br>• overpronated foot with unstable 1st ray
*peripheral neurological examination
*tenderness or a positive Tinel sign over the major nerve trunks
*hallux deformity or painful 1st MTPJ
*hammer or claw toes - if so, how flexible is the MTPJ. With the MTPJ reduced (if possible) is the fat pad reduced under the metatarsal heads?
*interdigital tenderness, palpable swelling or a positive metatarsal head compression test or Mulder's click
*interdigital corns
*tenderness and/or calluses under the metatarsal heads - check the relationship between the relative positions of heads and calluses. Most calluses are relatively diffuse although there may be increased thickening under the MT heads. However, a very localised callus should raise suspicions of a plantar condylar eminence
*metatarsophalangeal instability or irritability
*it is often possible to assess the relative heights and lengths of metatarsals by palpation
*look for scars of previous surgery<br>Always screen the patient for diabetes - a urine test is usually enough
 
This will usually indicate one or more possible factors which may be contibuting to forefoot pain. Differential injections around interdigital nerves and into MTP joints may help distinguish between MTP synovitis and interdigital neuralgia (although at least 10% of patients with each of these conditons also has the other) (Miller 2001). In the end it often requires experience-based judgement to decide which factors should be tackled and in what order. <ref>http://www.foothyperbook.com/elective/metatarsalgia/metatarsalgiaExam.html</ref>
 
For second metatarsophalangeal joint instability,&nbsp;Dotty and Jesse F. devided the clinical staging of examination findings in 4 grades:&nbsp;<ref>Doty, Jesse F., and Michael J. Coughlin. "Metatarsophalangeal joint instability of the lesser toes." The Journal of Foot and Ankle Surgery 53.4 (2014):</ref>  
 
*<u>Grade 0</u>: No MTP joint malalignment; prodromal phase with pain but no deformity
**Physical Examination Findings: MTP joint pain, thickening or swelling of the MTP joint, diminished toe purchase, negative drawer test result.
 
*<u>Grade 1</u>: Mild malalignment of MTP joint; widening of web space, medial deviation
**Physical Examination Findings: MTP joint pain, swelling of MTP joint, reduced toe purchase, mildly positive drawer test result (&lt;50% subluxated).  
 
*<u>Grade 2</u>: Moderate malalignment; medial, lateral, dorsal, or dorsomedial deformity, hyperextension of MTP joint
**Physical Examination Findings:&nbsp;MTP joint pain, reduced swelling, no toe purchase, moderately positive drawer test (&gt;50% subluxated).  
 
*<u>Grade 3</u>: Severe malalignment; dorsal or dorsomedial deformity; second toe can overlap hallux; might have flexible hammertoe
**Physical Examination Findings:&nbsp;Joint and toe pain, little swelling, no toe purchase (can dislocate MTP joint), flexible hammertoe.<br>  


== Medical Management  ==
== Medical Management  ==
Orthotics :
*[[File:Pointed toe box.jpg|right|frameless|182x182px]]Foot orthoses with metatarsal pads may help redistribute and relieve pressure from the noninflamed joints.
* With excess subtalar eversion or when the feet are highly arched, an orthotic that corrects these abnormal alignments should be prescribed.
* Shoes with rocker sole modifications may also help.
* For functional hallux limitus, orthosis modifications may further help to plantarflex the 1st ray to improve metatarsophalangeal joint motion and reduce pain.
* If the 1st ray elevation cannot be reduced by these means, an extended 1st ray elevation pad may be helpful.
* For more severe limitation of 1st metatarsophalangeal motion or pain, the use of rigid orthoses, carbon fiber plates, or external shoe bars or rocker soles may be necessary to reduce motion at the joint.<ref name=":4" />
Surgery may be needed if conservative therapies are ineffective. If inflammation (synovitis) is present, injection of a local corticosteroid/anesthetic mixture may be useful.


