Forefoot pain most often occurs from injury or in runners.

Metatarsalgia is a collective term for pain in the metatarsophalangeal joints. This condition is observed quite often in clinical practice. In severe cases, deformity and pain can significantly impair walking function and reduce quality of life.

The most common symptoms include:

Pain in the interdigital spaces (Morton's neuroma).
Pain in the metatarsophalangeal joints.
Sesamoiditis.
Atrophy of the subcutaneous fat pad in the area of the metatarsal heads, which is usually associated with aging.

Metatarsalgia is often accompanied by the formation of calluses over bony prominences, with increased sensitivity and pain to pressure around the callus.

Clinically Relevant Anatomy

Anatomy of the foot

When considering the clinical anatomy of metatarsalgia, the forefoot and metatarsal bones deserve the most attention.

Metatarsals

Consist of a proximal base, neck and head.
They connect proximally with the tarsal bones, and distally with the phalanges of the fingers.
Numbered from I to V, starting from the medial side.
Convex on the dorsal surface of the foot, and concave on the plantar surface.
Along with other bones, they form the arches of the feet, which are necessary both when walking and when carrying heavy objects.

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The joints between the metatarsal heads and the corresponding proximal phalanges are called metatarsophalangeal joints.

These joints form the front support of the foot, and the ability to move on these joints is very important for normal walking.
In addition, the bases of the metatarsal bones articulate with each other, forming intermetatarsal joints.

Metatarsalgia

Metatarsalgia is a general term for pain in the metatarsophalangeal joints. Often observed in clinical practice, deformity and pain can impair gait and reduce quality of life [2].

The most common reasons include:

Interdigital nerve pain (Morton's neuroma)
Pain in the metatarsophalangeal joint
Sesamoiditis
Atrophy of the submetatarsal head fat pad, usually associated with aging [3]

Metatarsalgias are often accompanied by excessive callus formation over the bony prominence, with severe pain and pressure sensitivity around the callus [4][5].

Clinically Relevant Anatomy

The most important and relevant anatomy is the forefoot and metatarsal bone. The metatarsal of the foot consists of five long bones called metatarsals.

Metatarsals:

Consists of: proximal base; shaft; distal head.
It is connected proximally to the tarsal bones and distally to the phalanges.
Named I to V from medial to lateral, along the dorsal surface of the foot.
Convex on their dorsal surfaces, but concave on their plantar surfaces
Along with the tarsals, they help form the arches of the foot, which are necessary both when leaning on the leg and when walking [6].

The joints between the metatarsal heads and the corresponding proximal phalanges are called metatarsophalangeal joints (MTP joints).

These joints form the ball of the foot, and the ability to move at these joints is very important for normal walking.
In addition, the bases of the metatarsal bones articulate with each other, forming intermetatarsal joints [6].

Etiology

Common reasons include:

Overtraining
Interdigital (Morton's) neuroma
Freiberg violation
Stress fractures involving the foot
Intermetatarsal bursitis
Adventitial bursitis
Inflammatory and degenerative arthritis
Synovitis/capsulitis of the metatarsophalangeal joint
Tendinosis/tenosynovitis
Tears/tears of the plantar plate
Schwannoma [7]
Pes cavus or highly arched foot
Excessive foot pronation
Clawed or hammertoes
Tight toe extensor tendons
Prominent metatarsal heads
Morton's foot—shortened first metatarsal bone, resulting in an abnormal subtalar joint and increased load through the second metatarsophalangeal joint [8].

Causes

There may be several causative factors. Often localized on the first metatarsal head. The next most common site of metatarsal head pain is under the second metatarsal [5][9][10].

Factors that can cause excessive pressure are:

Participating in high-impact activities without proper footwear and/or orthotics
Old age, as the ball of the foot tends to thin out, making it much more susceptible to pressure and pain
Imbalance in metatarsal length
Most appear to be associated with foot and ankle deformities
Gait disorders
Foot morphology (eg, increased length of bone that protrudes into the bottom of the foot)
Shortened Achilles tendon

Subspecies

Primary metatarsalgia refers to symptoms resulting from congenital anomalies of the patient's anatomy, resulting in overload of the affected metatarsal bone [11].
Secondary metatarsalgia can be caused by systemic diseases such as arthritis of the metatarsophalangeal joint.
Iatrogenic metatarsalgia can occur after (failed) reconstructive surgery.

