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Metatarsalgia

Metatarslagia is a clinical condition characterized by pain in the front part of the foot. Metatarsalgia is a disease caused by overuse injuries to the ball of the foot. This disease is commonly seen in athletes involved in high impact sports. Metatarsalgia is often times referred as a symptom rather than as a disease entity.


Presentation

Patients with metatarsalgia commonly present with the following signs and symptoms:

  • Sharp, burning, and aching pain – This is felt in the ball on the foot involving part of the sole just behind the toes. 
  • Shooting pain and numbness – The tingling sensation, numbness and pain are intermittently felt on the toes especially during walking or running.
  • Aggravating pain during high impact activities – Pain aggravates with jumping, bolting and flexing of the foot arches.
  • Foot discomfort – This is felt on the soles of the foot giving a sensation of pebbles and small rocks within the shoes. 
  • In general, pain worsens with time and duration. They progressively worsen with high impact activities that may soothen with rest and warm compress of the affected site. 
Localized Pain
  • Mortons Neuroma generally exhibits more localized pain, at the site of the nerve impingement.[icbmedical.com]
  • Conditions such as rheumatoid arthritis, sesamoiditis, and equinus can all lead to localized pain at the ball of the foot. In the case of secondary metatarsalgia, the practitioner should address both the symptom and the cause.[opedge.com]
Reiter's Syndrome
  • Abstract The differential diagnosis for metatarsalgia should include rheumatoid arthritis, SLE, mixed connective tissue disease, psoriatic arthritis, Reiter's syndrome, fibromyalgic syndrome, gout, post-traumatic joint disease, and septic arthritis.[ncbi.nlm.nih.gov]
Thrombosis
  • […] used Injury to the nerves surrounding the surgical site Loss of sensation in the tips of your toes Problems with wound healing Risk of infection Very rarely, people undergoing surgical procedures experience more serious complications, such as deep vein thrombosis[comfortingfootwear.com]
  • This includes the potential for: Wound healing problems Infection Nerve injury to the local nerves that provide sensation to the tips of the toes Deep Vein Thrombosis (DVT) – uncommon Pulmonary Embolism (PE) – very uncommon Specific Complications Surgery[footeducation.com]
Delayed Wound Healing
  • Two patients had delayed wound healing with serous discharge and the wounds were eventually healed up with wound dressing.[ncbi.nlm.nih.gov]
Skin Ulcer
  • CONCLUSION: The 3 most common complications of foot and ankle surgery are infection, wound dehiscence, and skin ulcer or blister.[ncbi.nlm.nih.gov]
Foot Pain
  • Reduction of the platelet count with chemotherapy eliminated the foot pain. The authors recommended that a platelet count be part of the work-up of patients with metatarsalgia when the etiology of the foot pain is unclear.[ncbi.nlm.nih.gov]
  • Why Do I Need to Be Seen for My Foot Pain? The majority of foot issues–like metatarsalgia–come on gradually. You have dull pain that becomes more acute. The best time to address foot pain is when it is recurring, dull pain, BEFORE it becomes acute.[milehighspine.com]
  • If that is the case, treating your foot pain could be a matter of simply wearing the right size shoes.[footsolutions.ie]
  • Find out more about the common symptoms and causes of metatarsalgia, as well as treatment plans for ball of foot pain relief.[powersteps.com]
  • Ball-of-foot pain is often caused from improper fitting footwear, most frequently by women’s dress shoes and other restrictive footwear.[foot.com]
Muscle Contracture
  • One specific cause, mechanical metatarsalgia, occurs because of gastrocnemius muscle contracture, which overloads the forefoot.[ncbi.nlm.nih.gov]
  • Activity modification : A calf muscle contracture (equinus contracture) will increase stress on the forefoot.[footeducation.com]
Foot Disease
  • Individuals suffering from gouty arthritis and rheumatoid arthritis are more likely to be afflicted by this foot disease. The metatarsal bones of the foot can easily be injured during prolonged exercise.[symptoma.com]
Low Back Pain
  • Untreated metatarsalgia can lead to the chronic intentional alteration of the gait causing pain on the opposite foot and low back pains.[symptoma.com]
Joint Effusion
  • Ultrasonography can also be used to identify soft tissue pathologies that may lead to metatarsalgia like neuromas, bursitis, and joint effusions.[symptoma.com]
Distractibility
  • Long-axis distraction and dorsal/plantar glides of the metatarsophalangeal joint are self-mobilization techniques that can be used throughout the treatment process.[emedicine.medscape.com]
  • At the very least, regular replacement of shoes, especially for runners, can help to maintain support for the foot.Patients should continue self-mobilization exercises, including long-axis distraction and dorsal/plantar glides as directed by the practitioner[webmd.com]

