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METATARSALGIA
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What is it?

“Metatarsalgia” is a nonspecific term that refers to pain over the balls of one’s feet. The metatarsals are the foot bones that correspond to this area. High-level dancers, track-and-field athletes, and baseball catchers are commonly affected, due to the repetitive “bursts” of impact or quick transfers of force to the forefoot, which can lead to overloading the metatarsals. In addition, exaggerated or abnormal foot mechanics, such as the demi pointe position in ballet dancers, can lead to excessive pressure on to the bones and ligaments in this area.

Symptoms

Pain is the main symptom and is often described as a dull ache over the top and sole of the 2nd to 4th toes. Pushing off the forefoot during walking and running worsens the pain. Usually, the pain gradually develops over a period of time (typically months). When associated with other conditions, there also can be numbness, which also develops over time. In chronic cases, calluses (also known as plantar keratosis) can form over the balls of the feet, which, in turn, can lead to more pressure over the forefoot and further intensify the symptoms.

Risk Factors

Predisposing factors may include “claw toes” or “hammer toes” (curled or bent deformity of the joints), abnormal metatarsal bone shape or length, toe flexor muscle weakness, overpronation, tight Achilles tendons, and increased joint mobility of the first toe. Use of high-heeled shoes can also increase the load on the forefoot. Other conditions that may have similar symptoms include stress fractures, sesamoiditis (inflammation of the sesamoid bones that flank the joints of the big toe), Morton’s neuromas (irritation of the nerves between the toes), “tarsal tunnel syndrome” (a specific irritation of the tibial nerve), and tears of the “plantar plate” (ligament on the sole of the foot).

Sports Medicine Evaluation & Treatment

The diagnosis begins with a thorough exam and history by the physician. Imaging may be obtained to rule out stress fractures of the metatarsals, which are also commonly encountered in this athletic group; this usually starts with x-rays, but may lead to a bone scan or magnetic resonance imaging (MRI). Ultrasound may be useful to look for a Morton’s neuroma or bursitis. In certain cases, blood work may be obtained to evaluate for an underlying inflammatory condition, such as rheumatoid arthritis or gout.

Treatment typically starts with rest, ice, and a course of NSAIDs (e.g., ibuprofen or naproxen). Metatarsal pads or orthotic inserts can also be helpful. Rehabilitation is also an important part of treatment and can begin with toe glides, stretches, and mobility exercises. Underlying problems, such as over-pronation and Achilles tendon tightness, should be addressed as well, and a physical therapy course can be helpful if a home program is not adequate. Failure to address underlying mechanical problems can lead to continued pain as well as chronic foot problems, including arthritis, toe deformities, and joint instability. When conservative treatment fails, surgery may be indicated to redistribute the forces evenly across the forefoot.

Return to Play

The athlete may return to the sport once symptoms subside and can perform without being hindered by pain, often within days to weeks. Modification or change of footwear may be necessary to achieve this goal and prevent recurrence of symptoms.

AMSSM Member Authors
Jason Brucker, MD and Craig Young, MD

References
Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008 Aug;29(8):871-9.
Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999 Jul;31: S448-58.

Category: Foot and Ankle,

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