Unloading pressure to the ball-of-the-foot can be accomplished with a variety of footcare products. Orthotics designed to relieve ball-of-foot pain usually feature a metatarsal pad. The orthotic is constructed with the pad placed behind the ball-of-the-foot to relieve pressure and redistribute weight from the painful area to more tolerant areas. Other products often recommend include: gel metatarsal cushions, metatarsal bandages, NSAID’s, such as ibuprofen&nbsp;; however, these agents rarely provide a long-term solution. NSAIDS are most commonly used for the relief of mild to moderate pain. But you have to use the right shoes. [4,7]
[[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDS]] are most commonly used for the relief of mild to moderate pain. But you have to use the right shoes.<ref name=":2" />,  


== Physical Therapy Management  ==
== Physical Therapy Management  ==
For the management of these disorders, physiotherapy treatment is usually attempted prior to surgical intervention.


The treatment is initially non conservative. The pressure on the forefoot can be reduced by stretching exercises to perform at the level of the lower limb, amounting. Also custom-made orthopedic insoles can reduce pressure. <br>Sometimes, in very specific cases, an infiltration, followed by taping a few weeks, brings some comfort, also some mobilization exercises are recommended. [2]
Physiotherapy Treatments include -  education, orthoses & corrective shoes, stretching of specific lower limb muscles, small foot strengthening exercises,  
 
# Education
Gajdosic and coworkers demonstrated that a 6-week stretching program increased the maximal ankle dorsiflexion angle and length extensibility. They further demonstrated that stretching enhances the dynamic passive length and passive resistive properties. <ref>Gajdosik, RL, et al., A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol.</ref> - level of evidence 1b.
#* Initially reducing or stopping exercise, substitute a non WB exercise eg pool running, cycling.  
 
#* Suspend training until the pain begins to subside
If these treatments have insufficient impact, surgery may be considered, depending on the defects, causes. In cases of hallux valgus or varus position, it should also be surgically corrected. The most common procedure is an [http://www.physio-pedia.com/index.php5?title=Ankle_%26_Foot_Arthropathies osteotomy], where the metatarsal (one or more) responsible for the excess pressure, is shortenend or lifted. After surgery, one can basically rely on an immediate postoperative specifically designed shoe.[2,4,5]
#* Once client ready to exercise/walk again avoid future injury by educating re appropriate footwear
 
#* Pain relief and apply ice packs to the affected area (pain-killers that contain anti-inflammatories to help reduce any swelling). Swelling can also be reduced by elevating feet.
Distal metatarsal osteotomies (such as The Weil osteotomy) provide a longitudinal decompression and is particularly relevant in patients suffering from metatarsalgia due to an excessively long metatarsal. One problem is the plantar translation of the metatarsal head during shortening. <ref>Maceira, E. et al, Analisis dela rigidez metatarso-falangica en las osteotomias de Weil. Revista de Medicina y Cirugia del Pie.</ref>&nbsp;- level of evidence&nbsp;3a .&nbsp;Based on those results, Maceira and coworkers introduced the so-called “triple-osteotomy”. This modified osteotomy affords precise and accurate shortening of the metatarsal without unwanted plantar translation of the heads. The triple osteotomy also preserves the relationship between the dorsal interossei and transverse axis of rotation of the MTP joint to avoid an extension deformity. <ref>Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8</ref> - level 4 evidence.
#[[Foot Orthoses|Orthoses]]
 
#* For symptomatic relief, an MT pad made of rubber, polyurethane, or silicone can be applied.  
The high pressure under the metatarsal heads can be reduced by applying metatarsal pads. In a double-blind study, tear-drop shaped, polyurethane metatarsal pads were applied by experienced physiatrists to a total of 18 feet. As a result, there were significantly decreased maximal peak pressures and pressure time intervals during exercise that correlated with better pain and function outcomes. [2,8]<br>  
#* The pad reduces pressure under painful MT heads by spreading it to a larger area, improving functional ability.  
 
