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Metatarsalgia; Types, Causes, Symptom, Diagnosis, Treatment

Metatarsalgia literally metatarsal pain and colloquially known as a stone bruise, is any painful foot condition affecting the metatarsalregion of the foot. This is a common problem that can affect the joints and bones of the metatarsals.Metatarsalgia is most often localized to the first metatarsal head – the ball of the foot just behind the big toe. There are two small sesamoid bones under the first metatarsal head. The next most frequent site of metatarsal head pain is under the second metatarsal. rxharun.com/tarsal-anatomy-foot-bone-an

Types of Metatarsalgia

Primary metatarsalgia refers to symptoms arising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal. According to Jesse F. Doty, metatarsophalangeal joint instability of the lesser toes (mainly due to plantar plate insufficiency) is also a common cause of metatarsalgia.
Secondairy metatarsalgia can be caused by systemic conditions such as arthritis of the MTP joint.
Iatrogenic metatarsalgia can occur after (failed) reconstructive surgery.

Causes of Metatarsalgia

Sometimes a single factor can lead to metatarsalgia. More often, several factors are involved, including:

Distance runners are at risk of metatarsalgia, primarily because the front of the foot absorbs significant force when a person runs. But anyone who participates in a high-impact sport is at risk, especially if your shoes fit poorly or are worn.
A high arch can put extra pressure on the metatarsals. So can having a second toe that’s longer than the big toe, which causes more weight than normal to be shifted to the second metatarsal head.
Wearing too-small shoes or high heels can cause your foot to be misshapen. A downward-curling toe (hammertoe) and swollen, painful bumps at the base of your big toes (bunions) can cause metatarsalgia.
Because most of your body weight transfers to your forefoot when you move, extra pounds mean more pressure on your metatarsals. Losing weight might reduce or eliminate symptoms.
High heels, which transfer extra weight to the front of your foot, are a common cause of metatarsalgia in women. Shoes with a narrow toe box or athletic shoes that lack support and padding also can contribute to the problem.
Small breaks in the metatarsals or toe bones can be painful and change the way you This noncancerous growth of fibrous tissue around a nerve usually occurs between the third and fourth metatarsal heads. It causes symptoms that are similar to metatarsalgia and can also contribute to metatarsal stress.
High level of activity
Prominent metatarsal heads
Tight toe extensors (muscles)
Weak toe flexors (muscles)
Hammertoe deformity
Hypermobile first foot bone
Tight Achilles tendon
Excessive pronation (side-to-side movement of the foot when walking or running)
Ill-fitting footwear or a high arch
Age – older people are more susceptible and degeneration of the bones is more likely.
A stress fracture is a hairline fracture which has gradually occurred with over use.
Repetitive high impact such as running or jumping.
Arthritis resulting in general wear and tear of the joints in the foot.
Diabetes which is responsible for a number of foot complications.
Morton’s neuroma which is pain caused by compression and inflammation of the nerve between the 3rd and 4th toes.
Gout which is a form of arthritis caused by a build up of Uric acid in the joint.
A short first metatarsal bone or a long second metatarsal bone is often seen in people with a Morton toe; the normal forefoot balance is disturbed, resulting in the shift of an increased amount of weight to the second metatarsal.
Hammertoe deformity

Risk Factors that can contribute to metatarsalgia include:

Footwear: Shoes that are too tight around the toes can cause pain, or high heels that add pressure to the ball of the foot as it is forced into a tight space.
Being overweight: The excess weight can put strain on the foot.
Age: The pad of fat that protects the foot can get thinner with age, leading to metatarsalgia.
High impact exercise: Running or playing high impact sports increases the risk, as the feet absorb large amounts of force.
Shape of the foot and toes: Having a high arch or a second toe that is longer than the big toe can add to the pressure.
Stress fractures: Small breaks in the toe bones can cause pain when pressure is applied.
Stiff ankle: This can add pressure to the metatarsal bones.