Characteristics/clinical presentation

Metatarsalgia most often occurs as a result of misalignment of the articular surfaces with altered biomechanics of the foot, which can cause

Joint subluxations,
Tears of the flexor plates (the fibrocartilaginous structure that lies directly plantar to the heads of the lesser metatarsals and acts as a sesamoid mechanism for each smaller joint of the foot[12])
Pain increases during mid-stance and gait, when body weight shifts forward onto the forefoot [13].
Capsular impingement
Destruction of articular cartilage (osteoarthritis).
Impingement of the synovium of the joints with minimal, if any, swelling (osteoarthritic synovitis).
Subluxation of the metatarsophalangeal joint - May occur as a result of chronic inflammatory arthropathy, especially rheumatoid arthritis (RA).
Pain in the metatarsophalangeal joint - a feeling of heaviness and stiffness in the morning.
Loss of the metatarsal fat pad (usually cushioning the tension between the metatarsals and interdigital nerves during walking) tends to move distally under the toes, causing interdigital neuralgia/Morton's neuroma.
To compensate for the loss of shock absorption, adventitial calluses and bursae may develop.
Coexisting rheumatoid nodules under or near the plantar metatarsal heads may increase pain. The 2nd metatarsophalangeal joint is most often affected.
Typically, inadequate function of the 1st ray (1st cuneiform and 1st metatarsal) results from excessive pronation (the leg rotates inward and the rear of the foot rotates outward or everts), often leading to capsulitis and toe deformity.
Overactivity of the anterior calf muscles in patients with pes cavus (high arch) and ankle equinus deformities (short Achilles tendon that limits ankle flexion) typically causes subluxation of the dorsal abducted toe joints and retrograde, increased pressure on the submetatarsal headache and pain [3].

Pain in the metatarsophalangeal joint can also be a result of functional hallux limitus.

Limits passive and active joint movement in the 1st metatarsophalangeal joint.
Patients usually have problems with pronation of the foot, which leads to elevation of the 1st ray with lowering of the medial longitudinal arch during load transfer.
As a result of the elevation of the 1st ray, the proximal phalanx of the big toe cannot rest freely on the head of the 1st metatarsal; As a result, pinching in the dorsal joint leads to osteoarthritis changes and loss of joint mobility (pain may develop over time).

Another cause of 1st MTP joint pain due to limited motion is direct trauma with hip flexor stenosis, usually occurring in the tarsal tunnel. If the pain is chronic, the joint may become less mobile due to arthrosis (hallux rigidus), which can be debilitating.
Acute arthritis can occur secondary to systemic arthritis such as gout, RA and spondyloarthropathy [3].

Differential diagnosis

Plantar fasciitis
Morton's toe
Systemic arthritis

Diagnostic procedures

Mainly clinical assessment
Rule out infection or arthropathy if signs of inflammation are present
To distinguish one diagnosis from another, the patient's medical history, physical examination, radiographs, cholesterol crystal force plate analysis, intra-articular/digital injections, and additional laboratory tests (electromyography, arteriograms, venograms, etc.) can be used [14].
Radiographic interventions may be performed to assess the extent of joint degeneration.

Treatment

Orthopedic products:

Foot orthoses with metatarsal pads can help redistribute and relieve pressure from non-inflamed joints.
When there is excessive subtalar eversion or when the feet are severely arched, an orthotic to correct these abnormalities should be prescribed.
Shoes with sole modifications may also help.
For functional hallux limitus, modifications to the orthosis may additionally help flex the 1st ray to improve MTP joint motion and reduce pain.
If the 1st beam height cannot be reduced using these means, the extended 1st beam height panel may be useful.
More severe limitation of motion or pain in the 1st metatarsophalangeal joint may require the use of rigid orthoses, carbon fiber plates, or external pads or rocker soles to reduce joint motion [3].

Surgery may be required if conservative therapy is ineffective. If inflammation (synovitis) is present, an injection of a local corticosteroid/anesthetic mixture may be helpful.

NSAIDs are most often used to relieve mild to moderate pain. But you should use the right shoes [9].

Physiotherapy

These disorders are usually treated with physical therapy before surgery.

Physiotherapeutic procedures include education, orthoses and corrective shoes, stretching of certain muscles of the lower extremities, and small exercises to strengthen the feet.

Education

After initially reducing or stopping the exercise, replace it with an exercise that does not involve stress on the leg, for example, running in the pool, riding a bicycle.
Pause your workout until the pain begins to subside
Once the patient is ready to exercise/walk again, avoid future injury by teaching him to wear appropriate footwear
Relieve pain and apply ice packs to the area (pain relievers that contain anti-inflammatory agents to help reduce swelling). Swelling can also be reduced by elevating your legs.

