Metatarsalgia

The term ‘metatarsalgia’ refers to pain in the sole of the foot. This can be associated with swelling and/or numbness depending on the cause.

The sole of the foot is formed by the long metatarsal bones in the foot meeting the toes. The ends, or ‘heads’ of the metatarsal bones are vulnerable because they carry so much weight and pressure during walking and running.

There are many causes of metatarsalgia including stress fractures, Morton’s Neuroma, Sesamoiditis and forms of arthritis.

Metatarsalgia is usually effectively treated with a combination of rest, orthotics (modified shoes) and physiotherapy. In more prolonged cases of metatarsalgia, steroid injections can help relieve inflammation and pain. Very rarely, surgery is required to relieve pain.

Symptoms

Metatarsalgia causes pain in the ball of the foot, often in both feet simultaneously. This pain usually develops over time, occurring initially with only high-impact activities, then with walking and finally most of the time.

If the metatarsalgia is caused by Morton’s Neuroma there may also be numbness in the toes.

Causes

There are a number of causes of pain in the ball of the foot, including

  • Stress fractures of the metatarsal head – this may be due to weak bones (osteoporosis) or through playing high-impact sports and dance.
    • Occasionally, the metatarsal head may be cut off from its blood supply and undergo avascular necrosis, or bone death. This is a rare cause of metatarsalgia.
  • Morton’s Neuroma
  • Sesamoiditis – inflammation in tendons that run under the sole of the foot and surround the small disc-shaped sesamoid bones
  • Loss of the fat pad that protects the ball of the foot. This occurs with age.
  • Inflammation in the metatarsal-phalangeal joints (synovitis) and arthritis, in particular rheumatoid and psoriatic arthritis.
  • Inflammation or irritation in other structures around the bones, for example bursitis.

Feet that have some abnormality (for example, high arches) that increases the strain placed on the metatarsal region are more likely to develop pain even when the above causes are absent.

Risk Factors

Metatarsalgia tends to be more common in:

  • People who play high-impact sports, especially those with lots of running, or activities like ballet that put a lot of strain on the forefoot
  • Being overweight can increase the strain placed on your feet
  • People who have other problems in their feet, including
    • A tight Achilles tendon
    • High arches (see Pes Cavus)
    • Toe deformities (eg Hammertoe, bunions) or very flexible toes
    • Previous surgery in the foot that has affected the way stresses are distributed through the bones
  • Wearing poor shoes, especially high-heeled shoes can drastically increase the strain placed on the soles of the feet

Investigations

Your doctor or surgeon will need to examine your foot to establish the site of pain. After this your doctor may order:

  • X-Rays. It’s important to understand that stress fractures can be very subtle and difficult to see on X-Ray. Your doctor may therefore need you to have a number of X-Rays taken at different times to make sure stress fractures are not overlooked.
  • Blood tests. Conditions like rheumatoid arthritis, gout and osteomyelitis can have similar symptoms to the other causes of metatarsalgia, so your doctor may need to order blood tests to exclude these diseases.
  • Bone scan. Specialists will sometimes order a bone scan to look for subtle fractures in the bones.
  • More sophisticated forms of imaging, like MRI scans can sometimes be used but are usually not necessary.

Complications

Treatment

Metatarsalgia is almost always treated successfully with a combination of physical therapies, orthotics and basic foot care.

The pain and irritation of metatarsalgia can usually be well controlled with simple measures like:

  • Rest, Ice, Compression and Elevation. Limiting those activities that put strain on your forefoot is very important in controlling metatarsalgia. Ice can be applied for 20 minutes at a time to help reduce swelling and pain. Keeping you foot elevated when you’re sitting down and sleeping can also help control pain.
  • Over the counter anti-inflammatory medications like ibuprofen are also very effective.
  • Weight loss reduces the forces acting through your feet and can improve symptoms of metatarsalgia

When this fails to work, you can start trying modified footwear. This may include:

  • Well-padded shoes, or inserting padding that protects the soles.
    • Most chemists will sell padding or gel pads that sit beneath the sole of the foot and protect the metatarsal heads.
  • Shoes with a wide toe-box
  • Orthotics – an orthotist can prescribe the type of orthotic you need. This may involve a full length insert that cushions the sole of your foot.

Physiotherapy

Physiotherapists can prescribe a series of exercises that strengthen the muscles acting around the foot. Getting these muscles to ‘balance’ correctly can improve the distribution of forces through the ball of the foot during activities like walking and running.

Surgery

When the above non-surgical methods fail to control the symptoms of metatarsalgia, surgery can be considered. This may involve:

  • Osteotomy – reshaping the bones to reduce the pressure on the metatarsal heads.
  • Fusion of the metatarsals and toes. This is usually only recommmended when deformity of the toes (like Hammertoe) is the cause of the metatarsalgia.

Risks of having these surgeries include:

  • Stiffness of the forefoot and/or toes
  • Numbness or tingling
  • The usual risks of surgery, including bleeding, infection and blood clots (CVT)

As these forms of surgery are minimally invasive, the risks of major complications are rare. However, you should discuss this in detail with your surgeon.

Recovery from the operation is usually fairly rapid, and most people are back to their normal activities after 6 weeks. You may require rehabilitation physiotherapy to regain the strength and flexibility in your leg and foot.

Seeking Advice

If you have persistent pain in the ball of your foot that does not get better with rest and basic treatments you should see your local healthcare provider.

Your Family Doctor (GP)

Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to

  • tell you about your problem
  • advise you of the best treatment methods
  • prescribe you medications
  • and if necessary, refer you to Specialists (Consultants) for further treatment

Prevention

You can prevent metatarsalgia by maintaining a healthy weight and avoiding shoes that place excessive pressure on the metatarsal heads, especially high-heeled shoes.

F.A.Q. | Frequently Asked Questions

When should I have surgery?

You will need to think about this carefully and discuss this with your family and friends as well as your doctors. Usually, surgery is only recommended when your symptoms are significantly impacting on your life.

If I have surgery, when can I return to work? When can i return to sports?

This varies and depends on both how you feel and your job. If you are able to remain seated with your leg elevated you can return to work very quickly, often within a fortnight of your operation. Otherwise, you may need more time.

You will need to discuss your return to sports with your physiotherapists. As frustrating as it can be to stay away from your usually activities, it is crucial to your recovery that you do not force your foot beyond what it can tolerate. Usually, you can return to sports within two to three months of your surgery.

When can I return to driving?

You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery. Your insurance company must be notified regarding the type of operation that you have undergone to ensure that cover is valid.

References

Durham, B. A., ‘Metatarsalgia’, Medscape Reference, URL: http://emedicine.medscape.com/article/85864-overview, accessed 26-09-2011.

Jenkin W.M., Chapter 7. Approach to the Patient with Ankle & Foot Pain, CURRENT Rheumatology Diagnosis & Treatment, 2e, 2011, Retrieved September 26, 2011 from http://www.accessmedicine.com.ezp.lib.unimelb.edu.au/content.aspx?aID=2730691.

Mann J.A., et al., Chapter 9. Foot & Ankle Surgery, CURRENT Diagnosis & Treatment in Orthopedics, 4e., H.B. Skinner (Ed), Retrieved September 26, 2011 from http://www.accessmedicine.com.ezp.lib.unimelb.edu.au/content.aspx?aID=2321540.