#* The optimal method is to apply an MT pad just proximal to the MT head. It also elevates the horizontal arch of the forefoot, which can widen the space between MT heads, reducing interdigital nerve compression and irritation<ref name=":5" />.  
Espinosa stated (with 2 clinical studies (level 2A evidence) and 1 retrospective study (level 2B evidence) as reference) that generally, accommodative insoles may redistribute pressure under the foot while functional orthoses are intended to control abnormal intersegmental motion. But both of them may be useful in the non-operative management of metatarsalgia.<ref>Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8</ref>  
#* Use of an MT bar or forefoot cushion is also effective for controlling metatarsalgia
 
#* In a double-blind study, tear-drop shaped, polyurethane metatarsal pads were applied by experienced physiatrists to a total of 18 feet. As a result, there were significantly decreased maximal peak pressures and pressure time intervals during exercise that correlated with better pain and function outcomes. <ref name=":1" />,
Not much scientific literature exists to confirm the effectiveness of these conservative treatment for the treatment of central metatarsalgia. Nevertheless, such measures often meet with success and have the additional benefit of not compromising future treatment&nbsp;<ref>Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8</ref>  
#* Accommodative insoles may redistribute pressure under the foot while functional orthoses are intended to control abnormal intersegmental motion.<ref>Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8</ref>[[File:Calf Stretch Composite.jpg|right|frameless|500x500px]]
 
#[[Stretching|Stretches]]
== Key Research  ==
#* A stretching regime is a fundamental element in recovery (helps to alleviate pain)
 
#* Gajdosic et al demonstrated that a 6-week stretching program increased the maximal ankle dorsiflexion angle and length extensibility and enhanced the dynamic passive length and passive resistive properties. <ref>Gajdosik, RL, et al., A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol.</ref>.The most important areas to focus on are the calf muscles, [[Achilles Tendon|achilles tendon]]<nowiki/>s, ankles, and toes. Below are five recommended stretches.
Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8 (2008) - level of evidence: 1a<br>
#* Calf-stretch Stand at an arm’s length away from a wall, placing your hands on it. Step forward with one foot, keeping the back heel on the floor with your knee straight. Hold the stretch for 30-60 seconds before switching legs  Achilles tendon - Stretch  Stand on a step, with your heels hanging off the edge. Slowly lower your heels until you feel the stretch, and hold for a few seconds. Lift your heels back up so that they’re level with the step. Repeat.
 
#* Ankle Extension Sit in a chair, and cross the injured foot over your knee. Hold the ankle with your hand on the same side, and your toes in the opposite hand. Pull your toes towards you until it’s uncomfortable (but not painful). Hold for 5-10 seconds. Ankle Flex  Again, sit in a chair with the injured foot over your knee. This time, hold your ankle with the hand of the opposite side, and your toes with the hand of the same side. Pull your toes towards you until it’s uncomfortable. Hold for 5-10 seconds.[[File:Towel crunch.PNG|right|frameless]]
== Resources ==
# Strengthening - Strengthening key muscles which can help in preventing metatarsalgia. Yoo et all found - After small foot exercising for 2 weeks, the pressure pain threshold increased from 1 to 1.5 kg, while the peak contact pressure decreased from 0.63 to 0.50 kg/cm2, and the navicular drop improved from 5 to 8 mm<ref>Yoo WG. Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion Exercise on Metatarsalgia with Morton’s Toe. Journal of physical therapy science. 2014;26(12):1997-8. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273076/ (last accessed 25.6.2020)</ref>.
 
#* Toe towel-scrunches: Stand barefooted, with one foot in front standing on a towel. Maintain a slight bend in the leg that is touching the towel. Use your toes to scrunch up the towel, making sure that the rest of the foot does not leave the ground. Perform 3 sets of 15 scrunches per foot.
*http://www.podiatrym.com/cme/Mar02CME1.pdf
#Electrotherapeutic modalities such as [[Cryotherapy|icing]], ultrasound or interferential therapy may be of assistance to reduce pain and inflammation in the beginning stages of treatment as well<ref>enertor [https://enertor.com/blogs/injury-prevention-and-advice/metatarsalgia-exercises metatarsalgia exercises] Available from:https://enertor.com/blogs/injury-prevention-and-advice/metatarsalgia-exercises (last accessed 25.6.2020)</ref>.
 
#Sometimes, in very specific cases, an infiltration, followed by taping a few weeks, brings some comfort.<ref name=":1" />
*http://journals.lww.com/jbjsjournal/Abstract/1980/62050/Metatarsalgia___diagnosis_and_treatment_.5.aspx
 
*http://pubs.rsna.org/doi/full/10.1148/radiographics.21.6.g01nv071425
 
*The use of collagen injections in the treatment of metatarsalgia: A Case Report http://www.jfas.org/article/S1067-2516(10)00288-7/abstract
 
*Sports medicine - metatarsalgia http://emedicine.medscape.com/article/85864-overview
 
*J. Gregg, P. Marks (2007). Australasian Radiology: Metatarsalgia: An ultrasound perspective. The Royal Australian and New Zealand College of Radiologists. Pages 493-499.
 
