Anterior Metatarsalgia (Submetatarsal Head Pain)

By admin Last updated Nov 28, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Kenneth M. Bielak

Benjamin D. England

Basics

Description

Refers to pain in the plantar aspects of the metatarsal heads. Metatarsalgia is not an anatomical diagnosis. It can be divided into primary and secondary metatarsalgia.
Primary metatarsalgia develops from intrinsic factors, such as a long 1st ray, hallux valgus, and other congenital deformities.
Secondary metatarsalgia may result from trauma, sesamoiditis, or neurogenic disorders.

Epidemiology

Common in athletes with high-impact sports involving the lower extremities (dancing, running, jumping)

Risk Factors

Overpronation
Foot deformities: Pes planus (flat foot), pes cavus, tight Achilles tendon, tarsal tunnel syndrome, hallux valgus, prominent metatarsal heads, hammertoe deformity, tight toe extensors, Morton's foot with a short 1st metatarsal and a relatively long 2nd metatarsal
Old or poorly fitted shoes
Competitive athletes in weight-bearing sports (soccer, ballet, basketball, baseball, football, etc.)
High heels or narrow, pointed shoes
Abnormal gait or stance due to intrinsic or extrinsic factors
Obesity
Fat pad atrophy or displacement
Soft tissue dysfunction: Intrinsic muscle weakness, laxity in the Lisfranc ligament
Dermatologic issues: Calluses and warts
Involvement of lesser metatarsals: Freiberg infarction (aseptic necrosis of metatarsal head, as seen in adolescent sprinters)

General Prevention

Wear properly fitted shoes with adequate padding.
Gradual progression of weight-bearing exercise programs

Etiology

Specific etiology variable, but repetitive/excessive stress combined with intrinsic and extrinsic factors (see “Risk Factors”)
Due to the 2 sesamoid bones, the 1st metatarsal (MT) head usually carries 30% of the load when walking. A normal metatarsal arch also ensures this balance with adequate padding around the 1st MT head. A pronated or splayfoot can disturb this balance, resulting in changed load bearing by the other metatarsal heads. Reactive tissue can build up a callus around the metatarsal head, which further compounds the discomfort.
Excessive or repetitive stress, such as wearing high heels or ballet dancers

Commonly Associated Conditions

Soft tissue dysfunction: Intrinsic muscle weakness, laxity in the Lisfranc ligament
Dermatologic issues: Calluses and warts
Hallux valgus or rigidus
Involvement of lesser metatarsals: Freiberg infarction (aseptic necrosis of metatarsal head, as seen in adolescent sprinters)
Hammertoe or clawtoe
Morton syndrome (long 2nd metatarsal)

Diagnosis

History

Gradual chronic onset is more common than acute presentation.
Patient may have history of repetitive stress with unaccustomed walking and running.
Symptoms located typically to plantar surface of metatarsal heads
Typical pain described as walking with a “pebble in the shoe”
Aggravated during midstance or propulsion phases of walking or running

Physical Exam

Pain is predominantly located in the plantar forefoot, especially in the distal half of the metatarsal shaft and head.
Calluses may indicate areas of excessive friction/pressure.
Palpation for tenderness may differentiate soft tissue injury from the bony metatarsal head.
Pain in interdigital space or positive metatarsal squeeze test suggests Morton neuroma.
Examination for the presence of callus, edema, erythema, swelling, gross deformity, breaks in the skin, and/or abnormal foot mechanics should be performed.
Range of motion of the phalanges, metatarsophalangeal joint, and ankle, especially to dorsiflexion, should be examined.
Gait analysis should be performed.
Diagnostic injection (metatarsophalangeal joint) with local anesthetic sometimes can help differentiate intra-articular pathology (synovitis, capsulitis) from extra-articular pathology (neuroma).

Diagnostic Tests & Interpretation

Lab

Not required, but may be considered to rule out additional pathology (differential diagnosis)
WBC count may be elevated in infection, but is normal in metatarsalgia.
Sedimentation rate will be normal, barring infection or arthritis.
Consider testing for:
- Gout—Uric acid level
- Pseudogout—Synovial fluid
- Systemic disease—Human leukocyte antigen, rheumatoid factor

Imaging

Not required, but may be considered to rule out additional pathology (differential diagnosis)
Weight-bearing anteroposterior and lateral foot and oblique radiographs should be normal.
Metatarsal and sesamoid axial films to rule out sesamoid fracture or skyline view of the metatarsal heads (MTP joints in dorsiflexion to view alignment) may be considered.
Bone scan is indicated if there is a high index of suspicion for stress fracture. Triple-phase bone scan will help delineate soft tissue from bony pathology.
MRI is indicated if a mass lesion is suspected.
Increasing use of ultrasonography, especially with effusions or neuromas.

