Introduction
Background
Metatarsalgia is a common overuse injury described as pain in the forefoot that is associated with increased stress over the metatarsal head region. Metatarsalgia is often referred to as a symptom, rather than as a specific disease. Common causes of metatarsalgia include interdigital neuroma (also known as Morton neuroma), metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, and inflammatory arthritis; however, these causes are often diagnosed separately. (See also the eMedicine articles Morton Neuroma [in the Physical Medicine and Rehabilitation section], Morton Neuroma [in the Orthopedic Surgery section], and Avascular Necrosis [in the Rheumatology section].)
For excellent patient education resources, visit eMedicine's Arthritis Center and Bone, Joint, and Muscle Center. See also Medscape's Arthritis Resource Center.
Frequency
United States
Athletes who participate in high-impact sports that involve the lower extremities commonly present with forefoot injuries, including metatarsalgia.1,2
Functional Anatomy
Body weight is transferred to the foot by gravity. This transfer of force is increased to the forefoot during the mid-stance and push-off phases of walking and running.2,3 In the forefoot region, the first and second metatarsal heads receive the greatest amount of this energy transfer. Peak vertical forces reach 275% of body weight during running, and a runner may absorb 110 tons per foot while running 1 mile.2 Pressure studies have shown that runners spend most of the time weighted over the forefoot while running.
Sport-Specific Biomechanics
Athletes who take part in high-impact sports that involve running or jumping are at high risk of forefoot injuries.1,2 Although track-and-field runners are exposed to the highest level of traumatic forces to the forefoot, many other athletes, including tennis, football, baseball, and soccer players, often present with forefoot injuries.
Clinical
History
- The primary symptom of metatarsalgia is pain at 1 or more of the metatarsal heads.3,4,5,6 Diffuse forefoot pain and midfoot pain are often present in athletes with combinations of high-impact inflammatory conditions.1,2
- The pain is typically aggravated during the mid-stance and propulsion phases of walking or running.
- A history of a gradual, chronic onset is more common than an acute presentation. Chronic symptoms may be of gradual onset over 6 months.
- A Morton neuroma (interdigital neuroma) produces symptoms of metatarsalgia due to irritation and inflammation of the digital nerve located in the web space between the metatarsal heads. Patients with a Morton neuroma may complain of toe numbness in addition to pain in the forefoot. The term Morton neuroma is a misnomer because no neuroma truly exists. Rather, the lesion results from a mechanical entrapment neuropathy. (See also the eMedicine articles Morton Neuroma [in the Physical Medicine and Rehabilitation section] and Morton Neuroma [in the Orthopedic Surgery section].)
Physical
- Palpable point tenderness at the distal end of the plantar metatarsal fat pad is a typical finding.
- Pain and tenderness are experienced on the plantar surface of the metatarsal head, which is often accompanied by the development of a callus formation (plantar keratosis). (See also the eMedicine article Intractable Plantar Keratosis.)
- Absence of pain in the interdigital space helps the clinician assess for the presence of a neuroma.
- Patients with an interdigital neuroma have maximal tenderness between the web spaces.
- Loss of sensation may be present in the adjacent toes.
- In patients with interdigital neuromas, the pain is usually aggravated by the metatarsal squeeze test.
- Compression between the metatarsal heads may produce a painful click, known as a Mulder sign.
Causes
- The foot is frequently injured during sports activities that typically involve repetitive high-pressure loading on the forefoot.1,2
- As in many other overuse syndromes, the condition may be the result of an alteration in normal biomechanics that has caused an abnormal weight distribution among the metatarsal heads.
- Persistent stress can lead to chronic irritation and inflammation of the periosteum and adjacent tissues.
- The following factors can contribute to excessive localized pressure over the forefoot:
- High level of activity
- Prominent metatarsal heads
- Tight toe extensors
- Weak toe flexors
- Hammertoe deformity (See also the eMedicine article Hammertoe Deformity.)
- Hypermobile first ray
- Tight Achilles tendon
- Excessive pronation
- Equinus deformity (See also the eMedicine article Clubfoot [in the Orthopedic Surgery section] and Clubfoot [in the Radiology section].)
- Some anatomic conditions may predispose individuals to forefoot problems.
- A high arch with stress to the forefoot, as seen with pes cavus foot type, often causes pain in the metatarsal region. (See also the eMedicine article Pes Cavus.)
- Individuals with a Morton toe have a short first metatarsal bone. The normal forefoot balance is disturbed, which results in abnormal subtalar joint pronation. This pronation results in the shift of an increased amount of weight to the second metatarsal.
- Iatrogenic changes from surgeries such as osteotomies can change the anatomy of the foot, resulting in unequal force distribution and metatarsalgia.7
- Hammertoe deformity causes metatarsalgia because the top of the shoe pushes the toe down, depressing the metatarsal head.
- The toes also share some weight bearing.
- Hallux valgus may create abnormal foot biomechanics. (See also the eMedicine article Hallux Valgus.)
- These musculoskeletal problems may contribute to forefoot trauma in athletes.
- Calluses are formed as a skin reaction to prolonged pressure, with the skin becoming thickened and hyperkeratotic.
More on Metatarsalgia |
 Overview: Metatarsalgia |
| Differential Diagnoses & Workup: Metatarsalgia |
| Treatment & Medication: Metatarsalgia |
| Follow-up: Metatarsalgia |
| References |
| Next Page » |
References
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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.
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.
Quirk R. Metatarsalgia. Aust Fam Physician. Jun 1996;25(6):863-5; 867-9. [Medline].
Steinberg GG, Akins CM, Baran DT, eds. Metatarsalgia. Orthopedics in Primary Care. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:284-7.
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].
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].
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].
Iagnocco A, Coari G, Palombi G, Valesini G. Sonography in the study of metatarsalgia. J Rheumatol. Jun 2001;28(6):1338-40. [Medline].
Yu JS, Tanner JR. Considerations in metatarsalgia and midfoot pain: an MR imaging perspective. Semin Musculoskelet Radiol. Jun 2002;6(2):91-104. [Medline].
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].
Kennedy JG, Deland JT. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. Dec 2006;453:309-13. [Medline].
O'Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int. May 2002;23(5):415-9. [Medline].
Further Reading
Keywords
overuse injury, pain in the forefoot, forefoot injuries, interdigital neuroma, metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, inflammatory arthritis, edema of the metatarsal heads