*Associatie orthopdedie Lier http://www.associatie-orthopedie-lier.be/Generic/servlet/Main.html;jsessionid=B2F5539057DBEF99F23742666B6A844C?p_pageid=37247
 
*Foot and ankle institute http://voetenenkelinstituut.be/aandoeningen/voorvoet/metatarsalgie/
 
*Figure: http://www.sunnybrook.ca/uploads/metatarsalgia.jpg
 
*Treatment &amp; medication http://emedicine.medscape.com/article/85864-treatment
 
*Walter R. Frontera, Julie K. Silver, Thomas D. Rizzo (2008). Essentials of Physical Medicine and Rehabilitation. Elsevier Health Sciences. Pages 461-475.
 
*Metatarsalgia - forefoot pain http://www.sportsinjurybulletin.com/archive/metatarsalgia.html


*Figure: http://www.sportsinjuryinsurance.co.uk/foot1.htm<br>
== Final Comments  ==
* Metatarsalgia is a condition in which the ball the foot becomes painful and inflamed.
[[File:Heel-foot-feature-1021x517.jpg|right|frameless]]
* Causes include - activities that involve running and jumping, foot deformities and shoes that are too tight or too loose.
* Generally not serious
* Conservative measures such as ice and rest, often relieve symptoms. Wearing proper footwear with shock-absorbing insoles or orthoses may prevent or minimize future problems with metatarsalgia.


== References  ==
== References  ==


1. Doty, Jesse F., and Michael J. Coughlin. "Metatarsophalangeal joint instability of the <br>lesser toes." The Journal of Foot and Ankle Surgery 53.4 (2014): 440-445.<br>(level of evidence: 2a)<br>2.Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: <br>metatarsalgia." Foot &amp; ankle international 29.8 (2008) <br>(level of evidence: 1a
[[Category:Foot]]
 
[[Category:Foot - Conditions]]
3.G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to <br>biomechanical disorders”. Physical Therapy 66(6): 970-2; July 1986 <br>(level of evidence: 3c)<br>4. Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia&nbsp;: Diagnosis <br>and Manangement, Etiologies and Differential diagnoses”. Podiatry Management <br>(level of evidence: 5)<br>5 . Britt A Durham, Metatarsalgia Treatment &amp; Management, medscape,2012<br>(level of evidence: 5)<br>6. W Yoo, Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal <br>Flexion Exercise on Metatarsalgia with Morton’s Toe, 2014, Pubmed<br>(level of evidence:3b)<br>7. Hashimoto T, Sakuraba K.: Strength training for the intrinsic flexor muscles of the foot: <br>effects on muscle strength, the foot arch, and dynamic parameters before and after the training. J <br>Phys Ther Sci, 2014, 26: 373–376. ,pubmed<br>(level of evidence: 5)<br>8. Med Clin North Am. 2014 Mar;98(2):233-51. doi: 10.1016/j.mcna.2013.10.003. Epub <br>2013 Dec 10. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot.<br>(level of evidence: 4)<br>&nbsp;9. Gajdosik, RL, et al., A stretching program increases the dynamic passive length and passive <br>resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl <br>Physiol. <br>(level of evidence: 1b)<br>10. Maceira, E. et al, Analisis dela rigidez metatarso-falangica en las osteotomias de Weil. <br>Revista de Medicina y Cirugia del Pie.<br>(level of evidence: 3a)<br>
[[Category:Conditions]]
 
[[Category:Musculoskeletal/Orthopaedics]]
12. Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot &amp; ankle international 29.8 (2008) (level of evidence: 2a)
<references />
 
13. G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders”. Physical Therapy 66(6): 970-2; July 1986 (level of evidence: 3c)
 
14. Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia&nbsp;: Diagnosis and Manangement, Etiologies and Differential diagnoses”. Podiatry Management (level of evidence: 5)
 
