Metatarsalgia is defined as pain under 1 or more of the metatarsal heads along the plantar aspect of the forefoot. It is the result of anatomic deformity or pathologic conditions of the foot and ankle and can therefore be viewed as more of a symptom rather than a distinct diagnosis. One study evaluating 98 patients with forefoot pain reported 23 distinct diagnoses.1 Because of the numerous etiologies, understanding foot and ankle biomechanics is paramount for successful management. The treatment of metatarsalgia is similar to that of many musculoskeletal conditions, starting with conservative approaches and transitioning to invasive procedures. The objective of this article is to provide a comprehensive review of metatarsalgia, including the various treatment options depending on the etiology.
A thorough history and physical examination are essential for the diagnosis of metatarsalgia. Gait should be examined first to assess for stiffness, deformities (long second metatarsal, claw toe, or hammertoe), or leg-length discrepancies. The shorter leg will compensate with rigid ankle equinus after walking with a significant leg-length discrepancy. This will increase loads on the forefoot and the metatarsal heads during weight bearing.
The foot must be assessed while bearing and not bearing weight, with the examiner looking for flexible or rigid deformities. The overall shape of the foot must be examined for pes planus or cavus. The Silfverskiold test can be used to differentiate tightness in the gastrocnemius alone from tightness in the gastrocnemius combined with the soleus.2 In addition, the neurovascular structures and muscles of the lower extremities must be assessed.
The active and passive range of motion of all joints between the ankle and distal interphalangeal joint must be examined. Each metatarsophalangeal joint space should be palpated to assess position, synovitis, and contracture. Palpable tenderness in the intermetatarsal web space or elicitation of a bursal/Mulder's click may suggest a Morton's neuroma. The stability of the metatarsophalangeal joints in the sagittal and transverse planes must be examined using the mini Lachman test.
The plantar foot must be examined for localized or diffuse patterns of hyperkeratosis. Plantar keratosis under the metatarsal heads that does not extend distally may be due to an elevated first metatarsal, gastrocnemius contracture, or pes cavus. An elevated first metatarsal transfers forces from the first metatarsal onto the second metatarsal, resulting in isolated keratosis underneath the second metatarsal head without distal extension. Pes cavus is responsible for callosities at the middle of the sole and under the first, fourth, and fifth metatarsal heads.3 Hallux valgus and a short first metatarsal leads to plantar keratosis that has an overall round appearance with distal extension.
Weight-bearing anteroposterior, lateral, and oblique views of the foot must be obtained. On evaluation of radiographs, important considerations include hallux deformities, bunion, relative metatarsal length (second ray is, on average, 3.4 mm longer than the first4), arthritis, metatarsophalangeal joint dislocations, and stress fractures. On the lateral view, inclination of the metatarsals should be assessed. When plain radiographs are inconclusive, magnetic resonance imaging can identify early bone abnormalities, such as Freiberg's disease or soft tissue disorders.5 Ultrasound can be a low-cost alternative to evaluate for plantar plate pathology, Morton's neuroma, transverse arch height, sesamoid rotation angle, and metatarsal height.6,7 However, more studies comparing ultrasound with other imaging modalities are needed to confirm its reliability.
Primary metatarsalgia is defined as metatarsal head pain arising from anatomic abnormalities of the metatarsals and their relationships to other parts of the foot.8 The most common causes are first ray insufficiency, a disproportionately long second metatarsal, and increased metatarsal declination.
First Ray Insufficiency
First ray insufficiency occurs due to the inability of the first ray to accept physiologic loads, leading to increased force transfer to the lesser metatarsals. Etiologies include hypermobility of the first metatarsophalangeal joint, hallux valgus, brachymetatarsia, and pes planus. Forefoot pain occurs during the propulsive, or third rocker, phase of gait.8 Findings on physical examination include increased pronation, pain and diffuse callus formation under the second and third metatarsal heads, pain under the second metatarsal base, absence of first metatarsal plantar callus formation, and subluxation or dislocation of the affected metatarsophalangeal joint.9 More specifically, callus formation from third rocker metatarsalgia is not directly under the metatarsal heads, but rather just distal and plantar. External rotation during the final propulsion creates a shear effect that results in a rounded callous appearance that spans several metatarsal heads. This results in a large and diffuse area of hyperkeratosis that extends distally toward the toes. Metatarsophalangeal hypermobility can lead to a second rocker callous formation directly under the metatarsal head within a third rocker callus formation.10 Radiographs may show widening of the second metatarsal shaft with cortical thickening or lesser metatarsal stress fractures due to increased loads.9 An internal oblique view allows better visualization of subluxed or dislocated metatarsophalangeal joints.
