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Metatarsalgia

- Ultrasound and MRI in recalcitrant cases especially if concern for stress fracture (3)[C] - MR arthrography of the metatarsophalangeal (MTP) joint can delineate capsular tears, typically of the distal lateral border of the plantar plate (an often underrecognized cause of metatarsalgia. - Only if diagnosis is in question - Erythrocyte sedimentation rate or C-reactive protein - Rheumatoid factor - Uric acid - Glucose - CBC with differential

- Relieve pain - Ice initially - Rest: temporary alteration of weight-bearing activity; use of cane or crutch. For more physically active patients, suggest an alternative exercise or cross-training: - Moist heat later - Taping or gel cast - Stiff-soled shoes will act as a splint.

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Pediatric Considerations

  • Muscle imbalance disorders (e.g., Duchenne muscular dystrophy) cause foot deformities in children.
  • In adolescent girls, consider Freiberg infraction.
  • Salter I injuries may affect subsequent growth and healing of the epiphysis.

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Pregnancy Considerations

  • Forefoot pain during pregnancy usually results from change in gait, center of mass, and joint laxity.
  • Wear properly fitted, low-heeled shoes.

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GENERAL PREVENTION

  • Wear properly fitted shoes with good padding.
  • Start weight-bearing exercise programs gradually.

COMMONLY ASSOCIATED CONDITIONS

  • Arthritis
  • Morton neuroma
  • Sesamoiditis
  • Plantar keratosis " “callous formation

DIAGNOSIS

HISTORY

  • Pain gradually develops and persists over the heads of one or more metatarsals. Pain is usually on the plantar surface and worse during midstance gait phase.
  • Pain is often chronic.
  • Predisposition with pes cavus and hyperpronation
  • Pain often described as walking with a pebble in the shoe; aggravated during midstance or propulsion phases of walking or running.

PHYSICAL EXAM

  • Point tenderness over plantar metatarsal heads
  • Pain in the interdigital space or a positive metatarsal squeeze test suggests Morton neuroma.
  • Plantar keratosis
  • Tenderness of the metatarsal head(s) with pressure applied by the examiner 's finger and thumb
  • Erythema and swelling (occasionally)

DIFFERENTIAL DIAGNOSIS

  • Stress fracture (most commonly 2nd metatarsal)
  • Morton neuroma (i.e., interdigital neuroma)
  • Tarsal tunnel syndrome
  • Sesamoiditis or sesamoid fracture
  • Salter I fracture in children
  • Arthritis (e.g., gouty, rheumatoid, inflammatory, osteoarthritis, septic, calcium pyrophosphate dihydrate crystal deposit disease [CPPD])
  • Lisfranc injury
  • Avascular necrosis of the metatarsal head
  • Ganglion cyst
  • Foreign body
  • Vasculitis (diabetes)
  • Bony tumors

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Weight-bearing radiographs: anteroposterior, lateral, and oblique views:Occasionally, metatarsal or sesamoid axial films (to rule out sesamoid fracture) or skyline view of the metatarsal heads to assess the plantar declination of the metatarsal heads: obtained with the metatarsophalangeal joints in dorsiflexion (to evaluate alignment)
  • Ultrasound and MRI in recalcitrant cases especially if concern for stress fracture (3)[C]
  • MR arthrography of the metatarsophalangeal (MTP) joint can delineate capsular tears, typically of the distal lateral border of the plantar plate (an often underrecognized cause of metatarsalgia.
  • Only if diagnosis is in questionErythrocyte sedimentation rate or C-reactive proteinRheumatoid factorUric acidGlucoseCBC with differential

Diagnostic Procedures/Other

Plantar pressure distribution analysis may help distinguish pressure distribution patterns due to malalignment. ‚

TREATMENT

Treatment for metatarsalgia is typically conservative. ‚

  • Relieve pain
  • Ice initially
  • Rest: temporary alteration of weight-bearing activity; use of cane or crutch. For more physically active patients, suggest an alternative exercise or cross-training:Moist heat laterTaping or gel castStiff-soled shoes will act as a splint.
  • Relieve the pressure beneath the area of maximal pain by redistributing the pressure load of the foot, which can be achieved by weight loss.

MEDICATION

Nonsteroidal anti-inflammatory medications for 7 to 14 days if no contraindications toward use ‚

ISSUES FOR REFERRAL

High-level athletes may benefit from early podiatric or orthopedic evaluation. ‚

ADDITIONAL THERAPIES

  • Physical therapy to restore normal foot biomechanics
  • Low-heeled (<2 cm height) wide-toe-box shoes
  • Metatarsal bars, pads, and arch supports. Metatarsal bars are often more effective than pads.
  • Orthotics/rocker bar (prescriptive orthotics have been shown to be effective treatment)
  • Thick-soled shoes
  • Shaving the callus may provide temporary relief. Callus excision is not recommended.
  • Corticosteroid injection may benefit interdigital neuritis but should be used with caution as it may cause MTP instability and fat pad atrophy.
  • Improve flexibility and strength of the intrinsic muscles of the foot with:Exercises (e.g., towel grasps, pencil curls)Physical therapy to maintain range of motion and restore normal biomechanics