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Some medical conditions that can cause metatarsalgia are:

rheumatoid arthritis, with swollen joints in the foot, or gout
diabetes if the small nerves in the foot can become irritated
a buildup of fluid in the foot

Symptoms of Metatarsalgia

Sharp, aching or burning pain in the ball of your foot — the part of the sole just behind your toes
Pain that worsens when you stand, run, flex your feet or walk — especially barefoot on a hard surface — and improves when you rest
Sharp or shooting pain, numbness, or tingling in your toes
A feeling of having a pebble in your shoe
Walking with a marble or pebbles in your shoe
sharp burning or shooting pain in the ball of your foot
Toes are numb or tingling
Pain in the ball of the foot – this can be sharp, aching, or burning. The pain may get worse when you stand, run, or walk.
You may also notice that your pain gets worse when you
- stand
- run
- walk barefoot
- participate in a high-impact sports activity

Diagnosis of Metatarsalgia

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
X-rays may be helpful in excluding other causes of forefoot pain.
A bone scan can pinpoint places of inflammation.
Ultrasound can help identify conditions such as bursitis or Morton neuroma that can be causing pain in the metatarsal region of the foot.
MRI to help detect and diagnose many causes of pain in the metatarsal and midfoot regions. These can include traumatic disorders, circulatory conditions, arthritis, neuroarthropathies,

For second metatarsophalangeal joint instability, Dotty and Jesse F. devided the clinical staging of examination findings in 4 grades

Grade 0: No MTP joint malalignment; prodromal phase with pain but no deformity

Physical Examination Findings: MTP joint pain, thickening or swelling of the MTP joint, diminished toe purchase, negative drawer test result.

Grade 1: Mild malalignment of MTP joint; widening of web space, medial deviation

Physical Examination Findings: MTP joint pain, swelling of MTP joint, reduced toe purchase, mildly positive drawer test result (<50% subluxated).

Grade 2: Moderate malalignment; medial, lateral, dorsal, or dorsomedial deformity, hyperextension of MTP joint

Physical Examination Findings: MTP joint pain, reduced swelling, no toe purchase, moderately positive drawer test (>50% subluxated).

Grade 3: Severe malalignment; dorsal or dorsomedial deformity; second toe can overlap hallux; might have flexible hammertoe

Physical Examination Findings: Joint and toe pain, little swelling, no toe purchase (can dislocate MTP joint), flexible hammertoe.

Treatment of Metatarsalgia

Follow these protocols to reduce pain in the balls of your feet and to work toward recovery from Metatarsalgia.

Resolve to put health before fashion. Shoes with high heels, narrow toes or an uncomfortable fit cause painful health conditions. Replace ill-fitting footwear with shoes that offer good support and a proper fit.
Reduce high-impact activities. If you’ve developed Metatarsalgia as a result of rigorous exercise, you must cut back on your activities. Feet bear the brunt of standing, walking and running every day and need adequate rest from the tasks.
Work toward achieving a healthy weight. Obesity causes a host of problems, including foot pain. Work with a doctor or nutritionist to find a safe way to reach a healthy weight.
Ice you feet for quick relief. While you are giving your feet a rest, the application of an ice pack can help reduce inflammation and relieve pain temporarily.
Support your feet with a good orthotic insert. If you’ve developed a condition like Metatarsalgia due to the use of improper footwear, you can improve your chances of recovery by adding extra support to properly-fitting shoes. HTP Heel Seats absorb shock when you walk, cushion the foot and apply gentle, therapeutic acupressure to stimulate your body’s natural ability to heal itself. The use of shoe inserts may speed up your recovery time and prevent future episodes of foot pain.
Seek Medical Help, If Necessary. If the above five techniques do not yield lasting relief from pain in the balls of your feet, you should see a doctor. It may be that you will require pain medication, physical therapy or other assistance. Most cases of Metatarsalgia can be treated at home via the methods described above, but if your pain persists, seek the advice of a physician.

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Medication

Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
Anesthetics – Used with precision, an injection of a “nerve block” can stop pain for a time.
Muscle Relaxants – These medications provide relief from spinal muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentine) that address neuropathic—
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bones health and healing fracture.
Corticosteroid Injection – Injecting corticosteroids into the involved joint can give temporary relief (1-3 months) in certain cases. If performed repetitively, cortisone may cause ligament degeneration and precipitate a toe deformity.

