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Basics ⬇

Author(s): DominicJacobelli, MD and KennethBielak, MD, FACSM, FAAFP, CAQSM

Description

  • Pain in the plantar aspect of the metatarsal (MT) heads
  • Metatarsalgia can be thought of as a symptom rather than a specific disease.
  • Primary metatarsalgia develops from intrinsic factors, such as a long first ray, hallux valgus, or other congenital deformities.
  • Secondary metatarsalgia may result from trauma, overuse, or poor footwear.

Epidemiology

Athletes in high-impact sports involving the lower extremities (dancing, running, jumping)

Etiology and Pathophysiology

  • Repetitive/excessive stress combined with intrinsic and extrinsic factors
  • The 1st MT head usually carries 30% of the load in weight-bearing. A normal MT arch ensures this balance by providing adequate padding around the 1st MT head. A pronated or splayfoot can disturb this balance, resulting in an abnormally high pressure over the 2nd through 5th MT heads. Over time, reactive tissue can form a callus around the MT heads, which further compounds pain.

Risk-Factors

  • Foot deformities: overpronation, pes planus, pes cavus, hallux valgus, prominent MT heads, hammertoe deformity, Morton foot (short 1st MT and a relatively long 2nd MT)
  • Muscle imbalance or soft tissue dysfunction: tight Achilles tendon or toe extensors, weak toe flexors, laxity in the Lisfranc ligament
  • Extrinsic factors: obesity, high heels, poorly fitted or worn-down shoes
  • Dermatologic issues: calluses and warts
  • Fat pad atrophy or displacement
  • Iatrogenic changes from surgeries resulting in unequal force distribution

General Prevention

  • Wear properly fitted shoes with adequate padding.
  • Gradual progression of weight-bearing exercise programs

Commonly Associated Conditions

  • Intrinsic foot muscle weakness
  • Calluses and warts
  • Hallux valgus or rigidus
  • Hammertoe or claw toe
  • Morton syndrome (long 2nd MT)
  • Freiberg infraction (aseptic necrosis of a MT head, most commonly the 2nd, as seen in adolescent sprinters)

Diagnosis ⬆ ⬇

History

  • Pain over the plantar surface of the MT heads, typically described as walking with a “pebble in the shoe”
  • Pain is typically gradual and chronic in onset rather than acute.
  • Pain is worse in midstance and propulsion phases of walking and running.

Physical Exam

  • Inspect for the presence of callus, edema, erythema, deformity, and skin breaks.
  • Palpate for tenderness, which is typically located over the distal half of the MT shaft and head.
  • Pain in the interdigital space or positive MT squeeze test suggests interdigital neuroma.
  • Range of motion of the phalanges, metatarsophalangeal (MTP) joint, and ankle, especially to dorsiflexion, to evaluate tight gastrocsoleus complex
  • Gait analysis should be performed.

Differential Diagnosis

  • Neuroma (plantar or Morton neuroma)
  • Idiopathic MTP joint synovitis
  • Freiberg disease: ischemic epiphyseal necrosis of the 2nd MT
  • Inflammatory arthritis of MT joint (rheumatoid arthritis, seronegative spondyloarthropathy, crystalline-induced arthritis, osteoarthritis, septic arthritis)
  • Stress fracture
  • Salter I fracture (pediatric population)
  • Sesamoiditis or sesamoid fracture
  • Lisfranc injury
  • Traumatic arthritis
  • Foreign body
  • Cellulitis or infection (diabetic foot, Lyme disease)
  • Ganglion cyst
  • Vasculitis (diabetes)
  • Tumor (rare)

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Lab usually not required but may be considered based on differential diagnosis
  • White blood cell (WBC) count and erythrocyte sedimentation rate (ESR) may be elevated in infection or inflammatory arthritis.
  • Consider testing for:
    • Gout—uric acid level.
    • Pseudogout—synovial fluid.
    • Systemic disease—rheumatoid factor.
  • Imaging usually not required but may be considered based on differential diagnosis
  • Weight-bearing anteroposterior (AP), lateral, and oblique films often normal but may demonstrate foot deformities that may predispose to metatarsalgia
  • Bone scan or magnetic resonance imaging (MRI) may be considered based on suspicion for stress fracture.
  • Ultrasonography can be used to evaluate for neuromas, bursitis, and joint effusions.