SURGERY/OTHER PROCEDURES

  • If no improvement with conservative therapy for 3 months, refer to foot/ankle orthopedic surgeon or podiatrist.
  • Surgery may help correct anatomic abnormality: bunionectomy, partial osteotomy, or surgical fusion. Success rates vary depending on procedure.
  • Direct plantar plate repair (grade II tear) combined with Weil osteotomy can restore normal alignment of the MTP joint, leading to diminished pain with improved functional scores.
  • The Weil osteotomy (distal metatarsal oblique osteotomy) is safe and effective for metatarsalgia.
  • Callus removal is generally not recommended (callus is a response to pressure change " ”not the cause).
  • Morton neurectomy or ultrasound-guided alcohol ablation of Morton neuroma are options (4)[C].
  • Surgery only as a last resort if no anatomic abnormality is present.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Magnetic insoles are not effective for chronic nonspecific foot pain. ‚

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Patients generally admitted only for surgery ‚

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

If stress fracture has been ruled out and patient 's condition has not improved >3 months of conservative treatment, consider surgical evaluation. ‚

PATIENT EDUCATION

  • Instruct about wearing proper shoes and gradual return to activity.
  • Cross-training until symptoms subside. Goal is to restore normal foot biomechanics, relieve abnormal pressure on the plantar metatarsal heads, and relieve pain (5)[C].

PROGNOSIS

Outcome depends on the severity of the problem and whether surgery is required to correct it. ‚

COMPLICATIONS

  • Back, knee, and hip pain due to change in gait
  • Transfer metatarsalgia following surgical intervention, which subsequently transfers stress to other areas.

REFERENCES

11 Hockenbury ‚ RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31(7 Suppl):S448 " “S458.22 DiPreta ‚ JA. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Med Clin North Am. 2014;98(2):233 " “251.33 Iagnocco ‚ A, Coari ‚ G, Palombi ‚ G, et al. Sonography in the study of metatarsalgia. J Rheumatol. 2001;28(6):1338 " “1340.44 Musson ‚ RE, Sawhney ‚ JS, Lamb ‚ L, et al. Ultrasound guided alcohol ablation of Morton 's neuroma. Foot Ankle Int. 2012;33(3):196 " “201.55 Espinosa ‚ N, Brodsky ‚ JW, Maceira ‚ E. Metatarsalgia. J Am Acad Orthop Surg. 2010;18(8):474 " “485.

ADDITIONAL READING

  • Birbilis ‚ T, Theodoropoulou ‚ E, Koulalis ‚ D. Forefoot complaints " ”the Morton 's metatarsalgia. The role of MR imaging. Acta Medica (Hradec Kralove). 2007;50(3):221 " “222.
  • Buda ‚ R, Di Caprio ‚ F, Bedetti ‚ L, et al. Foot overuse diseases in rock climbing: an epidemiologic study. J Am Podiatr Med Assoc. 2013;103(2):113 " “120.
  • Burns ‚ J, Landorf ‚ KB, Ryan ‚ MM, et al. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007;(4):CD006154.
  • Deshaies ‚ A, Roy ‚ P, Symeonidis ‚ PD, et al. Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head. Foot (Edinb). 2011;21(4):172 " “175.
  • Janisse ‚ DJ, Janisse ‚ E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008;16(3):152 " “158.
  • Ko ‚ PH, Hsiao ‚ TY, Kang ‚ JH, et al. Relationship between plantar pressure and soft tissue strain under metatarsal heads with different heel heights. Foot Ankle Int. 2009;30(11):1111 " “1116.
  • Pace ‚ A, Scammell ‚ B, Dhar ‚ S. The outcome of Morton 's neurectomy in the treatment of metatarsalgia. Int Orthop. 2010;34(4):511 " “515.
  • Thomas ‚ JL, Blitch ‚ ELIV, Chaney ‚ DM, et al. Diagnosis and treatment of forefoot disorders. Section 2. Central metatarsalgia. J Foot Ankle Surg. 2009;48(2):239 " “250.

SEE ALSO

Morton Neuroma (Interdigital Neuroma) ‚

CODES

ICD10

  • M77.40 Metatarsalgia, unspecified foot
  • G57.60 Lesion of plantar nerve, unspecified lower limb
  • M77.42 Metatarsalgia, left foot
  • M77.41 Metatarsalgia, right foot
  • G57.61 Lesion of plantar nerve, right lower limb
  • G57.62 Lesion of plantar nerve, left lower limb

ICD9

  • 726.70 Enthesopathy of ankle and tarsus, unspecified
  • 355.6 Lesion of plantar nerve

SNOMED

  • 10085004 metatarsalgia (finding)
  • 30085007 Mortons metatarsalgia (disorder)

CLINICAL PEARLS

  • Metatarsalgia refers to pain of the plantar surface of the forefoot in the region of the metatarsal heads.
  • Metatarsalgia is common in athletes who participate in high-impact sports involving the lower extremities.
  • Patients describe as "walking with a pebble in the shoe. " ť Pain is worse during midstance or propulsion phases of walking or running.
  • The most common physical finding is point tenderness over plantar metatarsal heads.
  • Pregnant patients should wear properly fitted, low-heeled shoes to reduce incidence of metatarsalgia.