Metatarsalgia

Description

Metatarsalgia refers to pain in the balls of the feet (the area between the toes and the arch). Metatarsalgia is often referred to as a symptom, rather than as a specific disease. Common causes of metatarsalgia include interdigital neuroma (also known as Morton neuroma), metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, and inflammatory arthritis. The most important structures in the balls of the feet are the five metatarsal heads (the ends of the metatarsal bones that connect to the toes) and the protective fatty pad that cushions the ball of the foot. Each time we take a step forward, we push-off with our toes and the ball of the foot, forcing ourselves forward. To do this, we force 100% of our body weight on these structures. If they are not aligned perfectly, or if we have insufficient fatty padding, we experience pain in the ball of the foot.

Symptoms

Symptoms of metatarsalgia may include:

Pain in the ball of your foot — the part of the sole just behind your toes.
The pain may be sharp, aching or burning pain.
Pain that gets worse when you stand, walk or run and improves when you rest.
The pain may radiate from the balls of the feet into the toes.
Numbness or tingling in your toes.
Pain that worsens when you flex your feet.
A feeling in your feet as if you’re walking with a pebble in your shoe.
Increased pain when you’re walking barefoot, especially on a hard surface.
Calluses on the ball of your foot.

Causes

Causes of Pain in the Balls of the Feet: The normal foot consists of bones and joints that are held together in perfect alignment by soft tissue structures known as ligaments, muscles, and tendons. When this alignment is abnormal in the ball of the foot, we not only feel pain, but we frequently also develop painful calluses in the underlying skin. Calluses are symptoms of some abnormality in the bones and joints of the ball of the foot. The most common causes of pain in the balls of the feet are:

Plantar flexed metatarsal or downward depressed metatarsal head: Each foot has five metatarsals that connect to one of our five toes. The metatarsals sit in a precise relationship, one to the other, forming the metatarsal arch (also called the transverse arch). As we step down on the ball of the foot, the metatarsal arch begins to flatten in response to our body weight. This allows the ball of the foot to function as a shock absorber. If one or more of the metatarsal heads sits lower than the other heads, it will bear a greater amount of our body’s weight than it should bear. After a time, the depressed metatarsal head becomes problematic from all of the extra or abnormal weight it is carrying, and it becomes inflamed and painful. Also, because the metatarsal head has “dropped,” it is sitting closer to the skin on the bottom of the foot, and it pushes its protective fat pad away, so that you may actually feel the protruding metatarsal head with your finger. Due to this lack of normal fatty pad under the metatarsal head, the head will apply abnormal pressure on the underlying skin. The skin may respond to this increased pressure by building up a painful callus. Causes of a dropped metatarsal include:

A flexible foot. In this type of foot the ligaments, tendons, and muscles are too lax to allow them to hold the bones and joints together in their most optimum alignment. The most common cause of a flexible foot is a biomechanical defect known as pronation.
High-heeled shoes. When the heel is raised, our weight is thrown forward onto the ball of the foot. This increased weight stretches the soft tissues that maintain the metatarsal arch, allowing one or more of the metatarsal heads to drop.
Injuries to the ball of the foot. When fractured metatarsals or dislocated joints are not properly treated, they may heal in an abnormal position, allowing the metatarsal head to drop.

Thinning or destruction (atrophy) of the protective fat pad in the ball of the foot: The fat pad in the ball of the foot functions as a shock absorber for the underlying bones, joints, and soft tissue structures. When the pad is not of optimum thickness, the force and weight of each step we take is passed on to the underlying structures, rather than absorbed and whisked away by the fat pad. This eventually produces inflammation and pain in the soft tissues, bones, and joints in the ball of the foot. The most common causes of a thin or absent fat pad include:

As we age, the fatty protective pad begins to absorb. The rate of this absorption will depend on your genes.
A metatarsal head which has been downward displaced will destroy the fatty pad between it and the skin.
Some diseases will cause the fatty pads in the feet to become thinner. Examples of these diseases include rheumatoid arthritis, connective tissue disorders, and some endocrine diseases.
Excessive and prolonged pressure on the ball of the foot will cause the fat pad to be thinned or destroyed. Some causes are high heel shoes, walking bare foot, or walking in shoes with very thin soles.