Diagnostic Procedures/Other

  • Diagnostic injection (MTP joint) with local anesthetic can help differentiate intra-articular pathology (synovitis/capsulitis) from extra-articular pathology (neuroma).
  • Plantar pressure distribution analysis may help to distinguish patterns of pressure distribution due to malalignment.

Treatment ⬆ ⬇

  • Acute:
    • Ice and rest with activity modification
    • Well-cushioned, correctly fitted athletic shoes (1)[C]
    • Analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Calluses should be pared down, preferably after soaking the foot in warm water and using a stone or emery board.
    • An MT pad may be placed just proximal to the MT heads to relieve pressure (avoid the pad directly beneath MT heads).
    • Stretching a tight Achilles tendon
  • Long-term treatment:
    • Prescriptive orthotics are beneficial:
      • Pes cavus (2)[C]
      • Hallux valgus (2)[C]
    • Arch support and a well-fitted, low-heel shoe for daily wear
    • Energy-absorbing running shoes, which are replaced every 350 miles or when showing early wear
    • Maintenance of gastrocsoleus flexibility
    • Physical therapy for the correction of postural or gait imbalance
    • Avoid hard surfaces and prolonged standing.

Medication

Analgesics, NSAIDs, or acetaminophen for symptom control

Issues for Referral

  • Athletes may warrant early podiatric or orthopedic evaluation.
  • If no improvement with conservative therapy for 3 to 6 mo, consider referral to foot/ankle orthopedist or surgical podiatrist.
  • Multiple types of osteotomies with varying success rates have been described as surgical interventions for metatarsalgia.
  • The Weil osteotomy, which is a shortening osteotomy performed to decrease pressure on a prominent MT head and performed by shifting the MT head back toward the heel, appears to be a safe and effective surgical procedure for the treatment for metatarsalgia of the second and 3rd MT (3)[B].
  • More recently, percutaneous surgical techniques have been developed, which in retrospective analysis, show significantly better long-term outcomes and lower rates of late metatarsalgia compared to open procedures (4)[B].

Additional Therapies

Corticosteroid injection should be avoided because it may cause fat pad atrophy.

Ongoing Care ⬆ ⬇

Patient Education

  • Instruct patient about wearing proper shoes and gradual return to activity.
  • Cross training until symptoms subside

Complications

  • Back, knee, and hip pain owing to compensatory gait change
  • Transfer metatarsalgia following surgical intervention as stress transfers to other areas

Additional Reading ⬆ ⬇

  • BakerCL, FlandryF, HendersonJM, eds. Reactive synovitis of the foot—metatarsalgia. In: The Hughston Clinic Sports Medicine Field Manual. Baltimore, MD: Williams & Wilkins; 1996:270.
  • Besse JL. Metatarsalgia. Orthop Traumatol Surg Res. 2017;103(1S):S29–S39.
  • DiPreta JA. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Med Clin North Am. 2014;98(2):233–251.
  • Gregg J, Marks P. Metatarsalgia: an ultrasound perspective. Australas Radiol. 2007;51(6):493–499.
  • Gregg JM, Schneider T, Marks P. MR imaging and ultrasound of metatarsalgia—the lesser metatarsals. Radiol Clin North Am. 2008;46(6):1061–1078.
  • Maceira E, Monteagudo M. Transfer metatarsalgia post hallux valgus surgery. Foot Ankle Clin. 2014;19(2):285–307.
  • Tóth K, Huszanyik I, Kellermann P, et al. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int. 2007;28(1):61–63.
  • Weber PC. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. 2007;458:248.

References ⬆ ⬇

  1. Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008;29(8):871–879.
  2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31(Suppl 7):S448–S458.
  3. Pérez-Muñoz I, Escobar-Antón D, Sanz-Gómez TA. The role of Weil and triple Weil osteotomies in the treatment of propulsive metatarsalgia. Foot Ankle Int. 2012;33(6):501–506.
  4. Bauer T, Gaumetou E, Klouche S, et al. Metatarsalgia and Morton’s disease: comparison of outcomes between open procedure and neurectomy versus percutaneous metatarsal osteotomies and ligament release with a minimum of 2 years of follow-up. J Foot Ankle Surg. 2015;54(3):373–377.

Clinical Pearls ⬆

  • Pain of the plantar surface of the forefoot, usually over the MT heads
  • May be caused by abnormal pressure distribution over the plantar surface of the MT heads
  • Common in athletes involved in high-impact sports (running, jumping, dancing)
  • Athletes may warrant early referral to podiatry or orthopedic surgery.