Metatarsalgia: Difference between revisions

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{{SK}} Capsulitis, Stone bruise, Ball-of-foot-pain
{{SK}} Metatarsophalangeal joint capsulitis, Stone bruise, Ball-of-foot-pain


==Overview==
==Overview==
'''Metatarsalgia''' (literally metatarsal pain, colloquially known as stone bruise) is a general term used to refer to any [[Pain and nociception|painful]] [[foot]] condition affecting the [[Metatarsus|metatarsal]] region of the foot (area just before the toes, commonly referred to as ball-of-the-foot). It is actually a common overuse injury that can affect the [[joint]]s and [[bone]]s of the metatarsals. Metatarsalgia is most often localized to the  the first metatarsal head (the ball of the foot just behind the big toe).  There are two small sesamoid bones under the first metatarsal head.  The next most frequent site of metatarsal head pain is under the second metatarsal.  This can be due to either too short a first metatarsal bone or to "hypermobility of the first ray" (metatarsal bone + medial cuneiform bone behind it), both of which result in excess pressure being transmitted into the second metatarsal head. Metatarsalgia is the irritation and inflammation of joint capsule surrounding these metatarsal heads due to due to excessive pressure over prolonged periods of time. Patient complaints of pain in the joint itself with the feeling of a marble in the shoe or a bunched up sock.
'''Metatarsalgia''' (literally [[metatarsal]] [[pain]], colloquially known as stone [[bruise]]) is a general [[Term logic|term]] [[Usage analysis|used]] to refer to any [[Pain and nociception|painful]] [[foot]] [[condition]] [[Affect|affecting]] the [[Metatarsus|metatarsal]] region of the [[foot]] ([[area]] just before the [[toes]], commonly [[Reference|referred]] to as [[Ball (anatomy)|ball]]-of-the-[[foot]]). It is actually a common overuse [[injury]] that can [[affect]] the [[joint]]s and [[bone]]s of the [[metatarsals]]. Metatarsalgia is most often localized to the  the [[first metatarsal]] [[head]] (the [[Ball (anatomy)|ball]] of the [[foot]] just behind the [[big toe]]).  There are two small [[sesamoid bones]] under the [[first metatarsal]] [[Head (anatomy)|head]].  The next most [[Frequentist|frequent]] [[Site-directed mutagenesis|site]] of [[metatarsal]] [[head]] [[pain]] is under the [[Second metatarsal bone|second metatarsal]].  This can be due to either too short a [[first metatarsal bone]] or to "[[hypermobility]] of the first [[Ray (optics)|ray]]" ([[Metatarsal bones|metatarsal bone]] + [[medial cuneiform bone]] behind it), both of which [[result]] in [[Excess risk|excessive]] [[pressure]] being [[Transmittance|transmitted]] into the [[Second metatarsal bone|second metatarsal]] [[head]]. Metatarsalgia is the [[irritation]] and [[inflammation]] of [[joint capsule]] surrounding these [[metatarsal]] [[Head|heads]] due to [[Excess risk|excessive]] [[pressure]] over prolonged [[periods]] of [[Time series|time]]. [[Patient]] complaints of [[pain]] in the [[joint]] itself with the [[feeling]] of a marble in the [[Shoe insert|shoe]] or a bunched up sock.


==Pathophysiology==
==Pathophysiology==
*Metatarsalgia usually occurs due to excessive pressure at the metatarsal heads over prolonged periods of time
*Metatarsalgia usually occurs due to excessive [[pressure]] at the [[metatarsal]] [[Head (anatomy)|heads]] over prolonged [[periods]] of [[Time-series|time]]<ref name="pmid14331319">{{cite journal| author=CALCAGNI V| title=[ON A CASE OF BILATERAL INTERMETATARSAL BURSITIS]. | journal=Minerva Ortop | year= 1965 | volume= 16 | issue=  | pages= 88-90 | pmid=14331319 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14331319  }} </ref>
*This results in the irritation and inflammation of joints, capsule or ligaments at metatarsal heads (ball of the foot), leading to capsulitis aka metatarsalgia
*This [[Result|results]] in the [[irritation]] and [[inflammation]] of [[joints]], [[capsule]] or [[ligaments]] at [[metatarsal]] [[Head|heads]] ([[Ball (anatomy)|ball]] of the [[foot]]), [[Leading strand|leading]] to [[metatarsophalangeal joint]] capsulitis aka metatarsalgia
*Common sites of involvement include:
*Common sites of involvement include:
**First metatarsal head (most common)
**[[First metatarsal bone|First metatarsal]] [[head]] (most common)
**Second metatarsal head
**[[Second metatarsal bone|Second metatarsal]] [[Head (anatomy)|head]]
**Third metatarsal head
**[[Third metatarsal bone|Third metatarsal]] [[Head (anatomy)|head]]
**Fourth metatarsal head
**[[Fourth metatarsal bone|Fourth metatarsal]] [[head]]


