History
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The pain is typically aggravated during the mid-stance and propulsion phases of walking or running.
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A history of a gradual, chronic onset is more common than an acute presentation. Chronic symptoms may be of gradual onset over 6 months.
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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 Medscape Reference articles Physical Medicine and Rehabilitation for Morton Neuroma and Surgery for Morton Neuroma.)
Physical
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Palpable point tenderness at the distal end of the plantar metatarsal fat pad is a typical finding.
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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 Medscape Reference article Intractable Plantar Keratosis.)
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Absence of pain in the interdigital space helps the clinician assess for the presence of a neuroma.
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Patients with an interdigital neuroma have maximal tenderness between the web spaces.
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Loss of sensation may be present in the adjacent toes.
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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
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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.
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Persistent stress can lead to chronic irritation and inflammation of the periosteum and adjacent tissues.
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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 Medscape Reference article Hammertoe Deformity.)
Hypermobile first ray
Tight Achilles tendon
Excessive pronation
Equinus deformity (See also the Medscape Reference articles Clubfoot and Clubfoot Imaging.)
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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 Medscape Reference 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]
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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 Medscape Reference 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.