Workup

The following diagnostic modalities and tests are implore in the work up of patients with metatarsalgia:

  • Blood Chemistry – Serum Uric acid levels are determined to rule out gout which may present similarly with metatarsalgia. Erythrocyte Sedimentation Rate (ESR) and C-reactive proteins are also used to determine extent of inflammation of the metatarsal.
  • Imaging Studies – Radiograph of the foot will help exclude the existence of stress fractures. Ultrasonography can also be used to identify soft tissue pathologies that may lead to metatarsalgia like neuromas, bursitis, and joint effusions [4]. The use of magnetic resonance imaging (MRI) in determining presence of arthritis, neruo-arthritis, circulatory disorders, and traumatic injuries in region of the foot has been proven to be most useful at this point of the workup [5].
  • F-scan – This is measuring device that determines the amount of pressure exerted in the different areas of the foot to guide podiatrist on the placement of orthotics on the soles of the foot to prevent the recurrence of the pain in metatarsalgia.

Treatment

The following treatment modalities are available for the treatment of metatarsalgia:

  • Physical Therapy – The initial treatment of the disorder involves the use of cold compress, passive elevation, and rest is basic to the initial phase of the physical therapy. Patient are subjected to a full range of motion exercise regimen. The use of orthotics like foot pads are used to buffer the pressure exerted on the foot area [6]. 
  • Occupational therapy – Patients are usually prescribed with semi-rigid orthosis within supportive shoes to relieve the pain symptoms of metatarsalgia [7]. The use of a teardrop shaped polyurethane foot pads as orthotics has been shown to give promising results [8]. 
  • Surgical Interventions – Patients presenting with persistent symptoms of metatarsalgia will benefit from a surgical intervention known as oblique osteotomy [9]. This invasive procedure improves the placement and positioning of the metatarsal bone on different planes. Osteotomy of the second and third metatarsal bone can allay the pain symptoms of central metatarsalgia [10]. 
  • Medical treatment – The presence of a concurrent interdigital neuroma will greatly benefit with the use of oral steroids to control the inflammation and pain. In some cases a nerve block can be arbitrarily performed to prevent further nerve irritations.

Prognosis

Metatarsalgia does not cause any mortality directly. Early diagnosis and therapeutic interventions can spell out a good outlook for patients. Untreated metatarsalgia can lead to the chronic intentional alteration of the gait causing pain on the opposite foot and low back pains. Morbidity increases with concomitant illnesses like diabetes mellitus, rheumatoid arthritis, and gouty arthritis.

Etiology

The following factors may lead to the development of metatarsalgia:

Epidemiology

In the United States, athletes involved in high impact sporting events are prone to the development of metatarsalgia [2]. Metatarsalgia has a slight predilection to the male gender because they are relatively heavier and more likely to involve in high impact sports and occupational activities. Females in their fourth and fifth decade of life who frequently wear high heels and ill-fitting foot wears are also predisposed to metatarsalgia [3].

Patients with basal metabolic index beyond 40% has more than twice the risk of developing the metatarsal disease. Individuals suffering from gouty arthritis and rheumatoid arthritis are more likely to be afflicted by this foot disease.

