Metatarsalgia: Difference between revisions

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

VisualWikitext

Latest revision as of 20:55, 19 August 2020

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

Metatarsalgia usually occurs due to excessive pressure at the metatarsal heads over prolonged periods of time^[1]
This results in the irritation and inflammation of joints, capsule or ligaments at metatarsal heads (ball of the foot), leading to metatarsophalangeal joint capsulitis aka metatarsalgia
Common sites of involvement include:
- First metatarsal head (most common)
- Second metatarsal head
- Third metatarsal head
- Fourth metatarsal head

Causes

Metatarsalgia can be 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)
Repetitive foot motion exerting pressure on the ball of foot resulting in connective tissue degeneration
High level of activity
Tight Achilles tendon
Severe foot deformities such as:
- Bunion
- 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
Structurally unstable arch of the foot i.e. high arch
Prominent metatarsal heads
Excessive pronation
Tight toe extensor muscles
Weak toe flexor muscles
Hypermobile first foot bone
Improper fitting footwear (women’s dress shoes, other restrictive footwear with narrow toe box)
High heels
High impact activities/sports (involving running or jumping) without proper footwear/orthotics such as:
- Track and field running
- Tennis
- Football
- Baseball
- Soccer
Older age (thinning of foot fat pad leads to more susceptibility to pain in the ball of the foot)

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:
- Pain is either sharp or dull
- It worsens on weight bearing such as walking (barefoot) or running
- It comes on gradually over a period of several months, not suddenly
Patient has a feeling of:^[2]
- A ''marble'' in the shoe
- Walking on ''pebbles''
- A bunched up sock
- Standing on a ''pea''
Patient often perceives it as a feeling of lump inside or underneath the foot
Swelling at the base of toe
Difficulty wearing shoes
Crossover toe (end-stage of capsulitis)

Imaging Fingings

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

Ultrasound

Ultrasound imaging of foot gives valuable information regarding the alterations responsible for causing metatarsalgia
It also helps to detect & exclude other causes of pain in the metatarsal foot region. These conditions include:^[3]
- Morton's neuroma
- Bursitis

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

Conservative medical therapy

Following are the conservative measures for the treatment of metatarsalgia:
- Changing the improper fitting footwear with shoes having:
  - High and wide toe box (allowing the foot to spread out)
  - Rocker sole (decreases the stress on the ball-of-the-foot)
- Unloading the pressure to the ball-of-the-foot by following foot-care 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)
  - Gel metatarsal cushions
  - Metatarsal bandages

Surgery

In some cases, off-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

Prevention

Primary preventive measures for metatarsalgia include the following:

Avoid high level of activity putting excessive pressure on the ball of the foot
Avoid excessive pronation
Avoid high heels
Avoid improper fitting footwear such as women’s dress shoes or other restrictive footwear with narrow toe box
Avoid high impact activities or sports (involving running or jumping) without proper footwear/orthotics such as:
- Track and field running
- Tennis
- Football
- Baseball
- Soccer

References

↑ CALCAGNI V (1965). "[ON A CASE OF BILATERAL INTERMETATARSAL BURSITIS]". Minerva Ortop. 16: 88–90. PMID 14331319.
↑ ^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.
↑ Iagnocco A, Coari G, Palombi G, Valesini G (2001). "Sonography in the study of metatarsalgia". J Rheumatol. 28 (6): 1338–40. PMID 11409128.

Template:Diseases of the musculoskeletal system and connective tissue

de:Metatarsalgie it:Metatarsalgia

Template:WikiDoc Sources

[pmid14331319-1] CALCAGNI V (1965). "[ON A CASE OF BILATERAL INTERMETATARSAL BURSITIS]". Minerva Ortop. 16: 88–90. PMID 14331319.

[pmid29470159-2] 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.

[pmid11409128-3] Iagnocco A, Coari G, Palombi G, Valesini G (2001). "Sonography in the study of metatarsalgia". J Rheumatol. 28 (6): 1338–40. PMID 11409128.

[1]

[2]

[3]