==Causes==
==Causes==
Metatarsalgia can be caused by any of the following:
Metatarsalgia can be [[Causes|caused]] by any of the following:
*Abnormal foot mechanics (putting excessive amount of weight bearing pressure on the ball of the foot beneath the toe joint)
*[[Abnormal]] [[foot]] [[mechanics]] (putting [[Excess risk|excessive]] [[Amount of substance|amount]] of [[weight]] bearing [[pressure]] on the [[Ball (anatomy)|ball]] of the [[foot]] beneath the [[toe]] [[joint]])
*Repetitive foot motion exerting pressure on the ball of foot resulting in connective tissue degeneration
*[[Repeating unit|Repetitive]] [[foot]] [[Motion (physics)|motion]] [[Exertion|exerting]] [[pressure]] on the [[Ball (anatomy)|ball]] of [[foot]] [[Result|resulting]] in [[connective tissue]] [[degeneration]]
*High level of activity
*High [[Leveling effect|level]] of [[Activity (chemistry)|activity]]
*Tight Achilles tendon
*Tight [[Achilles tendon]]
*Severe foot deformities such as:
*Severe [[foot]] [[deformities]] such as:
**Bunion
**[[Bunion]]
**Hammer toe
**[[Hammer toe]]
*Second toe longer than the big toe (or short first metatarsal bone), disturbs the normal forefoot balance which leads to the shift of an increased amount of weight to the second metatarsal bone
*[[Second]] [[toe]] longer than the [[big toe]] (or short [[first metatarsal bone]]), disturbs the normal [[Foot|forefoot]] [[Balance disorder|balance]] which [[Lead|leads]] to the [[Shift work|shift]] of an increased [[Amount of substance|amount]] of [[weight]] to the [[second metatarsal bone]]
*Structurally unstable arch of the foot i.e. high arch
*[[Structure factor|Structurally]] unstable [[Arch support|arch]] of the [[foot]] i.e. high [[Arch support|arch]]
*Prominent metatarsal heads
*Prominent [[metatarsal]] [[Head|heads]]
*Excessive pronation
*[[Excess risk|Excessive]] [[pronation]]
*Tight toe extensor muscles
*Tight [[toe]] [[Extensor muscle|extensor muscles]]
*Weak toe flexor muscles
*Weak [[toe]] [[Flexor muscle|flexor muscles]]
*Hypermobile first foot bone
*[[Hypermobile]] first [[foot]] [[bone]]
*Improper fitting footwear (women’s dress shoes, other restrictive footwear with narrow toe box)
*[[Improper rotation|Improper]] fitting [[Foot|footwear]] ([[Womens Pack|women’s]] [[dress]] [[Shoe insert|shoes]], other [[Restriction|restrictive]] [[Foot|footwear]] with narrow [[toe]] [[box]])
*High heels
*High [[Heel|heels]]
*High impact activities/sports (involving running or jumping) without proper footwear/orthotics such as:
*High [[Impacted|impact]] [[Activity (chemistry)|activities]]/[[Sports medicine|sports]] (involving [[running]] or [[jumping]]) without proper [[Foot|footwear]]/[[orthotics]] such as:
**Track and field running
**[[Tracking changes|Track]] and field [[running]]
**Tennis
**Tennis
**Football
**[[Footballs|Football]]
**Baseball
**Baseball
**Soccer
**Soccer
*Older age (thinning of foot fat pad leads to more susceptibility to pain in the ball of the foot)
*Older [[age]] (thinning of [[foot]] [[fat pad]] [[Lead|leads]] to more susceptibility to [[pain]] in the [[Ball (anatomy)|ball]] of the [[foot]])


