In this article, we talk about metatarsalgia in the forefoot. The causes are many, and only a precise diagnosis will make it possible to find the origin. Thus, we propose a targeted treatment and show you how to deal with metatarsalgia.
Table of Contents
- How to treat metatarsalgia?
- What Are the Symptoms of Metatarsalgia?
- What Are the Causes of Metatarsalgia?
- Metatarsal Heads of The Foot
- Metatarsal Socks
- Foot Metatarsals Pain
- First Ray Insufficiency Syndrome
- Severe Metatarsalgia
- Prevention of Metatarsalgia
How to treat metatarsalgia?
Some medical treatments may decrease the pain or provide temporary comfort. But it will not correct the cause of the pain. Surgery may be ideal if the pain and functional discomfort are too great.
You can start by reducing activities that involve a lot of walking and focus on sports without full load on the feet (cycling and swimming). Then orient yourself towards pedicure care and the wearing of orthopedic shoes. Rehabilitation can provide more lasting relief from painful phenomena. Pain relievers, muscle relaxers, and anti-inflammatories will help control inflammation. Significant weight loss should be vital.
Conservative treatment is different depending on the origin of the metatarsalgia and suffices to treat the painful symptomatology. Physiotherapy occupies a preponderant place in short gastrocnemius syndrome and musculotendinous imbalances.
Changing the footwear and putting in plantar supports give excellent results. We will choose a wider shoe size, with a low heel. The plantar supports, again to be adapted according to the etiology, including retro capital support which allows a redistribution of the loads on the forefoot. Finally, local infiltration may have a place in the treatment of Morton and some types of bursitis but should be done with caution.
The surgical treatment will focus on finding a more harmonious distribution of the body’s weight on the forefoot. This harmony aims to match the lengths of the metatarsals, but also their support on the ground. Two surgical techniques exist and the choice will be made according to the foot to be operated on:
- Minimally invasive osteotomy (breakage): We can make a small opening of five millimeters (percutaneous). Do not put screws and always break several metatarsals because the fact of leaning on the foot after the operation will allow all the bones to consolidate naturally with a better distribution of the weight on the foot. This technique is DMMO (Distal Minimally invasive Metatarsal Osteotomy)
- Weil’s osteotomy: It is necessary to make an incision of about two centimeters, the purpose of it is a shortening and an elevation of the heavier heads.
Recently, percutaneous surgery has changed these osteotomies by an absence of fixation, systematic management of the three central rays, and a different theoretical approach. The heads left free to move dorsally when the patient walks until we find a balance corresponding to a homogeneous distribution of the loads. Stabilization in this position is biodynamic and the shortening of the metatarsals occupies a secondary place.
Other static or dynamic disorders may respond to corrective surgery. The most classic examples are the management of hallux valgus, toe claws, gastrocnemius lengthening in the equine because of triceps sural or excision of Morton’s neuroma or endoscopic decompression of its canal.
What Are the Symptoms of Metatarsalgia?
Metatarsalgia is manifested by pain located under the sole at the base of the toes. This pain appears during exertion, making everyday activities relatively disabling since they can interfere with it. Then, it disappears during periods of rest such as sleep. The most representative sensations are:
- Diffuse burning sensation
- Numbness in the front of the feet
- Swelling on the top and front of the feet
- Presence of calluses on the front of the feet
- Difficulty squatting on the front of the foot
- Slenderness to the phalanges of the foot
When the metatarsalgia is very advanced, the pain can appear more quickly.
What Are the Causes of Metatarsalgia?
There are many causes of metatarsalgia, but it is mainly a problem of weight distribution over part or all of the forefoot at the level of the 5 metatarsal heads. Any imbalance triggers a modification and therefore an overload on one or more metatarsals.
Here are distinct problems that lead to the consultation:
- Bad length of a metatarsal
- Have flat or sagging feet
- Have a hollow foot with overutilization of the metatarsals
- Have limited ankle flexion because of an Achilles tendon that is too short
- Suffer from hallux valgus
- Pain in the metatarsal joint
- Too long metatarsals (propulsive metatarsalgia related to an architectural anomaly of the forefoot).