Feet with high arches: This foot type is usually rigid, and will not allow the high arch to come into contact with the ground when we step down. Therefore, as we step forward, all of our weight is thrown on to the balls of the feet, rather than some of the weight being carried by the arch. This will force the metatarsal heads in the balls of the feet to bear excessive weight. The results of this repetitive and excessive weight on the metatarsal heads are pain, inflammation, and swelling in the balls of the feet.

Arthritis may cause metatarsalgia; both osteoarthritis and rheumatoid arthritis can be a factor. Rheumatoid arthritis causes forefoot deformity and often may cause displacement and even dislocation of the metatarsal joints themselves. Osteoarthritis frequently affects the metatarsal joints as they victims of repeated minute trauma of daily activity. The thinning of the skin with age allows even more trauma to the metatarsal joints and will result in painful metarsalgia.

Morton’s Neuroma can also be a source of metarsalgia and is characterized by pain in the forefoot. There may be some accompanying numbness and other neurological symptoms associated with it. This condition is often aggravated with certain footgear.

Metatarsal Synovitis is a painful forefoot problem. This is characterized by persistent pain in one or more joints of the fore foot. Synovitis is closely related to osteoarthritis and is generally considered to be an irritation of the joint capsule of a particular metatarsal joint. Occasionally fluid can also be found in the joint space secondary to synovitis

Sesamoiditis is located on the plantar surface of the foot and will be located near the first metatarsal phalangeal joint. Most people have two or more sesamoids on each foot. The sesamoids beneath the first metatarsal joint frequently are a cause of metatarsalgia with either an irritation of the sesamoid or an actual stress fracture of the sesamoid.

Stress Fracture of a metatarsal can also be a source of metatarsalgia. Stress fractures are generally rather insidious in onset without a history of injury. Generally related to overuse syndrome.

Avascular necrosis occurs in the forefoot and also may be considered metatarsalgia. Generally affects younger individuals and may be related to injury. The disease process continues and is often problematic years later due to an abnormal parabolic curve of the metatarsal structures.

Custom Treatments

Custom-made orthotics are one of the most effective treatments for reducing or eliminating pain in the balls of the feet.

How Custom-Made Orthotics Work:

Custom-made orthotics is the treatment most recognized by doctors to be effective in the treatment of this disease. Our custom-made orthotics for Metatarsalgia are constructed of comfortable, shock-absorbent “space age” materials which gently and effectively:

Rebalance the metatarsal heads, so that the dropped metatarsal heads are raised to their normal and most optimum positions. This will insure that each metatarsal head will bear its “fair share” of our body weight. The orthotic will help redistribute the weight-bearing surface in a more normal manner. When this occurs, the pain in the balls of the feet will gradually subside. Just padding the ball of the foot will not provide this relief. In order to rebalance the foot, we must use a custom-made orthotic. Each person’s problem is truly unique. In order to provide lasting relief, the treatment must be directed toward elevating your specific metatarsal head, by the exact amount it has dropped. When this is accomplished, the pain will subside, and the metatarsal arch is re-formed, allowing it to function as the body’s shock absorber. This type of relief can only be obtained by using custom-made orthotics, which is made from molds of your feet.
Replace the fatty pad protection to the balls of the feet. In the construction of our custom-made orthotics, we protect the balls of the feet with materials that will absorb friction and excessive pressure, rather then passing them to the balls of the feet. The materials we use act as though more fat and padding were added to the feet, without adding excessive bulk.
Support high arches in order to relieve excess pressure on the balls of the feet. Our custom-made orthotics is designed to comfortably allow this type of arch to function as if it were of a normal height. By doing this, we allow the arch to bear its normal weight, thus reducing the weight that the ball of the foot must bear. This will reduce the pressure on the metatarsal heads and fatty pad, thus reducing pain and fatigue.
Adjust and accommodate for any abnormal walking patterns you have, such as pronation, intoeing, outtoeing, etc., that affect the way weight is distributed across the balls of your feet when you walk. Our custom-made orthotics will allow the feet to function in a normal position when they strike the ground, rather than in a twisted position, thus removing the excessive weight and pressure from the balls of the feet.