<span style="line-height: 1.5em; font-family: sans-serif; font-size: 13.28px; background-color: white;">
15. Britt A Durham, Metatarsalgia Treatment &amp; Management, medscape,2012 (level of evidence: 5)</span>
 
16. W Yoo, Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion Exercise on Metatarsalgia with Morton’s Toe, 2014, Pubmed (level of evidence:3b)
 
17. Hashimoto T, Sakuraba K.: Strength training for the intrinsic flexor muscles of the foot: effects on muscle strength, the foot arch, and dynamic parameters before and after the training. J Phys Ther Sci, 2014, 26: 373–376. ,pubmed (level of evidence: 5)
 
18. Med Clin North Am. 2014 Mar;98(2):233-51. doi: 10.1016/j.mcna.2013.10.003. Epub 2013 Dec 10. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. (level of evidence: 4)
 
19. Gajdosik, RL, et al., A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol. (level of evidence: 1b)
 
20. Maceira, E. et al, Analisis dela rigidez metatarso-falangica en las osteotomias de Weil. Revista de Medicina y Cirugia del Pie. (level of evidence: 3a)
 
[[Category:Foot]] [[Category:Foot_and_Ankle_Conditions]] [[Category:Musculoskeletal/Orthopaedics]]

Latest revision as of 23:33, 13 August 2023

Original Editors - David De Meyer

Top Contributors - Diego Zaragoza, Lucinda hampton, Maxim de Clippele, David De Meyer, Evan Thomas, Kim Jackson, Admin, Rachael Lowe, Adam Vallely Farrell, Chrysolite Jyothi Kommu, Jess Bell, 127.0.0.1, Simisola Ajeyalemi, Khloud Shreif and WikiSysop

Definition[edit | edit source]

[1]
Metatarsal bone animation01.gif

Metatarsalgia is a general term for pain in the area of the metatarsophalangeal joints. This is often seen in clinical practice, the deformity and pain can deteriorate gait function and decrease quality of life[2].

Most common causes include:

  • Interdigital nerve pain (Morton neuroma)
  • Metatarsophalangeal joint pain
  • Sesamoiditis
  • Submetatarsal head fat pad atrophy typically associated with aging[3]

Metatarsalgies are often accompanied by excessive callus formation over a bony protrusion, with severe pain and pressure sensitivity around the callus.[4][5]

Metatarsals of the Right foot

Clinically Relevant Anatomy[edit | edit source]

The most important and relevant anatomy is the forefoot and the metatarsal. The metatarsus of the foot consists of five long bones, which are called the metatarsals.

Metatarsals:

  • Comprised of: proximal base; shaft; distal head.
  • Proximally connected to the tarsal bones and distally to the phalanges.
  • Named I to V medially to laterally, from the dorsal surface of the foot.
  • Convex on their dorsal surfaces but concave on their plantar surfaces
  • Along with the tarsals, help form the arches of the foot, which are essential in both weight-bearing and walking.[6]

The joints between the head of the metatarsals and the respective proximal phalanx are called the metatarsophalangeal joint (MTP).

  • These joints form the ball of the foot, and the ability to move in these joints is very important for normal walking.
  • In addition, the bases of the metatarsals articulate with each other to form intermetatarsal joints.[6]

Etiology[edit | edit source]

Common causes include:

  • Overtraining
  • Interdigital (Morton) neuroma
  • Freiberg infraction
  • Foot 1.jpg
    Stress fractures involving the foot
  • Intermetatarsal bursitis
  • Adventitial bursitis
  • Inflammatory and degenerative arthritis
  • Metatarsophalangeal joint synovitis/capsulitis
  • Tendinosis/tenosynovitis
  • Plantar plate disruption / plantar plate tears
  • Schwannoma[7]
  • Pes cavus or high arched foot
  • Excessive pronation of the foot
  • Clawing or hammer toes
  • Tight extensor tendons of the toes
  • Prominent metatarsal heads
  • Morton’s foot—there is a shortened first metatarsal, which results in an abnormal subtalar joint, and increased weight going through the second metatarsophalangeal joint.[8]

Causes[edit | edit source]

Hallux valgus anatomy.jpg

There can be multiple causative factors. Often localized to the first metatarsal head.Next most frequent site of metatarsal head pain is under the second metatarsal.[5][9][10]

