> Table of Contents > Metatarsalgia
Metatarsalgia
Michael Y. Yang, MD
Marc W. McKenna, MD
image BASICS
DESCRIPTION
  • Metatarsalgia is a generic term referring to pain in the forefoot in the region of the metatarsal heads.
  • System affected: musculoskeletal
EPIDEMIOLOGY
Incidence
Especially common in athletes engaging in highimpact sports (running, jumping, dancing), in rock climbers (12.5%), and in older active adults.
Prevalence
Common
ETIOLOGY AND PATHOPHYSIOLOGY
  • The 1st metatarsal head bears significant weight when walking or running. A normal metatarsal arch ensures this balance. The 1st metatarsal head normally has adequate padding to accommodate increased forces.
  • Reactive tissue can build a callus around the metatarsal head, compounding the pain.
    • Excessive or repetitive stress. Forces are transmitted to the forefoot during several stages (midstance and push-off) of walking and running. These forces are translated across the metatarsal heads at nearly three times the body weight (1)[C].
    • A pronated splayfoot disturbs this balance, causing equal weight bearing on all metatarsal heads.
    • Any foot deformity changes distribution of weight, impacting areas of the foot that do not have sufficient padding.
    • Soft tissue dysfunction: intrinsic muscle weakness, laxity in the Lisfranc ligament
    • Abnormal foot posture: forefoot varus or valgus, cavus or equinus deformities, loss of the metatarsal arch, splayfoot, pronated foot, inappropriate footwear
    • Dermatologic: warts, calluses (2)[C]
  • Great toe
    • Hallux valgus (bunion), either varus or rigidus
  • Lesser metatarsals
    • Freiberg infraction (i.e., aseptic necrosis of the metatarsal head usually due to trauma in adolescents who jump or sprint)
    • Hammer toe or claw toe
    • Morton syndrome (i.e., long 2nd metatarsal)
RISK FACTORS
  • Obesity
  • High heels, narrow shoes, or overly tight-fitting shoes (rock climbers typically wear small shoes)
  • Competitive athletes in weight-bearing sports (e.g., ballet, basketball, running, soccer, baseball, football)
  • Foot deformities or changes in ROM (e.g., pes planus, pes cavus, tight Achilles tendon, tarsal tunnel syndrome, hallux valgus, prominent metatarsal heads, excessive pronation, hammer toe deformity, tight toe extensors) (2)[C]
Geriatric Considerations
  • Concomitant arthritis
  • Metatarsalgia is common in older athletes.
  • Age-related atrophy of the metatarsal fat pad may increase the risk for metatarsalgia.
Pediatric Considerations
  • Muscle imbalance disorders (e.g., Duchenne muscular dystrophy) cause foot deformities in children.
  • In adolescent girls, consider Freiberg infraction.
  • Salter I injuries may affect subsequent growth and healing of the epiphysis.
Pregnancy Considerations
  • Forefoot pain during pregnancy usually results from change in gait, center of mass, and joint laxity.
  • Wear properly fitted, low-heeled shoes.
GENERAL PREVENTION
  • Wear properly fitted shoes with good padding.
  • Start weight-bearing exercise programs gradually.
COMMONLY ASSOCIATED CONDITIONS
  • Arthritis
  • Morton neuroma
  • Sesamoiditis
  • Plantar keratosis-callous formation
image DIAGNOSIS
PHYSICAL EXAM
  • Point tenderness over plantar metatarsal heads
  • Pain in the interdigital space or a positive metatarsal squeeze test suggests Morton neuroma.
  • Plantar keratosis
  • Tenderness of the metatarsal head(s) with pressure applied by the examiner's finger and thumb
  • Erythema and swelling (occasionally)
DIFFERENTIAL DIAGNOSIS
  • Stress fracture (most commonly 2nd metatarsal)
  • Morton neuroma (i.e., interdigital neuroma)
  • Tarsal tunnel syndrome
  • Sesamoiditis or sesamoid fracture
  • Salter I fracture in children
  • Arthritis (e.g., gouty, rheumatoid, inflammatory, osteoarthritis, septic, calcium pyrophosphate dihydrate crystal deposit disease [CPPD])
  • Lisfranc injury
  • Avascular necrosis of the metatarsal head
  • Ganglion cyst
  • Foreign body
  • Vasculitis (diabetes)
  • Bony tumors
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Weight-bearing radiographs: anteroposterior, lateral, and oblique views:
    • Occasionally, metatarsal or sesamoid axial films (to rule out sesamoid fracture) or skyline view of the metatarsal heads to assess the plantar declination of the metatarsal heads: obtained with the metatarsophalangeal joints in dorsiflexion (to evaluate alignment)
  • Ultrasound and MRI in recalcitrant cases especially if concern for stress fracture (3)[C]
  • MR arthrography of the metatarsophalangeal (MTP) joint can delineate capsular tears, typically of the distal lateral border of the plantar plate (an often underrecognized cause of metatarsalgia.
  • Only if diagnosis is in question
    • Erythrocyte sedimentation rate or C-reactive protein
    • Rheumatoid factor
    • Uric acid
    • Glucose
    • CBC with differential
Diagnostic Procedures/Other
Plantar pressure distribution analysis may help distinguish pressure distribution patterns due to malalignment.
image TREATMENT
Treatment for metatarsalgia is typically conservative.
