What is Metatarsalgia?
Metatarsalgia is a symptom not really a condition and effectively is a term used for any pain in the forefoot. Most frequently it is a term used when that pain affects the area under the smaller four toes, rather than the base of the big toes, or pain over the top of the forefoot, although strictly speaking the term is perfectly valid for these areas too.
The metatarsals are the long bones of the foot that link the smaller bones of the lesser tarsus to the bones of the toes. The term metatarsalgia means metatarsal pain (algia). There are many conditions that can cause metatarsalgia, and because of this we will concentrate on the most common and touch lightly on the rare ones.
How do I know if I have Metatarsalgia?
If you have pain in the forefoot, particularly on the bottom of the forefoot (often called the balls of the feet), there is a very good chance that you have metatarsalgia.
Does the pain feel like any of the following:
Is the pain worse:
Common Metatarsalgia Conditions
Flexor (Plantar) Plate Strain / Capsular stretch
Flexor plate strains seem by far the most common condition to cause metatarsalgia. Symptoms usually start with vague discomfort under the ball of the foot in certain styles of shoes and/or longer walking distances...
Flexor (Plantar) Plate Ruptures / joint capsule tear (Pre Dislocation Syndrome)
Very sudden sharp onset of metatarsalgia is often caused by rupture of the metatarsophalangeal joint tear or rupture of the flexor plate...
Friction and Plantar Callus (or Callous) and Plantar Corns
This is a common problem, which can cause a burning pain on the bottom of the foot. The hardening of skin can cause irritation and pain and is often treated by a chiropodist...
Stress Fractures of the Metatarsals
All load bearing bones of the body can get fatigue fractures, and are therefore commong with metatarsals...
Morton’s Neuroma (Plantar Digital Neurofibroma)
Essentially where a soft tissue nerve becomes trapped - usually in the space between the 3rd and 4th metatarsals and can cause numbness in the toes, burning pains, aching pains or shooting pains...
Distal Plantar Muscle fatigue
If foot muscles become weak, it can lead to aching or burning sensations in the balls of the feet...
This condition produces sharp pain under the ball of the big toes on the push-off phase of walking, or it you rise up on your toes...
Other Rare Conditions
This is an avascular necrosis of the 2nd metatarsal head most commonly occurring in teenage girls. It has also been reported in adults and avascular necrosis can occur in the 3rd and 4th metatarsals too, but extremely rarely. The blood supply to the metatarsal head is disturbed for some reason, and the head of the metatarsal starts to die. It usually resolves in time, but can lead to a deformed joint causing osteoarthritis later.
This condition is common in the big toe joint, but rare in the other metatarso-phalangeal joints, except after previous problems such as Freibergs or a fatigue fracture.
This can commonly present in the lesser metatarsao-phalangeal joints, however it usually affects more than one joint, and often presents in the hands and/or knees at the same time. There is usually swelling and stiffness especially for the first hour or so of the day. These symptoms need to be investigated by your GP via a blood test.
Most common in people with psoriasis, a skin condition, (it can occur without psoriasis) the pain and swelling is more in the toe rather than the ball of the foot. The smaller toes can swell like a little sausage, and is often accompanies with enthesopathies, which are inflammatory problems where tendons and ligaments attach. Achilles tendon and plantar heel pain often accompany the swollen toe, but despite this it can be difficult to diagnose until you’ve seen a rheumatologist and had an MRI.
Cancers are very are in the foot, but can cause pain in the forefoot. The most common seems to be PVNS, a locally destructive cancer of the joint lining. Diagnosis is usually via a process of elimination, including an MRI. It is very rare.
Your Choice of Shoes
You will have noticed we return often to the subject of shoes when discussing metatarsalgia. That is because footwear has a large part to play in the development of most metatarsalgias, but equally important is that it is a difficult condition to treat if the footwear worn each day keeps provoking the problem. The British have a rather unhealthy relationship with their shoes, particular the ladies. Shoes have become a status symbol and an important part of “looking good” and “feeling good” about themselves, especially in the work place. Sadly the shoes picked by society to represent these values are the very ones most likely to damage the forefoot.
Sadly we have a growing epidemic of foot pathology in the UK and choosing the wrong shoe for the task necessary is a large part of the problem
Finding a suitable person to treat your Metatarsalgia
Beware! Many so called professions have no qualification and use a made up title. This means you are about to be treated by someone who is not regulated to practice by law, can not be struck off for mal-practice and may have no medical indemnity insurance, which means if things go wrong you can complain or sue and the person will continue to practice without you having any recourse even if they injury you.
WE STRONGLY RECOMMEND YOU INVESTIGATE ANYONE CALLING THEMSELVES A BIOMECHANICS CONSULTANT or FOOT HEALTH PRACTITIONER.
These professions are not regulated. Do not be impressed by laser scanning of the foot, fancy pressure plates or claims that they make the only foot orthoses (insoles or “orthotics”) that actually work.
Not all regulated professionals are experience in dealing with metatarsalgia, including podiatrists. This may be surprising, but until 2005 podiatry was an unregulated profession except there were rules for who could work in the NHS. As a consequence many podiatrists were only ever exposed to training for cutting toe nails and removing hard skin and today many even recently qualified podiatrists; continue to practice in a way which would be better understood by the term chiropodist. We suggest you ask whether the practitioner knows what a “dorsal or vertical stress test” is for diagnosing metatarsalgia. Anyone without that knowledge is unlikely to be very experienced in dealing with metatarsalgia.
Because the Health Profession Council and the many Podiatry Bodies do not recognise the treatment of metatarsalgia as something needing specialist treatment we cannot give you a national list of people we feel are safe to treat your condition. The best we can do is list those practitioners who have attended our own courses or who have an MSc, Diploma or Certificate in Clinical Podiatric Biomechanics from Staffordshire University and Cardiff.