Metatarsalgia is defined as pain at the plantar aspect of the lesser second, third, and/or fourth metatarsal heads.1 Patients often relate a history of gradual, chronic, atraumatic onset rather than an acute, traumatic presentation. The pain typically occurs with prolonged weight-bearing activities such as standing, walking, and running. Symptoms often worsen during the mid-stance and propulsion phases of gait since there is increased pressure upon the plantar forefoot at those periods.2,3 Predisposing factors that can lead to metatarsalgia include increased plantar flexion and disproportionate length of the affected lesser metatarsals.⁴

A thorough physical examination of the patient’s foot for metatarsalgia consists of its inspection during non-weight-bearing and weight-bearing positions. Each of the lesser metatarsophalangeal joints (MTPJs) is evaluated for pain, deformity, instability, or effusion. Patients will often have tenderness to palpation at the dorsal, central, and/or plantar aspects of the affected lesser MTPJs. Patients with plantar metatarsal pain may present with an area of thickened, keratotic skin or callus at the affected joint. The plantar forefoot should also be examined for atrophy of its fat pad as this can contribute to metatarsalgia.⁵ An examination of MTPJ range of motion reveals symmetric motion in dorsiflexion and plantar flexion, without contracture or crepitus. Each flexor and extensor tendon is evaluated for its strength and function. A “drawer” test is performed at each of the lesser MTPJs to assess for stability. This is done as the physician stabilizes the metatarsal neck with one hand and attempts to displace the proximal phalanx with the other hand. An abnormal result with this test may produce pain and reveal MTPJ instability or subluxation. Special care should also be taken to assess the patient’s standing and gait patterns. Most patients will display a normal gait pattern but describe pain with mid-stance and propulsion.²

Weight-bearing radiographs of both the feet are obtained in anteroposterior (AP), lateral, and oblique planes (Fig. 27-1).⁶ Careful attention is paid to the symptomatic MTPJs to assess for instability and/or arthritis. Radiographic signs of MTP instability include medial or lateral deviation of the joint, and dorsal joint subluxation seen on the AP and lateral films respectively (Fig. 27-2).⁷ Radiographic evidence of arthritis involves joint space narrowing and subchondral cystic changes. In addition, the cascade of the first to fifth MTPJs from the medial to lateral direction should be carefully assessed. This cascade should resemble an inverted parabola with the lesser metatarsal heads contained within and not protruding beyond this curve (Fig. 27-3).⁶