Sex distribution
Age distribution

Pathophysiology

The metatarsal bones of the foot can easily be injured during prolonged exercise. Patients develop this overuse type of injury due to the alteration in the biomechanics of the foot metatarsals. The imbalance of the downward forces causes an abnormal weight distribution on the foot causing the metatarsal sections to progressively inflame even during normal low impact activities.

The persistent stress on the metatarsal can also lead to the chronic irritation of the cartilaginous covering of the bone and the adjacent soft tissues like the tendons and ligaments contributing significantly to the pain symptoms of the foot. Some anatomic differences of the foot nomenclature like high dorsal arches, shortened metatarsal bone, and hammer toe deformity of the first digit can exert more stress on the metatarsal bone consequently causing the inflammatory disorder. Neuromas and bursitis causes a localized inflammatory reaction and irritates the nearby nerves by the metatarsal region of the foot.

Prevention

Patients who are athletic can prevent the pain felt in metatarsalgia by using the prescribed shoes in each sporting event. The avoidance of ill-fitting footwear significantly reduces the recurrence of the discomfort. For those involved in bolting and jumping activities, the use of insole cushions can avert unwanted injuries on the metatarsal bone. The maintenance of a healthy diet and weight can prevent metatarsalgia and other weight related disorders.

Summary

Metatarsalgia refers to the inflammation and pain of the metatarsal bones and joints in the ball of the foot. Patients who are fond of running and jumping are more prone to develop this disease. The use of ill-fitting foot wear can cause the condition while the use of corrective shoes with arch and insole support can prevent the recurrence of the symptoms of metatarsalgia.

Patient Information

  • Definition: Metatarsalgia is clinically described as the inflammation of the metatarsal bones and joints in the ball of the foot.
  • Cause: Metatarsalgia is an overuse type of injury commonly seen in athletes involved in high impact sports. The use of ill-fitting shoes has also been found to predispose to the disease. Neuoromas, bunions, and bursitis may lead to metatarsalgia.
  • Symptoms: Patients will generally present with sharp pain aggravated by high impact activities like jumping and running. Numbness may sometimes be felt on the toes in some cases.
  • Diagnosis: The diagnosis of metatarsalgia is usually clinical. Ancillary laboratory test can help determine levels of inflammation and rule out uric acid arthropathy. The use of imaging studies like radiographs, ultrasound, and MRI can help rule out other disorders with similar symptoms.
  • Treatment and follow-up: Patients with metatarsalgia are effectively treated with physical therapy and occupational therapy. Surgical interventions like metatarsal osteomies can help control the pain symptoms in metatarsalgia. 

References

Article

  1. Quirk R. Metatarsalgia. Aust Fam Physician. Jun 1996; 25(6):863-5; 867-9.
  2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. Jul 1999; 31(7 suppl):S448-58.
  3. Chang BC, Liu DH, Chang JL, Lee SH, Wang JY. Plantar pressure analysis of accommodative insole in older people with metatarsalgia. Gait Posture. 2014; 39(1):449-54 (ISSN: 1879-2219)
  4. Iagnocco A, Coari G, Palombi G, Valesini G. Sonography in the study of metatarsalgia. J Rheumatol. Jun 2001; 28(6):1338-40.
  5. Yu JS, Tanner JR. Considerations in metatarsalgia and midfoot pain: an MR imaging perspective. Semin Musculoskelet Radiol. Jun 2002; 6(2):91-104.
  6. Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskelet Disord. 2006; 7:95.
  7. Chalmers AC, Busby C, Goyert J, Porter B, Schulzer M. Metatarsalgia and rheumatoid arthritis--a randomized, single blind, sequential trial comparing 2 types of foot orthoses and supportive shoes. J Rheumatol. Jul 2000; 27(7):1643-7.
  8. Steinberg GG, Akins CM, Baran DT, eds. Metatarsalgia. Orthopedics in Primary Care. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:284-7.
  9. Kennedy JG, Deland JT. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. Dec 2006; 453:309-13.
  10. O'Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int. May 2002; 23(5):415-9.

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Last updated: 2019-07-11 22:10