Patient education

Metatarsalgia is a general term used to refer to a painful foot condition in the metatarsal region of the foot (the area between the arch and toes, or ball of the foot). This is a common foot disorder that can affect the bones and joints at the ball of the foot and occurs when one of the metatarsal joints becomes painful or inflamed.

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The ball of the foot is a weight bearing area where the metatarsals bear the greatest amount of weight and pressure. If one or more of these metatarsals is out of alignment then excessive pressure is generated in the area sometimes producing a callus. Many people say the painful feeling is “like walking on rocks.”

Anatomy

The ball of the foot is known as the metatarsophalangeal joint (MTPJ) region. The long bones of the forefoot (metatarsals) and the toes form the MTPJ’s.

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Metatarsalgia pain usually centers on one or more of the five bones (metatarsals) in the mid-portion of the foot. Also known as dropped metatarsal heads, metatarsalgia can cause abnormal weight distribution due to overpronation. Metatarsalgia is caused by the compression of a nerve between two displaced metatarsal bones.

Causes

Foot Structure: Metatarsalgia can develop from an abnormal foot structure and biomechanics, both of which are inherited features. Some inherited foot defects such as a high arch can put extra pressure on the metatarsals. Having a second toe that’s longer than the big toe can also cause more weight than normal to be shifted to the second metatarsal head. Also, if one leg is shorter than the other, the metatarsal-phalangeal joints of the shorter leg receive additional stress.

Footwear: High heels, which cause more weight to be transferred to the front of the foot, are a common cause of metatarsalgia in women. Shoes with a narrow toe box or athletic shoes that lack proper support and cushioning can also contribute to metatarsal problems. Improper footwear can exacerbate the problem that is usually caused by the original genetic structure.

Excess weight: Because most of your body weight transfers to your forefoot when you move, extra pounds mean more pressure on your metatarsals. Losing weight may help reduce or eliminate symptoms of metatarsalgia.

Foot Deformities: Other foot deformities can contribute to the problem such as digital deformities that create retrograde pressure on the metatarsal head (hammertoes) or bunion deformities where the big toe is weakened and extra stress is put on ball of foot. Arthritis, metatarsal stress fractures, neuromas, and even gout can cause pain and inflammation that change the way you walk and the distribution of weight in your feet.

Aging: As we get older, the fat pad in our foot tends to thin out, making us much more prone to pain in the ball of the foot.

Symptoms

Pain in the ball of your foot, which can be sharp aching or burning. Pain usually will increase when you’re walking barefoot, especially on a hard surface. May feel as if you’re walking with a rock in your shoe.

Pain in the toe area. Pain can be a sharp or shooting pain in your toes and may be accompanied with numbness or tingling. Sometimes these symptoms develop suddenly, especially if you’ve increased your usual activity of running, jumping or other high-impact exercise. However, usually problems develop over time.

Diagnosis

Physical exam:
Physical examination begins with observation of the foot for abnormalities and foot biomechanics such as a high arch, flat feet, excessive pronation, hammertoe or bunion deformity, tight Achilles tendon, or prominent metatarsal heads.

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Pressing the metatarsal heads may elicit pain. There may also be pain when the joint between the toe and metatarsal is moved. Squeezing the forefoot with one hand and pushing on the sole of the forefoot may elicit pain in cases of Morton’s neuroma.

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There may be slight swelling on the top of the foot in cases of metatarsal stress fracture. A layer of thickened skin (callus) may be present beneath the metatarsal head due to friction or pressure.

X-rays:

The diagnosis is confirmed with x-rays. Typically, the head of the involved metatarsal is widened and flattened, and the metatarsal joint may be sclerotic and irregular. X-rays are also useful in ruling out various conditions that contribute to metatarsalgia.

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Treatment

Non-Surgical Treatment

The first method of treating metarsalgia begins with accommodating the deformity. The goal is to reduce pressure in the painful area.

Padding and Taping: Unloading pressure to the ball of the foot can be accomplished with a variety of foot care products. Special padding at the ball of the foot may help relieve some of the metatarsalgia symptoms. These small pads, adhesive pads, are designed to sit under the middle of the foot and take pressure off the nerve. The placement of these pads is very important. The pad should not sit right under the ball of the foot, which would increase the pressure right at the nerve and increase pain. The pad should sit right behind the ball of the foot.

Medication: Prescription anti-inflammatory drugs or over the counter non-steroidal anti-inflammatory medication may be recommended to ease acute pain and inflammation. Anti-inflammatories may help to decrease pain, but they don’t specifically target the primary mechanical problem contributing to the pain of metatarsalgia.