@@ Line 13: / Line 13: @@
 }}
 {{SI}}
-{{CMG}}
+{{CMG}} {{AE}} {{S.M.}}
+{{SK}} 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 [[Pain and nociception|painful]] [[foot]] condition affecting the [[Metatarsus|metatarsal]] region of the foot. This is a common problem 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''' (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==
+*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 [[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:
+**[[First metatarsal bone|First metatarsal]] [[head]] (most common)
+**[[Second metatarsal bone|Second metatarsal]] [[Head (anatomy)|head]]
+**[[Third metatarsal bone|Third metatarsal]] [[Head (anatomy)|head]]
+**[[Fourth metatarsal bone|Fourth metatarsal]] [[head]]
+==Causes==
+Metatarsalgia can be [[Causes|caused]] by any of the following:
+*[[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]])
+*[[Repeating unit|Repetitive]] [[foot]] [[Motion (physics)|motion]] [[Exertion|exerting]] [[pressure]] on the [[Ball (anatomy)|ball]] of [[foot]] [[Result|resulting]] in [[connective tissue]] [[degeneration]]
+*High [[Leveling effect|level]] of [[Activity (chemistry)|activity]]
+*Tight [[Achilles tendon]]
+*Severe [[foot]] [[deformities]] such as:
+**[[Bunion]]
+**[[Hammer toe]]
+*[[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]]
+*[[Structure factor|Structurally]] unstable [[Arch support|arch]] of the [[foot]] i.e. high [[Arch support|arch]]
+*Prominent [[metatarsal]] [[Head|heads]]
+*[[Excess risk|Excessive]] [[pronation]]
+*Tight [[toe]] [[Extensor muscle|extensor muscles]]
+*Weak [[toe]] [[Flexor muscle|flexor muscles]]
+*[[Hypermobile]] first [[foot]] [[bone]]
+*[[Improper rotation|Improper]] fitting [[Foot|footwear]] ([[Womens Pack|women’s]] [[dress]] [[Shoe insert|shoes]], other [[Restriction|restrictive]] [[Foot|footwear]] with narrow [[toe]] [[box]])
+*High [[Heel|heels]]
+*High [[Impacted|impact]] [[Activity (chemistry)|activities]]/[[Sports medicine|sports]] (involving [[running]] or [[jumping]]) without proper [[Foot|footwear]]/[[orthotics]] such as:
+**[[Tracking changes|Track]] and field [[running]]
+**Tennis
+**[[Footballs|Football]]
+**Baseball
+**Soccer
+*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==
+* 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
+** 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
+* [[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 insert|shoe]]
+** [[Walking]] on <nowiki>''pebbles''</nowiki>
+** A bunched up sock
+** [[Standing]] on a <nowiki>''pea''</nowiki>
+* [[Patient]] often perceives it as a [[feeling]] of [[lump]] inside or underneath the [[foot]]
+* [[Swelling]] at the [[base]] of [[toe]]
+* Difficulty [[Wear red day|wearing]] [[Shoe insert|shoes]]
+* [[Crossover (genetic algorithm)|Crossover]] [[toe]] ([[End-stage disease|end-stage]] of capsulitis)
+==Imaging Fingings==
+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]] [[Help Menu|helps]] to exclude other [[causes]] of [[Foot|forefoot]] [[pain]]
+===MRI===
+[[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>
+* [[Trauma|Traumatic]] [[disorders]]
+* [[Circulatory]] [[conditions]]
+* [[Arthritis]]
+* Neuroarthropathies
+* Other [[conditions]] [[Leading strand|leading]] to biomechanical [[imbalance]]
+===Bone Scan===
+A [[bone scan]] pinpoints to the [[Place cell|places]] of [[inflammation]]
+===Ultrasound===
+*[[Ultrasound]] [[imaging]] of [[foot]] gives [[Value (mathematics)|valuable]] [[Information science|information]] regarding the alterations responsible for [[Causes|causing]] metatarsalgia
+*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]]
+**[[Bursitis]]
+==Treatment==
+* 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===
+* Following are the conservative [[Measure (mathematics)|measures]] for the [[Treatments|treatment]] of metatarsalgia:
+** [[Change detection|Changing]] the [[Improper rotation|improper]] fitting [[Foot|footwear]] with [[Shoe insert|shoes]] having:
+*** High and [[Wide and fast|wide]] [[toe]] [[box]] (allowing the [[foot]] to [[Spreading activation|spread]] out)
+*** Rocker [[Sole (foot)|sole]] (decreases the [[Stress (medicine)|stress]] on the [[Ball (anatomy)|ball]]-of-the-[[foot]])
+** 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 [[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
+*** [[Metatarsal]] [[bandages]]
+===Surgery===
+* In some [[Case-based reasoning|cases]], [[Off balance|off]]-[[Loading dose|loading]] of the [[joints]] doesn't eliminate the [[pain]]
+* In such [[Case-based reasoning|cases]], [[patient]] should be [[Reference|referred]] to [[foot]] and [[ankle]] [[surgeon]] for the [[surgery]] for [[pain relief]]
+==Prevention==
+[[Primary prevention|Primary preventive]] [[Measure (mathematics)|measures]] for metatarsalgia include the following:
+* [[Avoidance reaction|Avoid]] high [[Leveling effect|level]] of [[Activity (chemistry)|activity]] putting excessive [[pressure]] on the [[Ball (anatomy)|ball]] of the [[foot]]
+* [[Avoidance reaction|Avoid]] excessive [[pronation]]
+* [[Avoidance reaction|Avoid]] high [[Heel|heels]]
+* [[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]]
+* [[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:
+** [[Tracking changes|Track]] and field [[running]]
+**Tennis
+**[[Footballs|Football]]
+**Baseball
+**Soccer
 ==References==
 {{reflist|2}}
@@ Line 27: / Line 132: @@
 [[Category:Orthopedics]]
 [[Category:Rheumatology]]
+[[Category:Symptoms]]
 [[Category:Signs and symptoms]]
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