==History and symptoms==
==History and symptoms==
* The primary symptom of metatarsalgia is the pain at the end of one or more of the metatarsal bones (ball of the foot) with the following characteristics:
* The primary [[symptom]] of metatarsalgia is the [[pain]] at the [[End-group|end]] of one or more of the [[metatarsal bones]] ([[Ball (anatomy)|ball]] of the [[foot]]) with the following [[Characteristic impedance|characteristics]]:
** Pain is either sharp or dull
** [[Pain]] is either sharp or dull
** It worsens on weight bearing such as walking (barefoot) or running
** It worsens on [[weight]] bearing such as [[walking]] ([[Barefoot social work|barefoot]]) or [[running]]
** It comes on gradually over a period of several months, not suddenly
** It comes on gradually over a [[period]] of several months, not suddenly
* Patient has a feeling of:<ref name="pmid29470159">{{cite journal| author=Ganguly A, Warner J, Aniq H| title=Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma. | journal=AJR Am J Roentgenol | year= 2018 | volume= 210 | issue= 4 | pages= 821-833 | pmid=29470159 | doi=10.2214/AJR.17.18460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29470159  }} </ref>
* [[Patient]] has a [[feeling]] of:<ref name="pmid29470159">{{cite journal| author=Ganguly A, Warner J, Aniq H| title=Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma. | journal=AJR Am J Roentgenol | year= 2018 | volume= 210 | issue= 4 | pages= 821-833 | pmid=29470159 | doi=10.2214/AJR.17.18460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29470159  }} </ref>
** A <nowiki>''marble''</nowiki> in the shoe
** A <nowiki>''marble''</nowiki> in the [[Shoe insert|shoe]]
** Walking on <nowiki>''pebbles''</nowiki>
** [[Walking]] on <nowiki>''pebbles''</nowiki>
** A bunched up sock
** A bunched up sock
** Standing on a <nowiki>''pea''</nowiki>
** [[Standing]] on a <nowiki>''pea''</nowiki>
* Patient often perceives it as a feeling of lump inside or underneath the foot
* [[Patient]] often perceives it as a [[feeling]] of [[lump]] inside or underneath the [[foot]]
* Swelling at the base of toe
* [[Swelling]] at the [[base]] of [[toe]]
* Difficulty wearing shoes
* Difficulty [[Wear red day|wearing]] [[Shoe insert|shoes]]
* Crossover toe (end-stage of capsulitis)
* [[Crossover (genetic algorithm)|Crossover]] [[toe]] ([[End-stage disease|end-stage]] of capsulitis)


==Imaging Fingings==
==Imaging Fingings==
Following imaging tests may prove to be helpful in diagnosis and differentiating metatarsalgia from other causes of forefoot pain:
Following [[Imaging studies|imaging tests]] may prove to be [[Help Menu|helpful]] in [[Diagnose|diagnosing]] and [[Differentiate|differentiating]] metatarsalgia from other [[causes]] of [[Foot|forefoot]] [[pain]]:
===X-ray===
===X-ray===
X-ray helps to exclude other causes of forefoot pain
[[X-ray]] [[Help Menu|helps]] to exclude other [[causes]] of [[Foot|forefoot]] [[pain]]


===MRI===
===MRI===
MRI helps to diagnose & differentiate other causes of pain in mid-foot and metatarsal regions such as:<ref name="pmid29470159">{{cite journal| author=Ganguly A, Warner J, Aniq H| title=Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma. | journal=AJR Am J Roentgenol | year= 2018 | volume= 210 | issue= 4 | pages= 821-833 | pmid=29470159 | doi=10.2214/AJR.17.18460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29470159  }} </ref>
[[Magnetic resonance imaging|MRI]] [[Help Menu|helps]] to [[diagnose]] & [[differentiate]] other [[causes]] of [[pain]] in mid-[[foot]] and [[metatarsal]] [[Region of interest|regions]] such as:<ref name="pmid29470159">{{cite journal| author=Ganguly A, Warner J, Aniq H| title=Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma. | journal=AJR Am J Roentgenol | year= 2018 | volume= 210 | issue= 4 | pages= 821-833 | pmid=29470159 | doi=10.2214/AJR.17.18460 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29470159  }} </ref>
* Traumatic disorders
* [[Trauma|Traumatic]] [[disorders]]
* Circulatory conditions
* [[Circulatory]] [[conditions]]
* Arthritis
* [[Arthritis]]
* Neuroarthropathies
* Neuroarthropathies
* Other conditions leading to biomechanical imbalance
* Other [[conditions]] [[Leading strand|leading]] to biomechanical [[imbalance]]