Regardless of the etiology of first ray insufficiency, treatment initially begins with a trial of conservative management. Shoe wear modifications are often helpful, including a wider toe box, appropriate length, soft sole, rocker bottom, or metatarsal head padding (placed proximal to the distal head of the affected metatarsal).11 Orthotics with a built in metatarsal bar may be helpful, but they are expensive and there is poor evidence substantiating their use.12 Physical therapy focusing on Achilles and gastrocnemius stretching and strengthening may be useful if patients have equinus contracture or gastrocnemius tightness.
If conservative management fails, surgical modalities may be helpful depending on the exact etiology of first ray insufficiency. In cases of hallux valgus, addressing the deformity may be the only procedure required to offload the lesser metatarsals. Patients with a prominent metatarsal head on physical examination, with or without hammertoe deformities, will likely also require metatarsal osteotomies (distal or proximal).12
Procedures for first ray hypermobility (often associated with hallux valgus) with excessive motion in axial and sagittal planes include tarsometatarsal arthrodesis, exostectomy, capsulorrhaphy, and distal soft tissue releases, which can correct and stabilize the first metatarsal at the apex of the deformity.13 When performing tarsometatarsal arthrodesis, it is crucial to plantarflex the first metatarsal and correct the intermetatarsal angle.
In cases of brachymetatarsia (metatarsal ends 5 mm proximal to the metatarsal arc14,15), the 2 most widely used surgical techniques are a 1-stage lengthening with an interpositional bone graft or gradual lengthening by callotasis (stretching of bone callus).16–19
When lengthening the first metatarsal, it is crucial to monitor the first metatarsophalangeal and interphalangeal joints because patients may develop a hammertoe deformity. If lengthening acutely, it is crucial to monitor the capillary refill of the toe. In fact, excessive lengthening may lead to toe ischemia.
Disproportionately Long Second Metatarsal
The second metatarsal is relatively immobile compared with the more lateral metatarsals and is less accommodating to anatomic variation.8 Pain is encountered during the third rocker, or propulsive, phase of gait. Conservative therapy is the same as that for first ray insufficiency. Surgical modalities include proximal or distal shortening metatarsal osteotomies, or the minimally invasive distal metatarsal metaphyseal osteotomy.4,8 These osteotomies result in proximal translation of the metatarsal, redistributing forefoot pressures during gait.20 When a traditional open shortening is performed, care must be taken to avoid overshortening the metatarsal. This can lead to metatarsalgia of the neighboring metatarsal. If a percutaneous shortening is chosen, the second, third, fourth, and occasionally fifth metatarsals must all be osteotomized to prevent transfer metatarsalgia (Figure 1).
Preoperative weight-bearing anteroposterior radiograph of the foot of a 43-year-old man reporting second and third metatarsalgia and bunion pain (A). Postoperative weight-bearing anteroposterior radiograph showing the realigned first ray. The correction of the bunion alone allowed for complete resolution of the transfer metatarsalgia (B).
Increased Metatarsal Declination
Excessive metatarsal plantarflexion, typically in the setting of a cavus foot, results in increased declination of the affected metatarsal. Pain with heel strike (first rocker metatarsalgia) occurs in cavus feet due to increased pressure on the heel and metatarsal heads in the absence of adequate lateral plantar midfoot support.8 In a cavus foot, physical examination reveals callosities in the middle of the sole and under the first, fourth, and fifth metatarsal heads.3 Standing or static metatarsalgia (second rocker metatarsalgia) results from increased forefoot loading by bringing the affected metatarsal closer to the ground.4 Physical examination is notable for plantar keratosis under the metatarsal heads that do not extend distally.10 Radiographs are notable for increased metatarsal declination (normal range, 15° to 25°). Initial treatment is with shoe wear modifications, metatarsal pads, and orthotics with a lateral heel wedge and a well under the first metatarsal for patients with cavovarus foot alignment. Surgical treatment, which varies depending on the foot alignment, is reserved for patients for whom nonoperative treatment fails. In a flexible cavus foot, the surgeon may have to perform a reconstruction including a gastrocnemius recession, calcaneal osteotomy, peroneus longus to brevis transfer, plantar fasciotomy, dorsiflexion osteotomy of the first metatarsal, and possible posterior tibial tendon transfer.20 Rigid deformities may require a triple arthrodesis or midfoot derotational osteotomy. A mild cavus foot may otherwise be left alone and the metatarsalgia treated with metatarsal osteotomies.