Factors that can cause excessive pressure are:

  • Participating in high impact activities without proper footwear and/or orthotics
  • Older age as the pad in the foot tends to thin out making it much more susceptible pressue and pain
  • An imbalance in the length of the metatarsals
  • Majority seem to be related to foot and ankle deformity
  • Disturbances in gait
  • Morphology of the foot (e.g. increased bone length that protrudes into the bottom of the foot)
  • A shortened Achilles tendon

Subtypes[edit | edit source]

  • Primary metatarsalgia refers to symptoms arising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal. [11]
  • Secondairy metatarsalgia can be caused by systemic conditions such as arthritis of the MTP joint.
  • Iatrogenic metatarsalgia can occur after (failed) reconstructive surgery.

Characteristics/Clinical Presentation[edit | edit source]

  1. Metatarsalgia most commonly results from misalignment of the joint surfaces with altered foot biomechanics, may cause
    • Joint subluxations,
    • Flexor plate tears (a fibrocartilaginous structure that lies directly plantar to the lesser metatarsal heads and acts as a sesamoid-like mechanism for each lesser joint (MPJ) of the foot[12])
    • Increased pain during the mid-stance and propulsion phases of walking as body weight is shifted forward onto the forefoot.[13]
    • Capsular impingement
    • Joint cartilage destruction (osteoarthrosis).
    • Misaligned joints synovial impingement, with minimal if any heat and swelling (osteoarthritic synovitis).
    • Metatarsophalangeal joint subluxation - May occur as a result of chronic inflammatory arthropathy, particularly rheumatoid arthritis (RA)
    • Metatarsophalangeal joint pain - weight bearing and a sense of stiffness in the morning.
    • Loss of metatarsal fat pad (usually cushions the stress between the metatarsals and interdigital nerves during walking) tends to move distally under the toes, causing interdigital neuralgia/Morton neuroma.
    • To compensate for the loss of cushioning, adventitial calluses and bursae may develop.
    • Coexisting rheumatoid nodules beneath or near the plantarflexed metatarsal heads may increase pain.
      The 2nd metatarsophalangeal joint is most commonly affected.
    • Usually, inadequate 1st ray (1st cuneiform and 1st metatarsal) function results from excessive pronation (the foot rolling inward and the hindfoot turning outward or everted), often leading to capsulitis and hammer toe deformities.
    • Overactivity of the anterior shin muscles in patients with pes cavus (high arch) and ankle equinus (shortened Achilles tendon that restricts ankle dorsiflexion) deformities tends to cause dorsal joint subluxations with retracted (clawed) digits and retrograde, increased submetatarsal head pressure and pain[3].
      Hallux rigidus XR.jpg
  2. Metatarsophalangeal joint pain may also result from functional hallux limitus (see xray R)
    • Limits passive and active joint motion at the 1st metatarsophalangeal joint.
    • Patients usually have foot pronation disorders that result in elevation of the 1st ray with lowering of the medial longitudinal arch during weight bearing.
    • As a result of the 1st ray elevation, the proximal phalanx of the great toe cannot freely extend on the 1st metatarsal head; the result is jamming at the dorsal joint leading to osteoarthritic changes and loss of joint motion (with time, pain may develop).
  3. Another cause of 1st metatarsophalangeal joint pain due to limited motion is direct trauma with stenosis of the flexor hallucis brevis, usually occurring within the tarsal tunnel. If pain is chronic, the joint may become less mobile with an arthrosis (hallux rigidus), which can be debilitating.
  4. Acute arthritis can occur secondary to systemic arthritides such as gout, RA, and spondyloarthropathy.[3]

Differential Diagnosis[edit | edit source]

  1. Plantar fasciitis
  2. Morton's toe
  3. Systemic Arthtritis

Diagnostic Procedures[edit | edit source]

  • Mainly clinical evaluation
  • Exclusion of infection or arthropathy if signs of inflammation
  • To differentiate one diagnosis from another, the use of the patient’s history, physical exam, roentgenograms, cholesterol-crystal force-plate analysis, intra-articular/digital injections, and additional laboratory studies (electromyography, arteriograms, venograms,..) can be used.[14]
  • Investigations - X-rays can be performed to assess the degree of degeneration of the joint.

