Metatarsalgia (MTG)

Metatarsalgia can be described as a painful condition of the bottom of the foot and toes called the forefoot (or commonly referred to the “balls of the foot” or “toe box”). Usually, this discomfort can be sharp, burning or aching during weight-bearing activities like running and sports-related training as well as even walking, standing and stair climbing.

There could be a variety of factors as metatarsalgia can stem from an underlying pathology like a diabetic neuropathy, rheumatoid arthritis, a fracture, an injury to a structure called the plantar plate or even a Morton’s neuroma.

However, this article will concentrate on the acquired pain from a mechanical cause from metatarsophalangeal malalignment (poor positioning or posture of the toes). This type of primary metatarsalgia can result from an increase of pressure or loading on the forefoot. In addition to the discomfort, a person’s foot will have a wear pattern on the shoe and callouses at the region of excessive loading (usually at the 2^nd through 5^th forefoot or metatarsals, as well as the great toe).

The excessive stress on the metatarsal region can be from:

• Poor foot biomechanics with increased loading at the forefoot during the gait cycle
• Abnormal foot position like a low arch
• Hallux valgus (bunion) which studies show to be a significant cause of metatarsalgia.

Hallux valgus refers to the most common deformity of the foot as the first toe or metatarsophalangeal (MTP) joint will rotate and shift outward which significantly changes the function of the foot. While hallux valgus is more likely to affect women than men, it will occur in  about 25% of adults between the ages of 18 and 65 years old and 35% of individuals over 65 years old. 

In relation to metatarsalgia, as the hallux valgus (bunion) causes the great toe to shift laterally outward, towards the small toe), the other 2^nd through 5^th toes do not have room so those digits will be shifted up which can put pressure to the top of the shoe. At this point, the great toe cannot be loaded properly during the gait cycle and the weight-bearing pressure will transfer to the metatarsals which are not designed to take that amount of pressure. Hence, the forefoot region becomes agitated and inflamed resulting in metatarsalgia. Furthermore, the potential atrophy of the fat pad will exacerbate the symptoms of metatarsalgia.

If the hallux valgus deformity is not corrected, metatarsalgia can still occur but here are some options to reduce the symptoms:

• Use of padded socks
• Use of over-the-counter orthotics or custom-made orthotics.
• Add a plantar pad that elevates the 2^nd through 5^th toe as seen in pictures below with or without orthotics
• Refrain from wearing high heels.
• Obtain proper supportive and cushioned shoes as well as proper width of shoes.
• Reduce the amount of impact loading for a short amount of time (i.e. running, etc…).
• Reduce body weight if overweight.
• Use of ice.
• Potential use of NSAIDs but will require consultation with your physician.
• Gentle stretches and exercises (see attachment)

Bibliography

Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: a guide to everyday practice. World J Orthop. 2017;8:21–29.

Gutteck et al. Pain on the plantar surface of the foot. Dtsch Arztebl Int. 2019 Feb; 116 (6): 83-88.

Lee P et al Comparison of the pressure-relieving properties of various types of forefoot pads in older people with forefoot pain. Journal of Foot and Ankle Research. 2013, 6 (Suppl 1): 019. http://www. Jfootankleres.com/content/6/S1/019

 Levy JC, Mizel MS, Clifford PD, Temple HT. Value of radiographs in the initial evaluation of nontraumatic adult heel pain. Foot Ankle Int. 2006;27:427–430.

Mannikko K and Sahlman J. The effect of metatarsal padding on the pain and functional ability in metatarsalgia. Scand J Surg. 2017. Dec; 106 (4): 332 – 337.

Nishimura A, Nakazora S, Ito N, Fukuda A, Kato K, Sudo A. Endoscopic all-inside repair of the flexor hallucis longus tendon in posterior ankle impingement patients. Arthrosc Tech. 2017;6:e1829–e1835.

Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and metaanalysis. J Foot Ankle Res. 2010;3

Schneider HP, Baca J, Carpenter B, Dayton P, Fleischer AE, Sachs BD. American College of Foot and Ankle Surgeons Clinical Consensus Statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018;57:370–381.

Wulker N and Mittag F. The treatment of hallux valgus. Dtsch Arztebl Int. 2012 Dec; 109 (49): 857-868.

Pictures

Webmd.com

Physio-pedia.com

Medbridgeeducation.com for Exercises