  • Relieve pain
  • Ice initially
  • Rest: temporary alteration of weight-bearing activity; use of cane or crutch. For more physically active patients, suggest an alternative exercise or cross-training:
    • Moist heat later
    • Taping or gel cast
    • Stiff-soled shoes will act as a splint.
  • Relieve the pressure beneath the area of maximal pain by redistributing the pressure load of the foot, which can be achieved by weight loss.
MEDICATION
Nonsteroidal anti-inflammatory medications for 7 to 14 days if no contraindications toward use
P.671

ISSUES FOR REFERRAL
High-level athletes may benefit from early podiatric or orthopedic evaluation.
ADDITIONAL THERAPIES
  • Physical therapy to restore normal foot biomechanics
  • Low-heeled (<2 cm height) wide-toe-box shoes
  • Metatarsal bars, pads, and arch supports. Metatarsal bars are often more effective than pads.
  • Orthotics/rocker bar (prescriptive orthotics have been shown to be effective treatment)
  • Thick-soled shoes
  • Shaving the callus may provide temporary relief. Callus excision is not recommended.
  • Corticosteroid injection may benefit interdigital neuritis but should be used with caution as it may cause MTP instability and fat pad atrophy.
  • Improve flexibility and strength of the intrinsic muscles of the foot with:
    • Exercises (e.g., towel grasps, pencil curls)
    • Physical therapy to maintain range of motion and restore normal biomechanics
SURGERY/OTHER PROCEDURES
  • If no improvement with conservative therapy for 3 months, refer to foot/ankle orthopedic surgeon or podiatrist.
  • Surgery may help correct anatomic abnormality: bunionectomy, partial osteotomy, or surgical fusion. Success rates vary depending on procedure.
  • Direct plantar plate repair (grade II tear) combined with Weil osteotomy can restore normal alignment of the MTP joint, leading to diminished pain with improved functional scores.
  • The Weil osteotomy (distal metatarsal oblique osteotomy) is safe and effective for metatarsalgia.
  • Callus removal is generally not recommended (callus is a response to pressure change—not the cause).
  • Morton neurectomy or ultrasound-guided alcohol ablation of Morton neuroma are options (4)[C].
  • Surgery only as a last resort if no anatomic abnormality is present.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Magnetic insoles are not effective for chronic nonspecific foot pain.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Patients generally admitted only for surgery
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
If stress fracture has been ruled out and patient's condition has not improved >3 months of conservative treatment, consider surgical evaluation.
PATIENT EDUCATION
  • Instruct about wearing proper shoes and gradual return to activity.
  • Cross-training until symptoms subside. Goal is to restore normal foot biomechanics, relieve abnormal pressure on the plantar metatarsal heads, and relieve pain (5)[C].
PROGNOSIS
Outcome depends on the severity of the problem and whether surgery is required to correct it.
REFERENCES
1. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31(7 Suppl):S448-S458.
2. DiPreta JA. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Med Clin North Am. 2014;98(2):233-251.
3. Iagnocco A, Coari G, Palombi G, et al. Sonography in the study of metatarsalgia. J Rheumatol. 2001;28(6):1338-1340.
4. Musson RE, Sawhney JS, Lamb L, et al. Ultrasound guided alcohol ablation of Morton's neuroma. Foot Ankle Int. 2012;33(3):196-201.
5. Espinosa N, Brodsky JW, Maceira E. Metatarsalgia. J Am Acad Orthop Surg. 2010;18(8):474-485.
Additional Reading
&NA;
  • Birbilis T, Theodoropoulou E, Koulalis D. Forefoot complaints—the Morton's metatarsalgia. The role of MR imaging. Acta Medica (Hradec Kralove). 2007;50(3):221-222.
  • Buda R, Di Caprio F, Bedetti L, et al. Foot overuse diseases in rock climbing: an epidemiologic study. J Am Podiatr Med Assoc. 2013;103(2):113-120.
  • Burns J, Landorf KB, Ryan MM, et al. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007;(4):CD006154.
  • Deshaies A, Roy P, Symeonidis PD, et al. Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head. Foot (Edinb). 2011;21(4):172-175.
  • Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008;16(3):152-158.
  • Ko PH, Hsiao TY, Kang JH, et al. Relationship between plantar pressure and soft tissue strain under metatarsal heads with different heel heights. Foot Ankle Int. 2009;30(11):1111-1116.
  • Pace A, Scammell B, Dhar S. The outcome of Morton's neurectomy in the treatment of metatarsalgia. Int Orthop. 2010;34(4):511-515.
  • Thomas JL, Blitch EL IV, Chaney DM, et al. Diagnosis and treatment of forefoot disorders. Section 2. Central metatarsalgia. J Foot Ankle Surg. 2009;48(2):239-250.
See Also
&NA;
Morton Neuroma (Interdigital Neuroma)
Codes
&NA;
ICD10
  • M77.40 Metatarsalgia, unspecified foot
  • G57.60 Lesion of plantar nerve, unspecified lower limb
  • M77.42 Metatarsalgia, left foot
Clinical Pearls
&NA;
  • Metatarsalgia refers to pain of the plantar surface of the forefoot in the region of the metatarsal heads.
  • Metatarsalgia is common in athletes who participate in high-impact sports involving the lower extremities.
  • Patients describe as “walking with a pebble in the shoe.” Pain is worse during midstance or propulsion phases of walking or running.
  • The most common physical finding is point tenderness over plantar metatarsal heads.
  • Pregnant patients should wear properly fitted, lowheeled shoes to reduce incidence of metatarsalgia.