Secondary metatarsalgia is defined as metatarsal head pain arising from indirect overloading of the forefoot.8 Etiologies include equinus deformity, trauma, metabolic disorders, Morton's neuroma, and Freiberg's disease.
Posterior compartment tightness can result in equinus deformity with limited dorsiflexion and shift of loading from the hindfoot to forefoot during the swing phase.21 Etiologies include an isolated gastrocnemius contracture or an Achilles (gastrocnemiussoleus complex) contracture.22 This can be determined using the Silfverskiold test. Initial nonoperative treatment involves stretching exercises. This improves passive resistive properties, tendon length, and maximal dorsiflexion angle.23 For patients who fail to achieve symptomatic relief, surgical options include Achilles tendon lengthening or gastrocnemius recession.24–26
Fractures can be diagnosed by local tenderness on physical examination and identification on radiographs. A metatarsal fracture can displace the distal fragment and cause excessive plantarflexion. This can increase the pressure at the metatarsal head, leading to forefoot pain.8 Treatment involves weight bearing as tolerated in a hard-soled shoe or surgical fixation for more extensive injuries.
Acute trauma can also result in plantar plate rupture, although it is more commonly caused by chronic overloading of the metatarsophalangeal joint.27 The function of the plantar plate at the metatarsophalangeal joint is to prevent dorsal subluxation of the proximal phalanx. Plantar plate injury can lead to joint instability and excess metatarsal head loading.8 Prior history of intra-articular steroid injections can lead to accelerated degeneration of soft tissue and possible rupture of the plantar plate. The drawer test can identify dorsoplantar instability of the metatarsophalangeal joint when dorsiflexed 25° on physical examination.4 Ultrasound or magnetic resonance imaging can assist in identifying plantar plate pathology as a cause of metatarsalgia.6 Conservative treatment consists of metatarsal padding. Surgical management consists of plantar plate repair, with or without metatarsal shortening.27,28
Metatarsalgia may develop in patients with gout and various other chronic inflammatory diseases, including rheumatoid arthritis and psoriasis. These conditions cause chronic synovitis that induces metatarsophalangeal joint hyperextension with distal migration of the plantar fat pad.10 Relevant laboratory values include uric acid, erythrocyte sedimentation rate, rheumatoid factor, and C-reactive protein. Correcting the underlying etiology will usually provide pain relief.
Morton's neuroma is irritation of an intermetatarsal plantar nerve as it passes from the forefoot into the toes. The second and third interdigital nerves are most commonly affected. Pain results from compression or tension of the interdigital nerve around the transverse intermetatarsal ligament, or perineural fibrosis. This disorder is differentiated from other etiologies of metatarsalgia by its location within the metatarsal head interspaces. The presence of sensory disturbances (usually burning) on the plantar web space is helpful for diagnosis. Patients will often report increased pain when wearing shoes, and less pain when barefoot. Mulder's sign is described as a palpable click with pain when one hand is clasped around the metatarsal heads while the thumb of the other hand exerts firm pressure on the sole of the foot at the suspected area.29 The metatarsal approximation/foot squeeze test may also be helpful.
Magnetic resonance imaging or ultrasound should be performed for patients failing nonoperative treatment. A clinically relevant neuroma is at least 10 mm thick. Anything less will unlikely be causing the patient's symptoms.