Orthoses

A metatarsal pad made of rubber, polyurethane, or silicone can be used to relieve symptoms.
The pad relieves pressure under painful metatarsal heads, spreading it over a larger area, improving functionality.
The optimal method is to place a metatarsal pad only proximal to the metatarsal head. It also elevates the horizontal arch of the forefoot, which can expand the space between the metatarsal heads, reducing compression and irritation of the interdigital nerves [2].
Using a metatarsal bar or forefoot pad is also effective in combating metatarsalgia
In a double-blind study, experienced physical therapists applied teardrop-shaped polyurethane metatarsal pads to a total of 18 feet. The result was a significant reduction in maximum peak pressure and pressure time intervals during exercise, which correlated with improved pain and functional outcomes [5].
Accommodative insoles can redistribute pressure under the foot, while functional orthoses are designed to control abnormal intersegmental movements [17].

Stretching

A stretching regimen is fundamental to recovery (helps relieve pain).
Gajdosic et al. demonstrated that a 6-week stretching program increased maximum ankle dorsiflexion angle and length extensibility, and improved dynamic passive length and passive resistive properties [18]. The most important areas to focus on are the calves, Achilles tendons, ankles and toes. Below are five recommended stretches.
Stretch your calves and stand at arm's length from a wall with your hands on it. Step forward with one foot, placing your back heel on the floor and straightening your knee. Hold the stretch for 30-60 seconds before switching your legs to the Achilles stretch. Stand on the step with your heels dangling over the edge. Slowly lower your heels until you feel a stretch and hold for a few seconds. Raise your heels back so they are level with the step. Repeat.
Ankle extension. Sit in a chair and cross your injured leg over your knee. Hold your ankle with the hand on the same side and your toes with the opposite hand. Pull your toes toward you until you feel discomfort (but not pain). Hold for 5-10 seconds. Bend your ankle again and sit in a chair with your injured leg resting on your knee. This time, hold your ankle with your hand on the opposite side and your toes with your hand on the same side. Pull your toes towards you until you feel discomfort. Hold for 5-10 seconds.

Strengthening – Strengthening key muscles that can help prevent metatarsalgia. Yoo et al. found - After mild foot training for 2 weeks, pain threshold pressure increased from 1 to 1.5 kg, while peak contact pressure decreased from 0.63 to 0.50 kg/cm2 and navicular drop improved from 5 to 8 mm [19].

Leg Towel Twist: Stand barefoot, one foot forward, standing on a towel. Maintain a slight bend in the leg that touches the towel. Use your toes to scrunch up the towel, making sure to keep the rest of your foot off the ground. Perform 3 sets of 15 repetitions per leg.

Electrotherapeutic techniques such as icing, ultrasound, or interference therapy may also help reduce pain and inflammation during the initial stages of treatment [20].
Sometimes, in very specific cases, infiltration that follows taping for several weeks provides some relief [5].

Concluding remarks

Metatarsalgia is a condition in which the ball of the foot becomes painful and inflamed.
Causes include running and jumping activities, foot deformities, and shoes that are too tight or too loose.
In general, not serious

Conservative measures such as ice and rest often relieve symptoms. Wearing proper shoes with shock-absorbing insoles or orthoses can prevent or minimize future problems with metatarsalgia.

Sources

https://greenbayacupuncture.co/2017/05/17/metatarsalgia-forefoot-pain/
Park CH, Chang MC. Forefoot disorders and conservative treatment. Yeungnam University Journal of Medicine. 2019 May;36(2):92.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784640/ (last accessed 25.6.2020)
Mercks manual. MTP joint pain Available from: https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/foot-and-ankle-disorders/metatarsophalangeal-joint-pain (last accessed 6/25/2020)
Doty, Jesse F., and Michael J. Coughlin. "Metatarsophalangeal instability joint of the lesser toys." The Journal of Foot and Ankle Surgery 53.4 (2014): 440-445.
Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8 (2008)
https://www.kenhub.com/en/library/anatomy/metatarsal-bones
Radiopedia Metatarsalgia Available from: https://radiopaedia.org/articles/metatarsalgia (last accessed 25.6.2020)
Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders.” Physical Therapy 66(6): 970-2; July 1986
Sobel Ellen, DPM, Ph. D., C.P.E.D. and Levitz Steven, DPM; “Metatarsalgia: Diagnosis and Manangement, Etiologies and Differential diagnoses.” Podiatry Management
Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8 (2008)
Podiatry today Understanding PP injuries Available from: https://www.podiatrytoday.com/understanding-biomechanics-plantar-plate-injuries (last accessed 25.6.2020)
G. McPoil Thomas and Schuit Dale. “Management of metatarsalgia secondary to biomechanical disorders.” Physical Therapy 66(6): 970-2; July 1986
J Bone Joint Surg Am. 1980 Jul;62(5):723-32. Scranton PE Jr; Metatarsalgia: diagnosis and treatment
Martinez, Bruna Reclusa, et al. Validity and reliability of the Foot Function Index (FFI) questionnaire Brazilian-Portuguese version. 2021.
Haque, Syed, et al. Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia. Foot & Ankle International. 2015.
Espinosa, Norman, Ernesto Maceira, and Mark S. Myerson. "Current concept review: metatarsalgia." Foot & ankle international 29.8
Gajdosik, R.L., et al., A stretching program increases the dynamic passive length and passive resistive properties of the calf muscle-tendon unit of unconditioned younger women. Eur J Appl Physiol.
Yoo WG. Effect of the Intrinsic Foot Muscle Exercise Combined with Interphalangeal Flexion Exercise on Metatarsalgia with Morton's Toe. Journal of physical therapy science. 2014;26(12):1997-8. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273076/ (last accessed 25.6.2020)
enertor metatarsalgia exercises Available from: https://enertor.com/blogs/injury-prevention-and-advice/metatarsalgia-exercises (last accessed 25.6.2020)