Outcome Measures[edit | edit source]

  • Foot Function Index (FFI) - The Brazilian-Portuguese version of the FFI questionnaire was found to be a valid and reliable instrument for foot function evaluation, and can be used both in scientific settings and in clinical practice.[15]

Medical Management[edit | edit source]

Orthotics :

  • Pointed toe box.jpg
    Foot orthoses with metatarsal pads may help redistribute and relieve pressure from the noninflamed joints.
  • With excess subtalar eversion or when the feet are highly arched, an orthotic that corrects these abnormal alignments should be prescribed.
  • Shoes with rocker sole modifications may also help.
  • For functional hallux limitus, orthosis modifications may further help to plantarflex the 1st ray to improve metatarsophalangeal joint motion and reduce pain.
  • If the 1st ray elevation cannot be reduced by these means, an extended 1st ray elevation pad may be helpful.
  • For more severe limitation of 1st metatarsophalangeal motion or pain, the use of rigid orthoses, carbon fiber plates, or external shoe bars or rocker soles may be necessary to reduce motion at the joint.[3]

Surgery may be needed if conservative therapies are ineffective. If inflammation (synovitis) is present, injection of a local corticosteroid/anesthetic mixture may be useful.

NSAIDS are most commonly used for the relief of mild to moderate pain. But you have to use the right shoes.[9],

Physical Therapy Management[edit | edit source]

For the management of these disorders, physiotherapy treatment is usually attempted prior to surgical intervention.

Physiotherapy Treatments include - education, orthoses & corrective shoes, stretching of specific lower limb muscles, small foot strengthening exercises,

  1. Education
    • Initially reducing or stopping exercise, substitute a non WB exercise eg pool running, cycling.
    • Suspend training until the pain begins to subside
    • Once client ready to exercise/walk again avoid future injury by educating re appropriate footwear
    • Pain relief and apply ice packs to the affected area (pain-killers that contain anti-inflammatories to help reduce any swelling). Swelling can also be reduced by elevating feet.
  2. Orthoses
    • For symptomatic relief, an MT pad made of rubber, polyurethane, or silicone can be applied.
    • The pad reduces pressure under painful MT heads by spreading it to a larger area, improving functional ability.
    • The optimal method is to apply an MT pad just proximal to the MT head. It also elevates the horizontal arch of the forefoot, which can widen the space between MT heads, reducing interdigital nerve compression and irritation[2].
    • Use of an MT bar or forefoot cushion is also effective for controlling metatarsalgia
    • In a double-blind study, tear-drop shaped, polyurethane metatarsal pads were applied by experienced physiatrists to a total of 18 feet. As a result, there were significantly decreased maximal peak pressures and pressure time intervals during exercise that correlated with better pain and function outcomes. [5],
    • Accommodative insoles may redistribute pressure under the foot while functional orthoses are intended to control abnormal intersegmental motion.[17]
      Calf Stretch Composite.jpg
  3. Stretches
    • A stretching regime is a fundamental element in recovery (helps to alleviate pain)
    • Gajdosic et al demonstrated that a 6-week stretching program increased the maximal ankle dorsiflexion angle and length extensibility and enhanced the dynamic passive length and passive resistive properties. [18].The most important areas to focus on are the calf muscles, achilles tendons, ankles, and toes. Below are five recommended stretches.
    • Calf-stretch Stand at an arm’s length away from a wall, placing your hands on it. Step forward with one foot, keeping the back heel on the floor with your knee straight. Hold the stretch for 30-60 seconds before switching legs Achilles tendon - Stretch Stand on a step, with your heels hanging off the edge. Slowly lower your heels until you feel the stretch, and hold for a few seconds. Lift your heels back up so that they’re level with the step. Repeat.
    • Ankle Extension Sit in a chair, and cross the injured foot over your knee. Hold the ankle with your hand on the same side, and your toes in the opposite hand. Pull your toes towards you until it’s uncomfortable (but not painful). Hold for 5-10 seconds. Ankle Flex Again, sit in a chair with the injured foot over your knee. This time, hold your ankle with the hand of the opposite side, and your toes with the hand of the same side. Pull your toes towards you until it’s uncomfortable. Hold for 5-10 seconds.
      Towel crunch.PNG
  4. Strengthening - Strengthening key muscles which can help in preventing metatarsalgia. Yoo et all found - After small foot exercising for 2 weeks, the pressure pain threshold increased from 1 to 1.5 kg, while the peak contact pressure decreased from 0.63 to 0.50 kg/cm2, and the navicular drop improved from 5 to 8 mm[19].
    • Toe towel-scrunches: Stand barefooted, with one foot in front standing on a towel. Maintain a slight bend in the leg that is touching the towel. Use your toes to scrunch up the towel, making sure that the rest of the foot does not leave the ground. Perform 3 sets of 15 scrunches per foot.
  5. Electrotherapeutic modalities such as icing, ultrasound or interferential therapy may be of assistance to reduce pain and inflammation in the beginning stages of treatment as well[20].
  6. Sometimes, in very specific cases, an infiltration, followed by taping a few weeks, brings some comfort.[5]

