Metatarsalgia

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Original Editors -David De Meyer

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Search Strategy

Search in Google, Pubmed, Web of Knowledge and Pedro with keywords: “Metatarsalgia”, “foot” and “forefoot injuries” “orthopedic”. And search in libraries books about the foot, sports medicine, sport anatomy, and forefoot problems. One negative point is that I have not used Pedro to Verified quality of evidence.

Definition/Description

Metatarsalgia : It’s a general term used to denote a painful foot condition in the metatarsal region of the foot (the area just proximal the toes, more commonly referred as the ball-of-the-foot). This is a disorder that can affect the bones and joints at the plantar forefoot. Often this is accompanied by excessive callus formation over a bony protrusion, and there is severe pain and sensitivity to pressure around the callus.[1,2]

Clinically Relevant Anatomy

The most important anatomy is the bone structures of the forefoot, to be exact the metatarsals. The metatarsals are proximally connected to the tarsal bones and distally to the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern. Of course a knowledge of the other foot bones and structures (muscles, tendons, ligaments,…) is also necessary to distinguish the sctructures and pathologies.
More information about the human anatomy you can find by clicking on the link under references.

Epidemiology /Etiology

There is important variability in possible causative factors, but a majority seem to be related to foot and ankle deformity. Metatarsalgia is most often localized to the first metatarsal head (the ball of the foot just behind the big toe).
The next most frequent site of metatarsal head pain is under the second metatarsal. This can be due to either a too short first metatarsal bone or to "hypermobility of the first ray" (metatarsal bone medial cuneiform bone behind it), both of which result in excess pressure being transmitted into the second metatarsal head.[2,3,4]
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 improper fitting footwear, most frequently by women dress (high heel) shoes and other restrictive footwear (figure1:overcompression 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, the pad in the foot tends to thin out making it much more susceptible to pain; an imbalance in the length of the metatarsals; disturbances in gait, in morphology of the foot (a too long bone that protrude to the bottom of the foot) and a too short Achilles tendon.

Differential Diagnosis

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Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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 ; 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]

Physical Therapy Management

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.
Sometimes, in very specific cases, an infiltration, followed by taping a few weeks, brings some comfort, also some mobilization exercises are recommend. [2]

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 osteotomy, where the metatarsal (one or more) responsible for the excess pressure is relieved by him or by a few millimeters to shorten it slightly upward lift.
After surgery, one can basically rely on an immediate postoperative specifically designed shoe.[2,4,5]

Other Treatment
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]

Key Research

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Resources

1. The use of collagen injections in the treatment of metatarsalgia: A Case Report http://www.jfas.org/article/S1067-2516(10)00288-7/abstract
2. Sports medicine- metatarsalgia
http://emedicine.medscape.com/article/85864-overview

3. J.Gregg, P. Marks (2007). Australasian Radiology: Metatarsalgia: An ultrasound perspective. The Royal Australian and New Zealand College of Radiologists. Pages 493-499.
4. Associatie orthopdedie Lier http://www.associatie-orthopedie-lier.be/Generic/servlet/Main.html;jsessionid=B2F5539057DBEF99F23742666B6A844C?p_pageid=37247
5. Foot and ankle institute http://voetenenkelinstituut.be/aandoeningen/voorvoet/metatarsalgie/
6. Figuur: http://www.sunnybrook.ca/uploads/metatarsalgia.jpg
7. Treatment & medication
http://emedicine.medscape.com/article/85864-treatment

8. Walter R. Frontera, Julie K. Silver, Thomas D. Rizzo (2008). Essentials of Physical Medicine and Rehabilitation. Elsevier Health Sciences. Pages 461-475
9. Metatarsalgia- forefoot pain
http://www.sportsinjurybulletin.com/archive/metatarsalgia.html

10. Figuur: http://www.sportsinjuryinsurance.co.uk/foot1.htm

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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