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.

Characteristics/Clinical Presentation

Metatarsalgia typically affects the bottom of the second metatarsophalangeal joint (where the second toe joins the foot). 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 called “second metatarsophalangeal stress syndrome”.
The pain typically feels like a deep bruise. Sometimes, it will feel like there is a rock under the ball of the foot. These symptoms are usually worse 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 a bit. 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.

Differential Diagnosis

Twenty-three different diagnoses were made for people with pain in the fore part of the foot. These diagnoses were grouped in three main headings: primary metatarsalgia, secondary metatarsalgia and pain under the fore part of the foot. The following table shows the different diagnoses devided under the three main catogories.

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Diagnostic Procedures

To differentiate the one diagnose from the other 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,..) are used.
The primary cause for metatarsalgia is repetitive application of excessive force to one metatarsal area more than the others. The second metatarsal is most commonly affected typically because there are a number of factors that can lead to excess force on that bone/joint area.
Factors that can lead to metatarsalgia:
Metatarsal bone longer than the others, Metatarsal bone lower than the others, Adjacent unstable first metatarsal, Adjacent bone higher than the others (transfer loading), Associated hammertoe, Tight calf muscle, High heeled Shoes, Shoes with inadequate cushioning, Overweight, Overuse.

Outcome Measures

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Examination

Look for evidence of systemic disease especially:
• diabetic neuropathy
• inflammatory arthropathy
• neurological disease
• vascular disease
Examination must begin proximally
• 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
• 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
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.

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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