Metatarsalgia is a general term used to describe a painful foot condition in the metatarsal region of the foot (the area just before the toes, more commonly referred to as the ball-of-the-foot). This is a common foot disorder that can affect the bones and joints at the ball-of-the-foot. Metatarsalgia is often located under the 2nd, 3rd, and 4th metatarsal heads, or more isolated at the first metatarsal head. It can be associated with painful calluses under these areas.

Causes of Metatarsalgia

Metatarsalgia is most often a result of faulty distribution of weight on the forefoot. Normally when walking, weight is transferred from the heel to the outside of the foot and then finished with the weight on the inside as we “toe-off” at the end of each step. During toe-off, most of the weight is carried by the big toe. When standing, the first metatarsal (at the big toe) carries 2/6 of the body weight and each of the other carries 1/6. If increased weight is habitually carried on the outer metatarsals, this can cause micro-trauma in the joint capsule and around the head of that particular metatarsal and thereby leading to injury.

Normally, the little muscles that run between the bones of the feet contract during the final phase of each step to prevent the forefoot from widening and the toes from curling. If these little intrinsic muscles don’t do their job, the forefoot spreads and the toes curl which causes the metatarsal heads to be forced down and they contact the ground harder and this can lead to injury.

As you can probably guess, onset is usually gradual as micro-trauma takes a while to add up into an injury. However, it may arise suddenly if there is trauma to the area or if new shoes are involved. Sudden trauma might include landing hard on the ball of the foot while barefoot or while wearing non-cushioned shoes or stepping on a stone while running.

Other Causes

Bunions, metatarsal length deformities, hammer toes, high arched feet, arthritis, stress fractures, and increased loading due to bunion surgery are all possible causes of metatarsalgia. It is important to recognize that metatarsalgia may be due to one of these conditions or a combination of several. It is not uncommon to find several different forefoot problems occurring simultaneously.

Signs and Symptoms

• Pain in the area of the ball of the forefoot Pain is often a dull ache, much like a bruise.
• If one bends the toes upwards and applies pressure over the “knuckles” of the foot, the pain can often be localized to one metatarsal head.
• Pain is worse with walking barefoot, especially on hard surfaces like concrete or ceramic tile.
• Pain often forces a person to walk on the outside of the foot in an effort to avoid stepping on the ball of the foot.
• Pain is often less in good running shoes, especially those with forefoot cushioning.
• Sometimes a callus will form in the area of increased pressure and pain. A callus is the body’s attempt to protect itself from the increased pressure.

Treatment

The conservative treatment of many forefoot problems is the same. The majority of cases of metatarsalgia are due to biomechanical problems of the forefoot. Many cases can be treated with a metatarsal pad, arch support with metatarsal pad, or increased cushion to the forefoot either in the shoe or on the outer soles. If you pronate excessively, you will need a good motion control shoe. If you are replacing your shoes, consider a pair that offer some form of forefoot cushioning. A podiatrist can help you find a great shoe for your foot with these features.

Custom Orthotics and Metatarsalgia

If over-the-counter arch supports do not provide enough relief, custom functional orthotics, if properly prescribed and fitted, can relieve the symptoms of metatarsalgia. Custom foot orthotics are precision balanced medical devices worn in your shoes to allow the feet and lower extremities to function properly and help eliminate pain and deformity caused by improper function. They are specifically designed to fit your feet and act to restore the normal biomechanical function of the lower extremities. Orthotics for metatarsalgia are prescribed specifically to help take weight off of the painful area of the foot. The foot doctor will prescribe an orthotic that “hugs” the arch of your foot very closely in order to transfer force off of the metatarsal heads. Then we use accommodative pads to transfer force directly off the painful area and special shock absorbing materials to cushion the area.

In order to ensure best outcomes from your orthotics the doctor will first perform a detailed biomechanical examination, including a gait analysis on how you walk and how your feet work. A mold of each of your foot is then taken in a very specific position and the orthotic devices are prescribed in a manner to best reduce force and trauma to the area of your pain.

Other Treatments for Metatarsalgia

Shoes. Shoes that offer the correct support and cushion for your foot are an integral part of any biomechanical treatment plan. Based on our findings in your evaluation, the doctor will provide you with recommendations of appropriate shoes for your foot type and a list of shoe stores with personnel trained in proper fitting. Ask our office for a list of recommended shoes.

Shoe Modifications. Customizing the fit of a shoe can often solve a foot problem. Shoes can be modified with special soles and inserts to decrease weight on the metatarsal heads. Forefoot rocker soles, for example, are an important shoe modification that will dramatically decrease the load to the forefoot.

Cortisone. Injected cortisone has been helpful for some short term inflammatory disorders of the forefoot. Cortisone, although helpful in many cases, can contribute to fat pad atrophy (thinning of the cushion under ball of the foot). Thus we limit our use of cortisone injections. We normally only use cortisone injections after we have controlled the biomechanical problem with the use of proper shoes and orthotic devices. Even then, only a small percentage of patients need the injections.

Surgery. Surgery should only be considered if all conservative treatment has been tried and you are still having pain. Metatarsalgia has many causes including bunions, hammertoes and long metatarsal bone. Therefore, there is no one surgery to treat metatarsalgia. The surgical procedures for each of the common contributing factors are very different. A surgical procedure for a bunion deformity is vastly different than that used to treat a hammertoe. If surgery is necessary, Dr. Wang will evaluate your problem and choose the procedure that is best for you. Prior to surgery, the doctor will thoroughly describe the surgical procedure to be used and discuss post-operative course and expectations.

Remember – you don’t have to live with foot pain! Conservative treatment prescribed by the doctor has great chance of relieving symptoms. Early conservative treatment improves your chance of avoiding future surgery.

Contact our office if you would like to see our foot specialist regarding treatment for metatarsalgia.