Etiology

The most common reasons include:

Overtraining.
Interdigital Morton's neuroma.
Keller-Freiberg disease.
Stress fractures of the foot bones.
Intermetarsal bursitis.
Adventitial bursitis.
Inflammatory and degenerative arthritis.
Synovitis/capsulitis of the metatarsophalangeal joint.
Tendinosis/tenosynovitis.
Damage to the plantar fascia.
Schwannoma.
Pes cavus or hollow foot.
Excessive pronation of the foot.
Clawed or hammertoes.
Tight toe extensor tendons.
Protruding metatarsal heads.
Morton's Foot - Shortening of the first metatarsal leads to abnormal functioning of the subtalar joint and increased weight bearing on the second metatarsophalangeal joint.

Causes

There may be several causative factors. The pathological process is often localized in the area of the first metatarsal head. The next most common location is in the area of the second metatarsal.

Factors that can cause excessive pressure are:

Participating in high impact sports activities without proper footwear and/or orthotics.
Old age, because The plantar fat pad tends to thin out, making it much more susceptible to pressure and pain.
Imbalance in the length of the metatarsals.
Most cases appear to be associated with foot and ankle deformities.
Walking disorder.
Foot morphology (eg, increased metatarsal length).
Shortened Achilles tendon.

Subtypes of metatarsalgia

Primary metatarsalgia refers to cases that arise as a result of congenital abnormalities in the anatomy of the patient's foot, resulting in overload of the affected metatarsal bone.
Secondly, metatarsalgia can be caused by systemic diseases such as arthritis of the metatarsophalangeal joint.
Iatrogenic metatarsalgia can occur after (failed) reconstructive surgery.

Main features of the disease.

Metatarsalgia is a pain syndrome that is localized in the forefoot. Plantalgia, in turn, is pain that can be localized in any part of it. This terminology is applicable in situations where the doctor describes the patient’s condition, but the clinical picture is not completely clear. The term “metatarsalgia” itself is rarely used if a diagnosis has already been made and a specific treatment plan has been prescribed. Diagnosing pain in this area can be difficult even for an experienced specialist. Many diseases are accompanied by similar pain.

For example, there is “painful heel syndrome,” which can be observed in the following diseases:

Gout;
Rheumatoid arthritis;
Complications after compression fractures;
Lupus erythematosus.

When making a diagnosis, the doctor must correctly collect anamnesis, as well as conduct appropriate tests and reactions. To cure metatarsalgia, first of all, it is necessary to identify the substrate that provokes the appearance of pain. It is the lack of targeted therapy and uncertainty of etiology that become the root cause of treatment failures. Even radiography does not always clear up the picture. Thus, to determine the causes, it will be necessary to conduct analyzes of the nature of the pain, which may be limited to specific areas (for most diseases it is common to manifest themselves in strictly defined places corresponding to the focus of the pathology). With this approach, the diagnosis, which is based on palpation studies, clarifies the root cause of the syndrome.