When these things are achieved, the inflammation and pain of Metatarsalgia will gradually be reduced or eliminated. Custom-made orthotics is also very effective in preventing recurrences of these painful problems.

Our Custom-Made Orthotics for Metatarsalgia is constructed from the impressions of your feet that you make with our Foam Impression Kit. Using these impressions and the information you provide us, we design and construct a pair of orthotics that will help to stabilize your feet, reduce pressure on the balls of the feet, support the arch and metatarsals, and help to alleviate your foot pain. These orthotics will fit in any shoe with a heel height up to 1 1/2 inches. Click here for information on how to order these uniquely effective custom-made orthotics.

Self-Help Treatments & Prevention

Metatarsalgia pain occurs on the ball of the foot. Doctors to help relieve this pain prescribe the following remedies:

Rest: Elevate your feet after periods of standing and walking. This will take pressure off the ball of the foot, and allow it to recover.
Applications of ice packs that provide a comfortable cooling to the ball of the foot (not a freezing cold) will help reduce pain, swelling, and inflammation. Apply the ice to the ball and arch (not the toes). Make sure it is comfortable, and leave on your foot for about 20 minutes, 3 times a day. If you have any medical problems such as diabetes, poor circulation, etc., discuss the use of ice with your doctor before applying the ice.
Wear shoes with heel heights of no more than 3/4 to 1 inch. If the heel is higher, too much of your body weight will be thrown forward on the balls of the feet.
Avoid walking barefoot. Shoes-especially those with thick, cushioned soles-protect the feet and provide good shock absorption for the entire body.
When you are over-weight, abnormal amounts of weight are brought to bear on the foot each time a step is taken. This continuous excessive pressure on the ball can cause inflammation, swelling, and pain. Keeping body weight within a healthy range can decrease your chance of having metatarsalgia.
Gel “U”-Shaped Callus Pads (Self-Stick & Re-Usable) protect painful metatarsal heads and calluses, thus reducing ball of foot discomfort.
Metatarsal pads and supports help to reduce pain by elevating dropped metatarsal heads to a more normal height, thus decreasing pressure on the ball of the foot.
Modify your activities. Avoid squatting, going up on your tiptoes, downhill walking, and high heels. Decrease the time that you stand, walk, or engage in exercise that puts a load on the balls of your feet. Convert impact exercise to non-impact exercise – cycling, swimming, and pool running are acceptable alternatives.

If Conservative Care Fails

Some of the conditions mentioned above including Morton’s neuroma, stress fracture of the metatarsals, avascular necrosis, etc; may require specific treatment besides use of orthotic devices. This can include injections, oral medication, physical therapy and immobilization.

If conservative treatments fail and your symptoms persist, the doctor may recommend a surgical option to rebalance the metatarsal heads and reduce abnormal pressure on the ball of the foot. During surgery, the metatarsal bone is cut just behind the toe. This procedure is called an osteotomy. Generally, the bone is cut all the way through, and then manually raised and held in its corrected position with a metal pin or screw. This procedure allows the surgeon to reposition the metatarsal head so that it is at its optimal height in relation to the other metatarsal heads. This procedure usually reduces or eliminates the pain of metatarsalgia.

Because of the possible complications involved with any surgery, one should be sure to understand the risks that may be involved with surgery to correct metatarsalgia.