Final Comments[edit | edit source]

  • Metatarsalgia is a condition in which the ball the foot becomes painful and inflamed.
Heel-foot-feature-1021x517.jpg
  • Causes include - activities that involve running and jumping, foot deformities and shoes that are too tight or too loose.
  • Generally not serious
  • Conservative measures such as ice and rest, often relieve symptoms. Wearing proper footwear with shock-absorbing insoles or orthoses may prevent or minimize future problems with metatarsalgia.

References[edit | edit source]

  1. ↑ https://greenbayacupuncture.co/2017/05/17/metatarsalgia-forefoot-pain/
  2. ↑ 2.0 2.1 Park CH, Chang MC. Forefoot disorders and conservative treatment. Yeungnam University Journal of Medicine. 2019 May;36(2):92.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784640/ (last accessed 25.6.2020)
  3. ↑ 3.0 3.1 3.2 3.3 Mercks manual. MTP joint pain Available from:https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/foot-and-ankle-disorders/metatarsophalangeal-joint-pain (last accessed 25.6.2020)
  4. ↑ Doty, Jesse F., and Michael J. Coughlin. "Metatarsophalangeal joint instability of the lesser toes." The Journal of Foot and Ankle Surgery 53.4 (2014): 440-445.
  5. ↑ 5.0 5.1 5.2 5.3 Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8 (2008)
  6. ↑ 6.0 6.1 https://www.kenhub.com/en/library/anatomy/metatarsal-bones
  7. ↑ Radiopedia Metatarsalgia Available from:https://radiopaedia.org/articles/metatarsalgia (last accessed 25.6.2020)
  8. ↑ Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
  9. ↑ 9.0 9.1 G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders”. Physical Therapy 66(6): 970-2; July 1986
  10. ↑ Sobel Ellen, D.P.M., Ph. D., C.PED. and Levitz Steven, D.P.M.; “Metatarsalgia : Diagnosis and Manangement, Etiologies and Differential diagnoses”. Podiatry Management
  11. ↑ Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8 (2008)
  12. ↑ Podiatry today Understanding PP injuries Available from:https://www.podiatrytoday.com/understanding-biomechanics-plantar-plate-injuries (last accessed 25.6.2020)
  13. ↑ G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders”. Physical Therapy 66(6): 970-2; July 1986
  14. ↑ J Bone Joint Surg Am. 1980 Jul;62(5):723-32. Scranton PE Jr; Metatarsalgia: diagnosis and treatment
  15. ↑ Martinez, Bruna Reclusa, et al. Validity and reliability of the Foot Function Index (FFI) questionnaire Brazilian-Portuguese version. 2016.
  16. ↑ Haque, Syed, et al. Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia. Foot & Ankle International. 2015.
  17. ↑ Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8
  18. ↑ Gajdosik, RL, et al., A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol.
  19. ↑ Yoo WG. Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion Exercise on Metatarsalgia with Morton’s Toe. Journal of physical therapy science. 2014;26(12):1997-8. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273076/ (last accessed 25.6.2020)
  20. ↑ enertor metatarsalgia exercises Available from:https://enertor.com/blogs/injury-prevention-and-advice/metatarsalgia-exercises (last accessed 25.6.2020)
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