===Bone Scan===
===Bone Scan===
A bone scan pinpoints to the places of inflammation
A [[bone scan]] pinpoints to the [[Place cell|places]] of [[inflammation]]


===Ultrasound===
===Ultrasound===
*Ultrasound imaging of foot gives valuable information regarding the alterations responsible for causing metatarsalgia
*[[Ultrasound]] [[imaging]] of [[foot]] gives [[Value (mathematics)|valuable]] [[Information science|information]] regarding the alterations responsible for [[Causes|causing]] metatarsalgia
*It also helps to detect & exclude other causes of pain in the metatarsal foot region. These conditions include:<ref name="pmid11409128">{{cite journal| author=Iagnocco A, Coari G, Palombi G, Valesini G| title=Sonography in the study of metatarsalgia. | journal=J Rheumatol | year= 2001 | volume= 28 | issue= 6 | pages= 1338-40 | pmid=11409128 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11409128  }} </ref>
*It also [[Help Menu|helps]] to [[Detectable warning|detect]] & exclude other [[causes]] of [[pain]] in the [[metatarsal]] [[foot]] [[Region of interest|region]]. These [[conditions]] include:<ref name="pmid11409128">{{cite journal| author=Iagnocco A, Coari G, Palombi G, Valesini G| title=Sonography in the study of metatarsalgia. | journal=J Rheumatol | year= 2001 | volume= 28 | issue= 6 | pages= 1338-40 | pmid=11409128 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11409128  }} </ref>
**Morton's neuroma
**[[Morton's neuroma]]
**Bursitis
**[[Bursitis]]


==Treatment==
==Treatment==
* First step in the treatment of metatarsalgia is determining the cause of the pain and then carrying out the measures to eliminate that cause
* First [[Step function|step]] in the [[Treatments|treatment]] of metatarsalgia is determining the [[Causes|cause]] of the [[pain]] and then [[Carrying capacity|carrying]] out the [[Measure (mathematics)|measures]] to eliminate that [[Causes|cause]]
===Conservative medical therapy===
===Conservative medical therapy===
* Following are the conservative measures for the treatment of metatarsalgia:
* Following are the conservative [[Measure (mathematics)|measures]] for the [[Treatments|treatment]] of metatarsalgia:
** Changing the improper fitting footwear with shoes having:
** [[Change detection|Changing]] the [[Improper rotation|improper]] fitting [[Foot|footwear]] with [[Shoe insert|shoes]] having:
*** High and wide toe box (allowing the foot to spread out)
*** High and [[Wide and fast|wide]] [[toe]] [[box]] (allowing the [[foot]] to [[Spreading activation|spread]] out)
*** Rocker sole (decreases the stress on the ball-of-the-foot)
*** Rocker [[Sole (foot)|sole]] (decreases the [[Stress (medicine)|stress]] on the [[Ball (anatomy)|ball]]-of-the-[[foot]])
** Unloading the pressure to the ball-of-the-foot by following foot-care products:
** Unloading the [[pressure]] to the [[Ball (anatomy)|ball]]-of-the-[[foot]] by following [[foot]]-[[Care centers|care]] [[Product (biology)|products]]:
*** Orthotics with metatarsal pad which is placed behind the ball-of-the-foot (relieves the pressure, and redistributes the weight from painful area to the more tolerant areas)
*** [[Orthotics]] with [[metatarsal]] pad which is [[Place cell|placed]] behind the [[Ball (anatomy)|ball]]-of-the-[[foot]] (relieves the [[pressure]], and redistributes the [[weight]] from [[painful]] [[area]] to the more tolerant [[Area|areas]])
*** Gel metatarsal cushions
*** [[Gel]] [[metatarsal]] cushions
*** Metatarsal bandages
*** [[Metatarsal]] [[bandages]]
===Surgery===
===Surgery===
* In some cases, off-loading of the joints doesn't eliminate the pain
* In some [[Case-based reasoning|cases]], [[Off balance|off]]-[[Loading dose|loading]] of the [[joints]] doesn't eliminate the [[pain]]
* In such cases, patient should be referred to foot and ankle surgeon for the surgery for pain relief
* In such [[Case-based reasoning|cases]], [[patient]] should be [[Reference|referred]] to [[foot]] and [[ankle]] [[surgeon]] for the [[surgery]] for [[pain relief]]