Treatment

Orthotics

Foot orthoses with metatarsal pads can help redistribute the load and relieve pressure on non-inflamed joints.
If there is excessive eversion in the subtalar joint or with a high arch of the foot, an orthosis should be prescribed to correct these anomalies.
In functional hallux limitus, modifications to the orthosis can additionally promote plantar flexion of the 1st ray, which is necessary to improve motion at the metatarsophalangeal joint and reduce pain.
If 1st ray elevation cannot be reduced with these measures, an extended 1st ray elevation pad may help.
If the 1st MTP joint is more limited in motion or has severe pain, it may be necessary to use rigid orthoses, carbon fiber plates, or “rocker soles” to reduce motion in the joint.
If conservative treatment methods are ineffective, surgery may be required. If inflammation (synovitis) is present, local administration of a mixture of corticosteroids and anesthetics may be helpful.
NSAIDs are most often used to relieve mild to moderate pain.

Physical therapy

Valgus foot.
How to get rid of it? Exercises. Georgy Temichev Conservative treatment should precede surgical intervention.

Physiotherapy treatments include education, the use of orthoses and corrective shoes, stretching of specific muscles of the lower extremities, and exercises to strengthen the foot.

Education

First of all, reduce or stop physical activity, replace it with exercises that do not involve lifting weights, for example, running in the pool, cycling.
Pause your workouts until the pain begins to subside.
Pain relief and applying ice packs to the affected area (pain relievers containing anti-inflammatory agents help reduce swelling). Swelling can also be reduced by elevating your legs.

Orthotics

A metatarsal pad made of rubber, polyurethane, or silicone can be used to relieve symptoms.
This will relieve pressure under the painful metatarsal heads, distributing it over a larger area, thereby improving functionality.
The optimal method is to place the metatarsal pad just proximal to the metatarsal heads. It also allows the horizontal arch of the forefoot to be raised, which can expand the space between the metatarsal heads, reducing compression and irritation of the interdigital nerves.
In a double-blind study, teardrop-shaped polyurethane metatarsal pads were applied to a total of 18 feet. The result was a significant reduction in maximum peak pressure and pressure time intervals during exercise, which correlated with improvements in pain and functional scores.
Accommodative insoles can redistribute pressure under the foot, and functional orthoses are designed to control abnormal intersegmental motion.

Stretch marks

Stretching is fundamental to recovery because it helps relieve pain.
Gajdosic et al. demonstrated that a 6-week stretching program increased maximum ankle dorsiflexion angle and ankle mobility. The most important areas to focus on are the calf muscles, Achilles tendon, ankle and toes. Below are five recommended stretches. Stretching for the calf muscles. Stand at arm's length from a wall with your palms on it. Step forward with one foot, keeping the heel of your “back” foot on the floor, keeping your knee straight. Hold this position for 30-60 seconds, then switch legs
Achilles tendon stretch. Stand on the step with your heels hanging over the edge. Slowly lower your heels until you feel a stretch, holding this position for a few seconds. Lift your heels up until they are level with the step.
Extension of the ankle joint. Sit on a chair and place your injured leg over the knee of your other leg. Grasp the ankle joint with one (same side) hand, and the toes with the other (opposite) hand. Pull your toes towards you until you feel discomfort (but not pain). Hold this position for 5-10 seconds.
Flexion of the ankle joint. Sit back in the chair with your injured leg over the knee of your other leg. This time, hold your ankle with your opposite hand and your toes with your opposite hand. Pull your toes down until discomfort appears. Hold this position for 5-10 seconds.

Strengthening

Yoo et al. found that after performing small foot muscle exercises for 2 weeks, pain threshold pressure increased from 1 to 1.5 kg, peak contact pressure decreased from 0.63 to 0.50 kg/cm2, and navicular drop improved from 5 to 8 mm.

Rolling a towel into a tube. Stand barefoot with your foot on a towel. Twist the towel with your fingers, making sure to keep the rest of your foot flat on the floor. Perform 3 sets of 15 crossings on each foot.

Physiotherapeutic effects

Treatment modalities such as cryotherapy, ultrasound, or interference therapy may be useful in reducing pain and inflammation during the initial stages of treatment.

Sometimes, in very specific cases, infiltration followed by taping for several weeks brings some relief.

Diagnosis of metatarsalgia.

The diagnostic procedure includes the following steps:

1. Consultation with a doctor, taking an anamnesis and tests.
2. Radiography.
3. Magnetic resonance imaging (for example, to diagnose sciatica, an MRI of the spine is done).

Treatment can be either conservative, medicinal or surgical (depending on the type and degree of development). For certain joint problems, arthroscopy is prescribed. This is a minimally invasive intervention in which a large incision is not made - the doctor makes two small holes, an arthroscope is inserted through one, and surgical instruments are inserted through the other. Diagnostics and surgery are carried out simultaneously. Foot treatment often includes wearing insoles, physiotherapeutic procedures, massages, and exercise therapy.

For more detailed advice, please contact our clinic.