Nonoperative treatment modalities can reduce nerve irritation, pressure, and inflammation. Shoe modifications include wearing properly sized shoes with a wide toe box. A metatarsal pad can be inserted just proximal to the metatarsal heads to offload the affected interdigital nerve. Local anesthetic injections in the affected space represent a valuable diagnostic tool. The senior author (E.V.) is not in favor of local administration of steroid, given the low success rate and the degenerative effects of steroid on the soft tissues that may compromise future surgical treatment.30–33
Once nonoperative treatment has failed, surgical resection of the neuroma may be indicated. Almost half of patients with a neuroma will require surgical intervention.30–33 The dorsal approach is generally preferred because it avoids painful scar hypertrophy associated with the plantar approach. Studies have shown that the dorsal approach is associated with earlier weight bearing and return to work.34,35 Complications after surgical resection include persistent local plantar pain (typically because the neuroma was in fact not the source of pain) and stump neuroma. Interspace numbness and plantar numbness bordering the interspace are inevitable due to nerve resection.35
Freiberg's infraction is characterized by osteonecrosis of the metatarsal head. The second and third metatarsals are most commonly affected. The pathophysiology of the disease is not completely understood. It is likely due to a combination of vascular compromise, genetic predisposition, and altered biomechanics.36,37 The most widely used classification of Freiberg's infraction is attributed to Smillie,38 who described 5 stages of metatarsal head degeneration. Subchondral sclerosis is one of the earliest radiographic changes. The metatarsal head becomes fragmented, irregular, and flattened. Magnetic resonance imaging may be useful when plain radiographs are inconclusive. Magnetic resonance imaging initially shows hypointensity on T1-weighted images and hyperintensity on T2-weighted and short tau inversion recovery images of the affected metatarsal head. Bone scans may show a photopenic center with hyperactive collar suggesting avascular necrosis.39,40
The goal of nonoperative treatment is to unload the affected metatarsal. Spontaneous healing may occur in stages I, II, and III. Patients who do not respond to conservative measures, especially in stages IV and V, may benefit from surgery.39 No consensus exists as to which surgical procedure is most appropriate. Dorsal closing wedge osteotomy elevates the plantar aspect of the metatarsal head, which is often unaffected by the condition. This procedure can be effective in both early and late stage disease.36,41,42 Inter-positional arthroplasty with tendon autograft, allograft, or synthetic graft is indicated for more extensive involvement of the metatarsal head cartilage, with or without concomitant cartilage degeneration of the proximal phalanx.43 Other treatments include osteochondral transplant or Synthetic Cartilage Implant (Cartiva Inc, Alpharetta, Georgia).44–46
Iatrogenic metatarsalgia is due to sequelae from prior forefoot surgery, such as excessive shortening or elevation of a metatarsal (Figure 2). Forefoot surgery complications that cause iatrogenic metatarsalgia include non-union, malunion, and avascular necrosis. Attention must be paid to the reconstruction length, alignment, and rotation during forefoot surgery to avoid iatrogenic transfer metatarsalgia. Some examples include proximal metatarsal osteotomy altering metatarsal position,47 excessive shortening after metatarsal osteotomy48 or hallux valgus surgery (Figure 3), or elevation of the first metatarsal head leading to transfer metatarsalgia.4,49
Preoperative weight-bearing lateral radiograph of a 64-year-old man with neuropathic pain who had amputation of the hallux secondary to osteomyelitis. The patient reported severe lesser metatarsalgia. He underwent percutaneous second, third, fourth, and fifth distal metatarsal osteotomies (A). Postoperative weight-bearing lateral radiograph showing the elevation of the lesser metatarsals from the ground compared with preoperatively (B)
Preoperative weight-bearing anteroposterior radiograph showing the particularly long second metatarsal and the bunion deformity of a 42-year-old woman with severe second and third metatarsalgia but no bunion pain (A). Postoperative weight-bearing anteroposterior radiograph showing the shortening of the second, third, and fourth metatarsals following percutaneous distal osteotomies. The patient also underwent a bunionectomy to reduce the risk of recurrence of metatarsalgia (B).
Metatarsalgia is a broad term describing forefoot pain. There are numerous etiologies, but providers should understand whether the cause is primary, secondary, or iatrogenic. History, clinical examination, imaging, and laboratory values are useful for diagnosis. Conservative treatment includes physical therapy, shoe wear modification, and orthoses. When these options fail, correction of the underlying deformity may become necessary.
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