Diagnostic Procedures/Surgery

Diagnostic injection (metatarsophalangeal joint) with local anesthetic sometimes can help differentiate intra-articular pathology (synovitis, capsulitis) from extra-articular pathology (neuroma).
Plantar pressure distribution analysis may help to distinguish patterns of pressure distribution due to malalignment.

Differential Diagnosis

Neuroma (plantar or Morton's)
Idiopathic metatarsophalangeal joint synovitis
Freiberg disease: Ischemic epiphyseal necrosis of the 2nd metatarsal
Inflammatory arthritis of metatarsophalangeal joints (rheumatoid arthritis, seronegative spondyloarthropathy, crystalline-induced arthritis, osteoarthritis, septic arthritis)
Stress fracture

P.33

Salter I fracture (pediatric population)
Sesamoiditis or sesamoid fracture
Lisfranc injury
Traumatic arthritis
Foreign body
Cellulitis or infection (diabetic foot, Lyme disease, leprosy)
Ganglion cyst
Vasculitis (diabetes)
Cavovarus foot
Tumor (rare)

Treatment

Acute treatment:
- Ice and rest with activity modification
- Well-cushioned athletic shoes correctly fitted for the athlete's foot type (1)[C]
- Calluses should be pared down, preferably after soaking the foot in warm water and using a stone or emery board.
- A metatarsal pad may be placed just proximal to the metatarsal heads to relieve pressure. A common error is to place the pad directly beneath the metatarsal heads, which will exacerbate the symptoms.
- Analgesics such as acetaminophen or NSAIDs may be of benefit symptomatically.
- Stretching a tight Achilles tendon may help reduce metatarsal loading acutely.
Long-term treatment:
- Prescriptive orthotics are beneficial:
  - Pes cavus (2)[C]
  - Hallux valgus (2)[C]
- Arch support and a well-fitted, low-heel shoe for daily wear (1)[C]
- Energy-absorbing sole on shoe
- Enhance gastroc-soleus mechanism flexibility
- Correction of postural or gait imbalance
- Physical therapy may be helpful.
- Rarely, a cam walker boot, cane, or crutch may be necessary.
- Progressive return to sports activities as tolerated
- Replace daily and sports shoes after 350 miles of running or when they show early wear, such as creasing in the midsole under the ball of foot or heel.
- Avoid hard surfaces and prolonged standing.

Medication

Analgesics for symptom control
NSAIDs (ibuprofen, naproxen) or acetaminophen

Additional Treatment

Referral

Athletes may warrant early podiatric or orthopedic evaluation.
If no improvement with conservative therapy for 3 mos, consider referral to foot/ankle orthopedic or surgical podiatrist.
If a correctable anatomic abnormality exists, bunionectomy, partial osteotomy, or surgical fusion may be considered. Success rates vary, depending on procedure.
Surgery is considered a last resort if no anatomic abnormality is present.

Additional Therapies

Corticosteroid injection should be avoided because it may cause fat pad atrophy.

Ongoing Care

Patient Education

Instruct patient about wearing proper shoes and gradual return to activity.
Cross training until symptoms subside
Biomechanical evaluation by appropriately skilled clinician

Complications

Back, knee, and hip pain owing to compensatory gait change
Transfer metatarsalgia following surgical intervention as stress transfers to other areas

References

1. Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008;29:871–879.

2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;(7 suppl):S448–S458.

Additional Reading

Baker CL. Reactive synovitis of the foot—metatarsalgia. In The Hughston Clinic sports medicine field manual. Baltimore: Williams & Wilkins, 1996:270.

Birbilis T, Theodoropoulou E, Koulalis D. Forefoot complaints—the Morton's metatarsalgia. The role of MR imaging. Acta Medica (Hradec Kralove). 2007;50:221–222.

Gregg J, Marks P. Metatarsalgia: an ultrasound perspective. Australas Radiol. 2007;51:493–499.

Gregg JM, Schneider T, Marks P. MR imaging and ultrasound of metatarsalgia—The lesser metatarsals. Radiol Clin North Am. 2008;46:1061–1078.

Tóth K, Huszanyik I, Kellermann P, et al. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int. 2007;28:61–63.

Weber PC. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. 2007;458:248.

Codes

ICD9

355.6 Lesion of plantar nerve
726.70 Enthesopathy of ankle and tarsus, unspecified

ICD10

M77.4 metatarsalgia