All about Metatarsalgia
Metatarsalgia (also referred to as the stone bruise) is a leading cause of forefoot pain, especially ball of the foot pain and is frequently reported in athletes. It is characterized by inflammation of the metatarsal heads. Metatarsalgia can affect both males and females. According to some estimates, 1 of every 10 individuals develop metatarsalgia at some point in their life.
Symptoms of Metatarsalgia
The symptoms of metatarsalgia are varied and may include:
- Pain and discomfort often in the ball of your foot that may range from burning or aching to stabbing in character.
- Generalized pain in the foot that may interfere with the physical independence.
- Tingling sensation or numbness in your toes.
- The feeling of having a pebble in your foot
- Severe pain that generally worsens with prolonged standing, running flexing or walking and improves at rest
The intensity, frequency and severity of pain in the metatarsalgia may vary from person to person.
The exact cause of metatarsalgia is not known, but it is believed that a history of strong impact of force or injury directly involving the head of first metatarsal is reported in most cases of metatarsalgia.
Risk Factors and Triggers:
Certain triggers or risk factors(1) can influence your risk of developing metatarsalgia. Some statistically significant risk factors include:
- Squeezing the metatarsal heads over one another which may damage the nerves and lead to pain and inflammation. This occurs in:
- Shoes with tight toe boxes;
- High heeled shoes;
- Ill-fitting shoes;
- Dancers, snow skiers, football players; and,
- Athletes whose feet can swell during the day with constant activity.
- Obesity and physical imbalance by causing friction-induced damage to the metatarsals.
- Aging. The tendons and connective tissue elements change with age making a person more prone to develop this condition.
- High arches. High arches are usually associated with metatarsal damage and recurring episodes of metatarsalgia.
- Certain other anatomical features such as a long second toe or a hammertoe can also increase the risk of developing Metatarsalgia
- History of gout, arthritis or other musculoskeletal conditions
The diagnosis of metatarsalgia is usually made on the history and clinical investigation/ examination by an experienced clinician. Clinical diagnosis is usually made by a combination of signs and symptoms and exclusion. You doctor should ask about your history of other musculoskeletal conditions/ ailments, your lifestyle, occupation and hobbies, and most importantly, the characteristics and associated symptoms of the pain.
Your provider may ask for the following tests:
- Radiological imaging tests: these tests include X-ray imaging, ultrasonography and magnetic resonance imaging (MRI).
- Blood tests: Such as uric acid levels to exclude the diagnosis of Gout.
Differential Diagnosis of Metatarsalgia:
The following conditions are often confused with Metatarsalgia:
- Rheumatoid Arthritis and Gout: Metatarsalgia is often confused with Rheumatoid Arthritis or Gout due to similar symptoms and presentation. Even more confusing is the fact that Inflammatory conditions like Rheumatoid Arthritis or Gout can aggravate the risk of Metatarsalgia and vice versa.
- Fluid accumulation/edema: Accumulation of fluid around the metatarsal joint due to metabolic or circulatory dysfunction can lead to damage to muscles and nerves; thereby aggravating the risk of metatarsalgia.
- Morton’s neuroma: Morton’s neuroma is a condition characterized by the formation of fibrous thickening of nerves that supply the head of metatarsals usually effecting the 3rd webspace. A significant number of Morton neuroma cases are misdiagnosed as metatarsalgia.
- Bunion: A Bunion usually shows up as a bump near the base of first metatarsal. Moderate to large-sized bunions can irritate the nerves of metatarsals and cause inflammation and painful swelling.
Without adequate treatment the following complications are possible:
- Intense pain radiating to leg and hip region
- Swelling of the foot
- Poor gait leading to hip and back arthritis
Following are some common treatments to manage metatarsalgia:
- Cold Therapy: Application of cold compress over inflamed or affected area. Wrap some ice in a soft cloth and place it over the foot for 10-20 minutes
- Medications: Anti-inflammatory medications (non-steroidal anti-inflammatory drugs) such as ibuprofen, diclofenac sodium etc. can be used for adequate pain relief. Fortunately, most cases of metatarsalgia respond well to over-the-counter painkillers to alleviate ongoing pain and inflammation.
- Rest: Try not to put too much pressure over the affected foot
- Physical Therapy: Perform light exercises to keep the metatarsals active and stretched
- Footwear: Wear comfortable footwear, in which the toes are not compressed.
- Other Treatments: Some preferred medical treatments include cortico-steroid injections that are administered to control inflammation and pain. In addition, a variety of surgeries can also be performed in case of intense pain to aid in reshaping the metatarsals, or releasing the nerve pressure for optimal restoration of normal activity.
If your metatarsalgia is due to Morton’s neuroma then you should be seen by a clinician well experienced in diagnosing and treating Morton’s neuroma.
- Bencardino, J., Rosenberg, Z. S., Beltran, J., Liu, X., & Marty-Delfaut, E. (2000). Morton’s neuroma: is it always symptomatic?. American Journal of Roentgenology, 175(3), 649-653.
Janet D. Pearl, MD, MSc is the Medical Director of The Center for Morton’s Neuroma and Complete Spine and Pain Care, an interventional and integrated Pain Management program located in Framingham, Massachusetts. Previously, Dr. Pearl was the Co-Director of the Pain Management Center at St. Elizabeth’s Medical Center, where she was also the Director of the Fellowship program. She is the former Director of a satellite pain center of the Brigham and Women’s Hospital, Pain Management Center, located at the HealthSouth Braintree Rehabilitation Hospital. Dr. Pearl held academic appointments at Harvard Medical School and Tufts Medical School. She serves on the Health Care Services Board of the Commonwealth of Massachusetts Department of Industrial Accidents since 2000 as one of its physician representatives and is Chair of the Committee on Pain Management.