A Look at Metatarsalgia from Your Middletown Podiatrist

Metatarsalgia is a term that is used for any pain or inflammatory process that occurs across the ball of the foot. It can occur in one specific area, or across the entire ball of the foot. Metatarsalgia is a very non-specific term, and many different disease processes can cause pain in the foot. The following is a brief list of the different causes of Metatarsalgia.

If the pain is under the first metatarsal phalangeal joint (big toe), the problem could be sesamoiditis. Sesamoiditis is inflammation in and around the two small bones that are positioned just beneath the long bone that leads to the toe. There are many causes of this, including fracture of a sesamoid, "turf toe" (hyperextension or flexion of the first metatarsal phalangeal joint), gout or a bunion deformity. Any of these disease processes can cause pain under the big toe joint.

Sesamoiditis usually can be treated conservatively. That is, without surgery. The treatment can consist of non-weight bearing to the area with the use of crutches or a walker, weight bearing in a removable cast boot (CAM walker), or walking in a stiff soled shoe, such as a sneaker or surgical shoe. Anti-inflammatory medication, such as Motrin or Aleve can also be beneficial. These medications must be used judiciously, as they can cause stomach upset or even bleeding within the stomach if taken in large doses or over a prolonged period of time.

Turf toe is hyperextension or hyperflexion of the first metatarsal phalangeal joint. This commonly happens when there is forced movement of the toe against a relatively stiff surface. Soccer and football players have this injury most often when playing in cleats on Astroturf. The forced flexion or extension of the toe against the immovable Astroturf causes inflammation to the joint, which in turn causes pain. If the flexion or extension force is great enough, the capsule surrounding the first metatarsal phalangeal joint can actually tear. If the capsule tears, there will be swelling and some redness around the area, and the person will not be able to bear weight on the affected toe. The treatment for a partial tear of the capsule, or just an inflammatory response to the injury, is the same; non-weight bearing in a cast with crutches or a walker, or limited weight bearing in a cast boot. Anti-inflammatory medications are also indicated in this disease process. Again, caution must be observed when taking these medications. RICE protocol (rest, ice, compression and elevation) should also be used when turf toe is diagnosed. Ice should be applied to the area 20 minutes each hour while awake. Sitting with the affected foot elevated above the level of the heart will limit the amount of swelling, which will in turn limit the amount of pain. Turf toe is very rarely a surgical diagnosis.

Fracture of a sesamoid must be differentiated from a bipartite sesamoid. A certain percentage of the population is born with sesamoids (bones under the big toe) that are in several different pieces. Generally, this is a very benign process that is diagnosed on an x-ray when looking for another problem. However, a fracture of a sesamoid is very painful and does cause swelling and redness with a possible ecchymotic area (black and blue). A bipartite sesamoid can be distinguished from a fractured sesamoid in that a bipartite sesamoid generally has pieces that when added together will be larger than a normal sesamoid. The line on the x-ray that can be thought of as a fracture line is smooth and regular where as in a fracture the line is irregular and jagged. In general, a sesamoid fracture is first treated with cast immobilization and non-weight bearing to the foot. If the bones do not heal, surgery can be performed. This is generally accomplished using a very small screw though the pieces of the bone to hold it in the proper position, followed by casting and non-weight bearing.

Gout is a systemic disease where small crystals of uric acid form in the blood and are deposited in joints around the body. The most common site of deposition is the first metatarsal phalangeal joint. The joint becomes painful, red, hot and swollen. This does mimic infection, and care must be taken to distinguish the two entities. Gout can be diagnosed by aspiration of the joint and sending the fluid to the lab for identification of crystals. The second most common site of gout is in the ankle joint. If the patient has no site of infection, the white blood cell count is not elevated, but the first metatarsal phalangeal joint is erythematous and edematous, gout must be considered. Since this is mainly an inflammatory response to the deposition of crystals, the main treatment is anti-inflammatory in nature. This consists of an NSAID type medication such as Motrin or Aleve, and a corticosteroid. The steroid can be injected into the joint, or given by mouth in the form of a prednisone taper or Medrol dose pack. The patient must be warned that once they have had a gout attack, that they have increased odds of having another attack.

A bunion deformity, or hallux abducto valgus, is an increase in the angle between the first and second metatarsals with a bump forming on the medial (inside) of the foot. The hallux (big toe) starts to drift laterally (towards the second toe) and can actually ride next to, above or below the second to is severe cases. Bunions can cause pain and trouble finding shoes that fit. Once a bunion forms, there is little conservative therapy can do to reverse the problem. Wearing wider shoes, some orthotics and some splints may help, but generally this is not the case. The surgical correction of the bunion usually involves the cutting and shifting of the metatarsal into a lateral position and fixating it with screws or wires. This surgery is one of the most common podiatric procedures and generally has very good outcomes.