Here are different factors that can increase the situation:
- Wearing shoes that are too tight in the forefoot or having a lack of absorption of the sole or being too flexible
- Wearing too high heels which increase the speed of onset of pain
- Overweight and significant and rapid weight gain
- Excessive and too rapid practice of sport with effects (running or walking)
Metatarsal Heads of The Foot
Forefoot pain defines Metatarsalgia in the area of the metatarsal heads. They represent the first cause of specialized consultations. The etiologies are many, and a specific clinical examination makes it possible to make a diagnosis and to propose an appropriate treatment.
A biomechanical approach to forefoot disorders is, therefore, necessary to treat these various pathologies according to precise criteria. It is the aim of this text, defining the different metatarsalgia, their classification, clinical presentation, and treatment.
Someone conventionally composed the walking cycle of an oscillating phase and a stance phase. We can separate the latter into three distinct phases:
- Phase 1: It begins with the attack of the heel on the ground and continues until contact with the toes.
- Phase 2: This phase is defined by the sliding of the tibia on the talar dome and by the displacement of the center of gravity anteriorly. Overloading of one or more of the metatarsal heads is common in this context.
It is classically a sagittal misalignment of the metatarsals that causes a localized hyper-pressure under the offending heads. We define them as static metatarsalgia and show the development of hyperkeratosis of proximal location and centered precisely under the offending metatarsal head.
- Phase 3: It starts with an elevation of the heel and induces propulsion through the forefoot. As being different in position and foot support, it presents a different type of metatarsalgia, called propulsive, where classically an excessively long metatarsal leads to chronic over-support of the head and surrounding soft tissues.
We associate them with a more diffuse, distal hyperkeratosis extending to the root of the toes and encompassing both the metatarsal region and the soft tissues surrounding it.
Thickening of the interdigital sensory nerve leads to a feeling of numbness and loss of sensation in the toes, a typical sensation of a bad sock that causes Morton’s neuroma. Here, burning, the perception of small electric shocks during the step, and the immediate feeling of relief may accompany the pain when shoes are removed.
They link this type of symptomatology to nerve compression and the consequent thickening of the interdigital nerve. But it is not always easy to distinguish between biomechanical metatarsalgia and Morton’s neuroma.
It is for this reason that a careful physical examination and an evaluation with an X-ray in charge that can help us in the diagnosis of exclusion is of primary importance. Ultrasounds and resonances are often positive for Morton’s Neuroma, even when the neuroma is not the problem.
So, using metatarsal socks can help to
- Relieve humeral pain, football pain, sacral pain, neuroma, blistering and sore feet.
- Eliminate burning and stress on your feet by redistributing your weight on an ultra-soft gel pad.
- Best gift as a parent or family member.
- We can wear lightweight and thin inside socks and Metatarsal Boots.
- Suitable for all kinds of various scenes and shoes.
- Provide some forefoot support.
Foot Metatarsals Pain
Rheumatoid arthritis and diabetic polyneuropathy have metatarsalgia of metatarsophalangeal origin in common. The misalignment of the toes in all planes is due in the first case to direct joint damage, and with polyneuropathy to an imbalance between intrinsic and extrinsic muscles. The weakly compensated tendon action induces dorsiflexion of the phalanx on the metatarsal’s head. The plantar plate, then the only brake on migration, ends up weakening or giving way and first precipitates instability and then a metatarsophalangeal dislocation. The powerful flexors then cause vital support of the phalanx on the metatarsal head that shows an often severe and characteristic hyper-support.
Damage defines Morton’s syndrome to the nerve in the third intermetatarsal space. The latter, anastomosis of the lateral and medial plantar nerves, travels in a restricted space, delimited by the neighboring metatarsals and covered by the intermetatarsal ligament. Chronic suffering from compression of this nerve (duct syndrome) causes thickening and then the formation of a histological pseudo-tumor lesion.