==Prevention==
==Prevention==


Primary preventive measures for metatarsalgia include the following:
[[Primary prevention|Primary preventive]] [[Measure (mathematics)|measures]] for metatarsalgia include the following:
* Avoid high level of activity putting excessive pressure on ball of the foot
* [[Avoidance reaction|Avoid]] high [[Leveling effect|level]] of [[Activity (chemistry)|activity]] putting excessive [[pressure]] on the [[Ball (anatomy)|ball]] of the [[foot]]
* Avoid excessive pronation
* [[Avoidance reaction|Avoid]] excessive [[pronation]]
* Avoid high heels
* [[Avoidance reaction|Avoid]] high [[Heel|heels]]
* Avoid improper fitting footwear such as women’s dress shoes or other restrictive footwear with narrow toe box
* [[Avoidance response|Avoid]] [[Improper rotation|improper]] fitting [[Foot|footwear]] such as [[Womens Pack|women’s]] [[dress]] [[Shoe insert|shoes]] or other [[Restriction|restrictive]] [[Foot|footwear]] with narrow [[toe]] [[box]]
* Avoid high impact activities or sports (involving running or jumping) without proper footwear/orthotics such as:
* [[Avoidance response|Avoid]] high [[Impacted|impact]] [[Activities of daily living|activities]] or [[Sports Medicine|sports]] (involving [[running]] or [[jumping]]) without proper [[Foot|footwear]]/[[orthotics]] such as:
** Track and field running
** [[Tracking changes|Track]] and field [[running]]
**Tennis
**Tennis
**Football
**[[Footballs|Football]]
**Baseball
**Baseball
**Soccer
**Soccer

Latest revision as of 20:55, 19 August 2020

Metatarsalgia
ICD-10 M77.4
ICD-9 726.70
MeSH D037061

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mohsin, M.D.[2]

Synonyms and keywords: Metatarsophalangeal joint capsulitis, Stone bruise, Ball-of-foot-pain

Overview

Metatarsalgia (literally metatarsal pain, colloquially known as stone bruise) is a general term used to refer to any painful foot condition affecting the metatarsal region of the foot (area just before the toes, commonly referred to as ball-of-the-foot). It is actually a common overuse injury that can affect the joints and bones of the metatarsals. Metatarsalgia is most often localized to the the first metatarsal head (the ball of the foot just behind the big toe). There are two small sesamoid bones under the first metatarsal head. The next most frequent site of metatarsal head pain is under the second metatarsal. This can be due to either too short a first metatarsal bone or to "hypermobility of the first ray" (metatarsal bone + medial cuneiform bone behind it), both of which result in excessive pressure being transmitted into the second metatarsal head. Metatarsalgia is the irritation and inflammation of joint capsule surrounding these metatarsal heads due to excessive pressure over prolonged periods of time. Patient complaints of pain in the joint itself with the feeling of a marble in the shoe or a bunched up sock.

Pathophysiology

Causes

Metatarsalgia can be caused by any of the following:

History and symptoms

Imaging Fingings

Following imaging tests may prove to be helpful in diagnosing and differentiating metatarsalgia from other causes of forefoot pain:

X-ray

X-ray helps to exclude other causes of forefoot pain

MRI

MRI helps to diagnose & differentiate other causes of pain in mid-foot and metatarsal regions such as:[2]

Bone Scan

A bone scan pinpoints to the places of inflammation

Ultrasound

Treatment

Conservative medical therapy

Surgery

Prevention

Primary preventive measures for metatarsalgia include the following:

References

  1. ↑ CALCAGNI V (1965). "[ON A CASE OF BILATERAL INTERMETATARSAL BURSITIS]". Minerva Ortop. 16: 88–90. PMID 14331319.
  2. ↑ 2.0 2.1 Ganguly A, Warner J, Aniq H (2018). "Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma". AJR Am J Roentgenol. 210 (4): 821–833. doi:10.2214/AJR.17.18460. PMID 29470159.
  3. ↑ Iagnocco A, Coari G, Palombi G, Valesini G (2001). "Sonography in the study of metatarsalgia". J Rheumatol. 28 (6): 1338–40. PMID 11409128.

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