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BASICS

DESCRIPTION
- Metatarsalgia is pain in the forefoot under one or more metatarsal heads.
- Groups:
- Primary: anatomic issues between metatarsal and foot
- Secondary: increased metatarsal loading due to synovitis, fracture, or MTP joint injury
- Iatrogenic: post-forefoot surgery (e.g., hallux valgus surgery)

EPIDEMIOLOGY

  • Incidence: 5-36% in general population; common in athletes (running, jumping, dancing), rock climbers (12.5%), older active adults.
  • Most common in women aged 30 to 60 years.
  • Prevalence: common.

ETIOLOGY AND PATHOPHYSIOLOGY

  • 1st metatarsal head bears significant weight during walking/running.
  • Normal metatarsal arch balances weight; loss leads to excessive force on metatarsal heads.
  • Forces transmitted can be nearly 3 times body weight during gait phases (midstance, push-off).
  • Pronated splayfoot disturbs weight distribution causing equal loading on all metatarsals.
  • Foot deformities (forefoot varus/valgus, cavus, equinus, splayfoot, pronation, inappropriate footwear) affect force distribution and cause pain.
  • Soft tissue dysfunction includes muscle weakness, ligament laxity (Lisfranc ligament).
  • Dermatologic causes: warts, calluses.
  • Specific conditions:
  • Hallux valgus (bunion)
  • Freiberg infraction (aseptic necrosis of metatarsal head)
  • Hammer/claw toe
  • Morton syndrome (long 2nd metatarsal)

RISK FACTORS

  • Obesity
  • Forefoot surgery or trauma
  • High heels, narrow/tight shoes (especially in rock climbers)
  • Competitive athletes in weight-bearing sports (ballet, basketball, running, soccer, baseball, football)
  • Foot deformities (pes planus, pes cavus, tight Achilles, tarsal tunnel syndrome, hallux valgus, pronation, hammer toe, tight toe extensors)
  • Geriatric: arthritis, fat pad atrophy
  • Pediatric: muscle imbalance disorders (Duchenne dystrophy), Freiberg infraction, Salter-Harris I injuries
  • Pregnancy: gait changes, joint laxity; advise low-heeled shoes.

GENERAL PREVENTION

  • Wear properly fitted shoes with good padding.
  • Gradual start to weight-bearing exercises.
  • Adequate calf stretching.
  • Weight loss if overweight.

COMMONLY ASSOCIATED CONDITIONS

  • Arthritis
  • Morton neuroma
  • Sesamoiditis
  • Plantar keratosis (callus)

DIAGNOSIS

HISTORY
- Gradual, persistent plantar pain under metatarsals.
- Worse during midstance and propulsion phases.
- Patients often describe feeling like “walking with a pebble in the shoe.”
- Predisposed by pes cavus, hyperpronation.

PHYSICAL EXAM
- Point tenderness over plantar metatarsal heads.
- Pain/interdigital tenderness with positive metatarsal squeeze test suggests Morton neuroma.
- Plantar keratosis, occasional erythema/swelling.

DIFFERENTIAL DIAGNOSIS

  • Stress fracture (commonly 2nd metatarsal)
  • Morton neuroma
  • Tarsal tunnel syndrome
  • Sesamoiditis or sesamoid fracture
  • Salter-Harris I fracture (children)
  • Arthritis (gout, RA, OA, septic, CPPD)
  • Lisfranc injury
  • Avascular necrosis of metatarsal head
  • Ganglion cyst
  • Foreign body
  • Vasculitis (diabetes)
  • Bone tumors

DIAGNOSTIC TESTS & INTERPRETATION

  • Usually clinical diagnosis.
  • Weight-bearing X-rays (AP, lateral, oblique); sesamoid axial or skyline views if needed.
  • Ultrasound/MRI in recalcitrant cases or suspected stress fracture.
  • Labs: ESR, CRP, rheumatoid factor, uric acid, glucose, CBC if indicated.
  • Plantar pressure distribution analysis may assist in malalignment cases.

TREATMENT

  • Conservative: rest, ice, activity modification, proper padding.
  • Moist heat later, taping, gel metatarsal cushions.
  • Stiff-soled shoes act as splints.
  • Gastrocnemius stretching exercises.
  • Orthotics to redistribute plantar pressure.
  • Weight loss if overweight.

MEDICATION
- NSAIDs for 7-14 days if no contraindications.

ISSUES FOR REFERRAL
- High-level athletes or refractory cases to podiatry or orthopedics.

ADDITIONAL THERAPIES
- Physical therapy for foot biomechanics.
- Low-heeled, wide-toe-box shoes recommended.
- Metatarsal bars, pads, arch supports; bars more effective than pads.
- Valgus splint if hallux valgus present.
- Corticosteroid injection for interdigital neuritis (cautious use).

SURGERY/OTHER PROCEDURES

  • Consider if no improvement after 3 months conservative care.
  • Surgery corrects anatomy: bunionectomy, osteotomy, arthrodesis.
  • Direct plantar plate repair + Weil osteotomy improves alignment and function.
  • Morton neurectomy or ultrasound-guided alcohol ablation for Morton neuroma.
  • Callus removal generally not recommended.
  • Surgery as last resort if no anatomic abnormalities.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Magnetic insoles ineffective for chronic nonspecific foot pain.

ONGOING CARE

  • Patients usually admitted only for surgery.
  • Monitor and re-evaluate if symptoms persist beyond 3 months or stress fracture ruled out.

PATIENT EDUCATION

  • Wear proper shoes, low heels, wide toe box.
  • Gradual return to activity and cross-training.
  • Goal: restore foot biomechanics, reduce abnormal pressure, relieve pain.

PROGNOSIS

  • Depends on severity and surgical intervention need.

COMPLICATIONS

  • Back, knee, hip pain from altered gait.
  • Transfer metatarsalgia post-surgery shifting stress to other foot areas.

REFERENCES

  1. DiPreta JA. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Med Clin North Am. 2014;98(2):233-251.
  2. Besse JL. Metatarsalgia. Orthop Traumatol Surg Res. 2017;103(1S):S29-S39.
  3. Musson RE, Sawhney JS, Lamb L, et al. Ultrasound guided alcohol ablation of Morton's neuroma. Foot Ankle Int. 2012;33(3):196-201.
  4. Espinosa N, Brodsky JW, Maceira E. Metatarsalgia. J Am Acad Orthop Surg. 2010;18(8):474-485.

ICD10 Codes

  • M77.40 Metatarsalgia, unspecified foot
  • G57.60 Lesion of plantar nerve, unspecified lower limb
  • M77.42 Metatarsalgia, left foot

Clinical Pearls

  • Metatarsalgia is plantar forefoot pain near metatarsal heads, common in high-impact athletes.
  • Patients describe “walking with a pebble in the shoe”.
  • Pain worsens in midstance and propulsion phases.
  • Most common physical finding is point tenderness over plantar metatarsal heads.
  • Treatment is typically conservative: rest, ice, activity modification, padding.
  • Pregnant patients should wear properly fitted, low-heeled shoes to reduce incidence.