Dominic Jacobelli, MD
Kenneth Bielak, MD, FACSM, FAAFP, CAQSM
Pain in the plantar aspect of the metatarsal (MT) heads
Metatarsalgia can be thought of as a symptom rather than a specific disease.
Primary metatarsalgia develops from intrinsic factors, such as a long first ray, hallux valgus, or other congenital deformities.
Secondary metatarsalgia may result from trauma, overuse, or poor footwear.
Athletes in high-impact sports involving the lower extremities (dancing, running, jumping)
ETIOLOGY AND PATHOPHYSIOLOGY
Repetitive/excessive stress combined with intrinsic and extrinsic factors
The 1st MT head usually carries 30% of the load in weight-bearing. A normal MT arch ensures this balance by providing adequate padding around the 1st MT head. A pronated or splayfoot can disturb this balance, resulting in an abnormally high pressure over the 2nd through 5th MT heads. Over time, reactive tissue can form a callus around the MT heads, which further compounds pain.
Foot deformities: overpronation, pes planus, pes cavus, hallux valgus, prominent MT heads, hammertoe deformity, Morton foot (short 1st MT and a relatively long 2nd MT)
Muscle imbalance or soft tissue dysfunction: tight Achilles tendon or toe extensors, weak toe flexors, laxity in the Lisfranc ligament
Extrinsic factors: obesity, high heels, poorly fitted or worn-down shoes
Dermatologic issues: calluses and warts
Fat pad atrophy or displacement
Iatrogenic changes from surgeries resulting in unequal force distribution
Wear properly fitted shoes with adequate padding.
Gradual progression of weight-bearing exercise programs
COMMONLY ASSOCIATED CONDITIONS
Intrinsic foot muscle weakness
Calluses and warts
Hallux valgus or rigidus
Hammertoe or claw toe
Morton syndrome (long 2nd MT)
Freiberg infraction (aseptic necrosis of a MT head, most commonly the 2nd, as seen in adolescent sprinters)
Premium Wordpress Themes by UFO Themes
Pain over the plantar surface of the MT heads, typically described as walking with a “pebble in the shoe”
Pain is typically gradual and chronic in onset rather than acute.
Pain is worse in midstance and propulsion phases of walking and running.
Inspect for the presence of callus, edema, erythema, deformity, and skin breaks.
Palpate for tenderness, which is typically located over the distal half of the MT shaft and head.
Pain in the interdigital space or positive MT squeeze test suggests interdigital neuroma.
Range of motion of the phalanges, metatarsophalangeal (MTP) joint, and ankle, especially to dorsiflexion, to evaluate tight gastrocsoleus complex
Gait analysis should be performed.
Neuroma (plantar or Morton neuroma)
Idiopathic MTP joint synovitis
Freiberg disease: ischemic epiphyseal necrosis of the 2nd MT
Inflammatory arthritis of MT joint (rheumatoid arthritis, seronegative spondyloarthropathy, crystalline-induced arthritis, osteoarthritis, septic arthritis)
Salter I fracture (pediatric population)
Sesamoiditis or sesamoid fracture
Cellulitis or infection (diabetic foot, Lyme disease)
WordPress theme by UFO themes