eMedicine Specialties > Sports Medicine > Foot and Ankle

Metatarsalgia: Differential Diagnoses & Workup

Author: Britt A Durham, MD, Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center and University of California at Los Angeles; CFO of Durcress Medical Group
Coauthor(s): Daniel Kaplan, MD, Assistant Professor, Department of Orthopedics, University of California Irvine
Contributor Information and Disclosures

Updated: Nov 1, 2007

Differential Diagnoses

Metatarsal Stress Fracture

Other Problems to Be Considered

Arthritis (See also Medscape's Arthritis Resource Center.)
Avascular Necrosis
Gouty arthritis (See also the eMedicine article Gout.)

Hammertoe Deformity

Lisfranc Fracture Dislocation

Lyme Disease8 (See also Medscape's Lyme Disease Resource Center.)

Morton Neuroma (in the Physical Medicine and Rehabilitation section); see also Morton Neuroma (in the Orthopedic Surgery section)

Neuropathic plantar ulcer

Osteomyelitis (in the Emergency Medicine section) (See also the Medscape article Osteomyelitis and the eMedicine article)

Postsurgical shortening of the first metatarsal7

Salter I fracture (See also the eMedicine article Salter-Harris Fractures.)

Sesamoiditis

Stress Fractures

Synovitis

Workup

Laboratory Studies

  • Although appearing clinically different from traumatic injuries to the first metatarsophalangeal joint, gout commonly presents with pain at the base of the first toe. Testing of uric acid levels, the erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may be helpful in excluding gouty arthritis and other rheumatologic conditions in subtle cases. Otherwise, laboratory studies are of little benefit in the evaluation of metatarsalgia. (See also the eMedicine article Gout.)

Imaging Studies

  • A radiographic foot survey is indicated as an initial imaging test and may be helpful in excluding other etiologies of forefoot pain.
  • Order repeat radiographs and a bone scan to assist the physician with diagnosing or excluding a metatarsal stress fracture. (See also the eMedicine article Metatarsal Stress Fracture.)
  • Ultrasonography provides useful information about possible pathologic conditions that may be responsible for pain in the metatarsal region of the foot, including bursitis, Morton neuroma, and joint effusions.9 (See also the eMedicine article Bursitis.)
  • Yu and Tanner demonstrated that magnetic resonance imaging (MRI) is a powerful, noninvasive method for detecting and diagnosing many causes of pain in the metatarsal and midfoot regions, including conditions caused by trauma, circulatory disorders, arthritides, neuroarthropathies, and those that result in biomechanic imbalance.10

Other Tests

F-Scan (Tekscan, Inc, South Boston, Mass) is an objective measurement system that is used to assess plantar pressures, identify the location of peak pressures, and help with the molding and placement of orthotic devices that can be most effective in dispersing excessive localized forces.

Procedures

  • A local digital nerve block just below the transverse tarsal ligament may be helpful in the diagnosis of an interdigital neuroma. Patients with an interdigital neuroma should receive relief after the injection.

More on Metatarsalgia

Overview: Metatarsalgia
Differential Diagnoses & Workup: Metatarsalgia
Treatment & Medication: Metatarsalgia
Follow-up: Metatarsalgia
References
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References

  1. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. Jul 1999;31(7 suppl):S448-58. [Medline].

  2. Safran MR, McKeag DB, Van Camp SP, eds. The foot: endurance events, marathon. Manual of Sports Medicine. Philadelphia, Pa: Lippincott-Raven; 1998:485, 558-9.

  3. McPoil TG, McGarvey T. The foot in athletics. In: Hunt GC, McPoil TG, eds. Clinics in Physical Therapy: Physical Therapy for the Foot and Ankle. 2nd ed. New York, NY: Churchill Livingstone; 1995:207-35.

  4. Quirk R. Metatarsalgia. Aust Fam Physician. Jun 1996;25(6):863-5; 867-9. [Medline].

  5. Steinberg GG, Akins CM, Baran DT, eds. Metatarsalgia. Orthopedics in Primary Care. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:284-7.

  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. [Medline]. [Full Text].

  7. Tóth K, Huszanyik I, Kellermann P, Boda K, Róde L. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int. Jan 2007;28(1):61-3. [Medline].

  8. Endres S, Quante M. Oedema of the metatarsal heads II-IV and forefoot pain as an unusual manifestation of Lyme disease: a case report. J Med Case Reports. 2007;1:44. [Medline]. [Full Text].

  9. Iagnocco A, Coari G, Palombi G, Valesini G. Sonography in the study of metatarsalgia. J Rheumatol. Jun 2001;28(6):1338-40. [Medline].

  10. Yu JS, Tanner JR. Considerations in metatarsalgia and midfoot pain: an MR imaging perspective. Semin Musculoskelet Radiol. Jun 2002;6(2):91-104. [Medline].

  11. 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. [Medline].

  12. Kennedy JG, Deland JT. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. Dec 2006;453:309-13. [Medline].

  13. O'Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int. May 2002;23(5):415-9. [Medline].

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Further Reading

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Keywords

overuse injury, pain in the forefoot, forefoot injuries, interdigital neuroma, metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, inflammatory arthritis, edema of the metatarsal heads

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Contributor Information and Disclosures

Author

Britt A Durham, MD, Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center and University of California at Los Angeles; CFO of Durcress Medical Group
Britt A Durham, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Kaplan, MD, Assistant Professor, Department of Orthopedics, University of California Irvine
Daniel Kaplan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Association of Pediatric Program Directors, California Medical Association, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, Medical Director, Center for Sports Medicine, O'Connor Hospital; Private Practice
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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