Orthotic Devices: Custom functional orthotics prescribed by your doctor can be useful in controlling foot function. An orthotic device may reduce symptoms and prevent the worsening of the condition by relieving pressure and redistributing weight from the painful area.

Shoes: Wear shoes with plenty of room for the toes to move, low heels, and laces or buckles that allow for width adjustment. Wear shoes with thick, shock-absorbent soles and proper insoles that are designed to keep excessive pressure off of the foot. High heels should be avoided because they place undo strain on the forefoot and can contribute to a number of foot deformities.

Ice: Ice the ball of the foot for 15 minutes twice a day to decrease inflammation and discomfort.

Decrease activity: Limit high impact activity and high impact athletic endeavors.

Conservative treatments for metatarsalgia are often limited because they cannot correct any bone deformities that contribute to the symptoms. If conservative treatment fails or the pain progresses to the point where conservative treatment is no longer a viable option, surgical intervention may be needed to correct the deformity.

Surgical Treatment

Both the traditional and minimally invasive metatarsalgia surgical correction techniques are performed at the Coeur d’Alene Foot and Ankle Surgery Center. The surgery consists of cutting the metatarsal bone just behind the toe to eliminate pressure on the ball of the foot. Generally, the bone is cut all the way through, and then elevated and held in its corrected position through the use of hardware or external splinting to redistribute weight to achieve normal alignment.

Traditional Metatarsalgia Correction

Open or traditional surgical correction techniques involve larger incisions to perform the cutting of the metatarsal bone and elevation is accomplished by holding its corrected position with a pin or screw (osteosynthesis). Incisions are then closed with sutures. Following the surgery, the patient may be placed in a cast, or may be required to use crutches for several weeks. During the healing period, the foot should be protected from excessive weight bearing. Walking prematurely on the foot can jeapordize the osteosynthesis.

Minimally Invasive Metatarsalgia Correction

Incisions used in minimally invasive or minimal incision percutaneous surgery are much smaller in length (approximately 5 mm). The surgical metatarsal bone cut is accomplished through this small surgical insicion and usually suturing is not necessary. For this technique, surgeons use instruments which are very fine and rotate at high speed to make tiny, precise cuts. Surgery is performed under Fluoroscopic viewing. MIS surgeons are able to rely on external fixation in the form of a compression dressing and surgical postoperative footwear for stabilization immediately following surgery, eliminating the need for pins or screws (osteosynthesis) and casting of the foot or crutches and enabling immediate ambulation. A surgical shoe or boot is provided for stability.

Video

Minimally Invasive Metatarsal Surgery – Image Gallery

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Surgical Day Visit

Preoperative instructions
One week post-operative osteotomy

Surgeries are performed at the CDA Foot and Ankle Surgery Center and are done with local anesthesia wherein the foot usually stays asleep 4 to 6 hours. A small surgical incision is used which enables the surgeon to use fine specially designed instruments to obtain the best long term pain free, functional and cosmetic results. Often times no sutures are required due to the small incision size. Dr. Nunez also uses a fluoroscope during surgery, enabling him to visualize foot anatomy during surgery in spite of the small incisions. The entire surgery takes approximately 1- 2 hours. This includes viewing a preoperative video and procedure explanation, anesthetic administration, setting up the sterile field, the surgical procedure and postoperative dressing and instructions.

Patients are not required to discontinue their prescription medication unless specifically instructed. There are no restrictions on diet or fluid intake the night before surgery. As recommended by the CDC (Centers for Disease Control), an antibiotic is usually administered at the time of surgery. The patient is given a postoperative pain medication prescription and if appropriate one dose of antibiotic to be taken that evening. Occasionally an RX is also given to the patient for continued antibiotic therapy if necessary according to their medical history.

The dressing must stay dry, clean and intact and is not changed until the first post-operative office visit.
The patient leaves the facility walking with a special surgical shoe or boot. This will be provided for the patient. Crutches or walkers are usually NOT needed.

All minimally invasive surgical techniques are performed in compliance with the Standards of Care published by the Academy of Ambulatory Foot and Ankle Surgery and can be viewed on the U.S Department of Health & Human Services National Guideline Clearinghouse: www.guideline.gov

The Coeur d’Alene Foot and Ankle Surgery Center  is Medicare Certified and an Accredited surgical facility with the Academy of Ambulatory Foot and Ankle Surgery.