First Ray Insufficiency Syndrome
The stability of the first ray is essential for a physiological distribution of the loads. Any defect at this level inevitably leads to a pathology of overload of the lateral rays. Several tables can then appear.
The first is an insufficiency linked to a hallux valgus. In this case, either the cuneometatarsal joint is primarily incompetent, or the lateral migration of the extensor/flexor tendons no longer allows dynamic stabilization of this joint. In both cases, the wedge-metatarsal instability induces an elevation of the first radius when walking, a lack of internal support, and therefore a lateral overload.
The other possibility is a short first metatarsal. The insufficiency is not due to instability speaking but to a reduced lever arm and a lateral overload. Clinically, the overload appears during the propulsion phase of walking. It leads to diffuse hyperkeratosis of the forefoot. Metatarsalgia can be the main symptom and sometimes shows acute decompensation in the form of stress fractures of the metatarsals.
Other biomechanical causes can lead to metatarsalgia such as postfracture, post-surgical status, and other etiology. They will be leading to an imbalance in the frontal or sagittal plane of the metatarsal heads. Each case must be analyzed specifically.
The entire lower limb should be explored for axis or length defect, flexed, surgical scars, or equine. For the latter, the patient is placed in a sitting position, then the dorsiflexion of the ankle is measured with the knee flexed and then the knee extended (Silfverskiöld test). The gastrocnemius is anatomically relaxed in the first case and tense in the second. In the case of an equine with a significant difference between flexed and stretched knee, it is a short gastrocnemius syndrome. Otherwise, the equine originates directly from the ankle.
The morphological examination of the foot makes it possible to find a flat or hollow foot, often the cause of metatarsalgia. The presence of a hallux valgus and, in this context, the stability of the Cuneo-metatarsal joint. The position of the toes must be controlled as well as the reducibility of the deformities.
Finally, the plantar examination must be rigorous. Static and dynamic hyperkeratosis, their precise or diffuse localization, and their severity will be recognized. Any chronic overload of a metatarsal head ultimately results in bursitis, which is painful on palpation. In the long term, this damage ends up tearing the plantar plate and destabilizing the metatarsophalangeal joint (Lachmann’s sign) before causing a dislocation.
Recent studies have shown that over 60% of asymptomatic patients show signs on MRI consistent with Morton’s syndrome. They mention wrongly this pathology during pain in the forefoot.
Therefore, only the clinical examination can make a precise diagnosis. Typically, the patient complains of pain in the third intermetatarsal space, often burning, and regularly accompanied by paresthesias or paresis of the third and fourth toes. On palpation, the pain is elective in the intermetatarsal space and absent in the metatarsal heads. This peculiarity is essential, although classic metatarsalgia of another origin can be added to the picture and make the distinction more difficult.
Finally, this pathology can develop in the second metatarsal space (second space syndrome). We must rule a diagnosis of exclusion and any other etiology out.
Prevention of Metatarsalgia
It is not always possible to prevent metatarsalgia. However, choose the right footwear, making sure:
- A wide shoe or sandals (plenty of room for the foot) will help your foot not to receive unnecessary pressure
- A slight heel
- Well-cushioned and solid shoes
- A good sole not too thin, heel and of adequate width
- Renew their shoes and work boots annually
- Wear your prescribed orthotics daily
- Lose weight if needed
- Pay attention and change your working position frequently when necessary (avoid keeping your toes in hyperextension)
- Renew your running shoes every 800-1000km run.
Metatarsalgia is not a specific entity, but the symptomatic expression of pathologies of various origins. Their treatment, firstly conservative, must focus on the cause of the imbalance. In the event of failure, the surgical approach, recently extended by the addition of minimally invasive surgery, offers a range of possibilities based on a precise diagnosis, itself dependent on a careful clinical examination.
Beyond a simple classification or etiological research, the management of these pathologies is part of a biomechanical vision of the statics of the foot and units.