Physical Therapy

The primary focus of treatment is restoration of normal biomechanics and relief of pressure in the symptomatic area. Therapy needs to allow the inflammation to subside or resolve by relieving the repeated excessive pressure.

Once the athlete is pain-free, isometric, isotonic, and isokinetic exercises will be started for strengthening. Passive range of motion exercises will progress to active exercises as the inflammation disappears.

Ankle cross

Sit with your feet on the floor and place one ankle across the opposite thigh, foot flexed slightly.
Using the hand on the same side, gently, but firmly, pull your toes back towards your shin until you feel a stretch along the arch.
Hold the stretch for 10-20 seconds and release for 10 seconds. Repeat 5-10 times, several times a day. Repeat with the other foot.
To ensure you have the right stretch position, gently run your opposite fingers across the sole of your foot; the fascia ligament should feel like a firm string along the arch. This is also a great stretch for plantar fasciitis.

Foot roll

Sit with both feet on the floor, hands loosely on your knees. Sit forward in a chair with your back straight and feet close to the chair. You can also do this standing, if that’s more comfortable.
Roll a tennis ball back and forth under the arch of your foot for 2-5 minutes. Rest. Switch sides and repeat with your other foot.
You can also do this stretch with a frozen water bottle (put a towel underneath the bottle to catch condensation)—the cold helps relieve metatarsalgia pain and inflammation.

Range of motion

Sit down so that your feet do not touch the floor.
Use your big toe to trace the letters of the alphabet in the air. Block print or script—your choice! Switch feet.
Keep the movement small, using just your foot and ankle, not your whole leg.

Best Shoes for Metatarsalgia

Whenever you look up what causes foot problems like metatarsalgia, you’ll find that high heels are front-and-center culprits. Similarly, when you look up treatments for ball of foot pain, you’ll find advice to not wear high heels—at least not heels over two inches, and particularly not heels with pointed toes. But many, if not most, women are going to be challenged by this dictum. And frankly, high heels aren’t the only “bad” shoes out there.

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Contrary to popular opinion, wearing shoes like ballet flats or flip flops instead of high heels is not necessarily better for your feet. These shoes offer very little shock absorption or support, and wearing them to walk even short distances can create increased pressure on the ball of the foot causing or aggravating metatarsalgia. Wearing improper athletic shoes—like running shoes for hiking—and old athletic shoes can also make metatarsalgia worse.

The solution is to limit when and for how long you wear heels, buy high-quality casual and exercise shoes, and replace old, worn shoes regularly.Take advantage of over-the-counter inserts and insoles that provide extra padding and support for the ball of your foot

Metatarsal Pads and Inserts

Metatarsalgia pain usually lasts from a few days to a few weeks. If it doesn’t subside on its own or after some self-treatment, see a podiatrist or doctor. Your doctor may recommend you work with a physical therapist to exercise and strengthen your feet and legs or an occupational therapist to fit you with proper orthotics.

Extra padding and arch support can alleviate ball of foot pain and relieve the pressure of metatarsalgia. Over-the-counter orthotic inserts can help align the foot, provide extra cushioning, and absorb shock while walking. A gel pad under the ball of your foot can ease pain as well.

Profoot Toe Beds—These ball of foot gel pads cradle each toe plus the ball of foot. Featuring a raised toe bed that gently positions your toes to prevent the painful corns, foot fatigue, and callus formation that can often lead to metatarsalgia. They provide all-day comfort in all kinds of shoes for your toes and metatarsals.
Profoot Bottom of the Foot Cushion—This ball of foot gel cushion works as a shock absorber for metatarsalgia pressure, providing comfort and relief from ball of foot pain. Using PORON® technology to provide maximum comfort, this expertly designed orthotic absorbs shock and helps prevent calluses from forming on the bottom of the foot.
Profoot Triad Orthotic—These inserts provide 3-Zone support for heel, arch, and ball of foot. These three zones give shock absorption and relief to the balls of your feet, arches, and heels to protect your knees, legs, and back.

Recreational Therapy

Alternate forms of conditioning and training during healing should be encouraged. For example, swimming is an excellent exercise for maintaining physical conditioning while the patient is in a restricted weight-bearing phase of healing.

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