Pain under the second toe of the foot can be caused by a neuroma, a plantar plate rupture, dislocation of the toe, fracture of the bone or Freiberg's infraction. All of these disease processes can cause pain under the second toe, and be termed metatarsalgia.

A neuroma is swelling of a nerve. This in and of itself can cause pain. When the neuroma becomes trapped or swells to the point that it is pressing on surrounding structures, this can cause added pain. Neuromas in the foot most commonly occur in the third interspace and are termed Morton's Neuroma. That is not to say that neuromas can not form any other place. Neuromas can form anywhere there is a nerve, such as the hallux, second toe, second interspace, or site of injury to the nerve. In the last several years, multiple therapy modalities have been developed for treatment of neuromas. This can include injection of steroids into the area in order to reduce the inflammation, injection of sterile alcohol into the neuroma to cause sclerosing (dehydration) of the neuroma which in turn reduces the swelling of the nerve, or surgical excision of the nerve. This involves taking the swollen part of the nerve out. The patient should be warned that the sides of the toes where the neuroma was taken from will be numb. Nerve tissue does not regenerate, and therefore there will be no sensation along the areas where the nerve was removed.

There is a ligament that runs from the medial side of the foot to the lateral side of the foot at the level of the first toe joint. This is called the plantar plate. When abnormal pressure is applied to this plantar plate, it can rupture (tear). When this happens, the area becomes swollen and painful. In addition, this rupture generally occurs at the side of a joint, such as the second metatarsal phalangeal joint. A tear in the joint capsule can cause the toe to start to dislocate in a dorsal direction. That is to say that the toe starts to float off the ground. If severe enough, the toe can completely sublux and ride on the dorsal aspect of the metatarsal bone. If this indeed occurs, the only treatment is surgical correction of the subuluxation.

Stress fractures of the metatarsals is very common, especially in patients who perform repetitive activity, such as running or jogging, or people who are starting a new sport. The fracture is generally in the long bone behind the toe, but can form anywhere along the length of the bone. This can cause referred pain to the joint, and pain plantarly. The area in which the fracture occurred can be edematous and erythematous, with possible ecchymosis (swollen and red with possible black and blue). Treatment of these fractures is non-weight bearing in a cast of cast boot. A bone stimulator may also be employed. There are several different types of bone stimulators, but in general, they cause the bones to heal together at an increased pace. The fractured bones generally heal in 6-8 weeks if the patient can remain non-weight bearing.

Freiberg's infraction is a vascular insult to the bone of second metatarsal. Usually, there is an incident of trauma, which may or may not be remembered, which causes a decrease in blood flow or even a complete lack of blood flow to the end of the metatarsal closest to the toe. When this happens, the articular cartilage at the end of the bone begins to sink into the dead bone. This can cause pain and swelling of the joint. There is usually no ecchymosis associated with this, but a vague, deep sense of joint pain. X-rays are usually beneficial to stage this deformity. This can be minor, with just subchondral sclerosis and a small amount of joint narrowing or expansion, to severe with complete collapse of the head of the metatarsal. Conservative therapy includes non-weight bearing in a cast with the use of crutches or a walker, with or without a bone stimulator. Several surgical procedures have been proposed for correction of this deformity, and each must be reviewed with the patient. It is generally the surgeon's preference when surgical intervention is undertaken.

Pain below the third and fourth toe joint generally has the same causes as discussed above. The fifth metatarsal phalangeal joint has one added deformity to be discussed. A tailor's bunion occurs off the lateral aspect of the fifth metatarsal. This can be an enlargement of the head of the fifth metatarsal, or a bowing of the fifth metatarsal. Either way, there is a prominence off the lateral aspect of the foot. This can cause pain with weight bearing, callus formation on the plantar aspect of the foot and inability to find shoes that are wide enough, especially if there is also a bunion deformity on the medial aspect of the foot. Treatment of this deformity can be conservative (wider shoes, parring of callus) or surgical. Surgical correction can be as simple as a shaving of the bone off the lateral aspect of the head of the metatarsal or a cutting and shifting of the fifth metatarsal into a more corrected position. Generally speaking, if a shave of the bone is performed, and the metatarsal is not moved, the deformity will recur, causing pain and inability to walk without pain.

The above is a very brief synopsis of things that can cause pain under the ball of the foot. This is by no means a complete list, and is not meant to be diagnostic for all foot problems. If you think you have one of the above conditions, please call and make an appointment with your Warwick, Middletown or Fall River podiatrist immediately. Should you need to find a podiatrist in your area, contact the APMA at www.apma.org