01
Common conditions that come under the broad category of metatarsalgia:
Morton’s neuroma
Morton’s neuroma is one of the most common causes of forefoot pain. This condition refers to the entrapment of the common digital plantar nerve that runs between the metatarsal bones. The nerve in the third webspace of the foot is most frequently affected, followed by the second webspace. Mechanical irritation of the affected nerve causes numbness, and sharp burning pain which can shoot towards the toes.
Intermetatarsal bursitis
Intermetatarsal bursae are small fluid filled sacs that act as a cushion between the interossei muscles and metatarsal heads. Compression, trauma and repetitive use of the joints can result in increased friction to the bursal sacs, leading to inflammation. Sometimes, bursitis can occur in conjunction with neuromas, forming an interdigital mass known as a bursal-neuroma complex.
Capsulitis
The metatarsophalangeal capsule ligament surrounds the metatarsophalangeal joint to make up the joint capsule. Chronic overloading of the joint or sudden trauma can lead to capsular inflammation and progressive weakening of the ligament if not treated. Capsulitis most commonly occurs in the 2nd toe joint.
Plantar plate injury
The plantar plate is a ligamentous structure which lies beneath the metatarsophalangeal joints of the lesser digits. It is responsible for holding the toes in position, and preventing hyperextension (bending upwards) or splaying. Injury or chronic stretching of the plantar plate ligament can lead to the toe drifting out of alignment, and eventually dislocation. Hammertoe deformities are often acquired this way. Much like capsulitis, it is most common for the 2nd toe to be affected.
Sesamoiditis
Sesamoiditis is a common cause of pain in the bottom of the big toe joint. The sesamoid bones are two small oval shaped bones that sit beneath the 1st metatarsal head and are embedded in the toe flexor tendon. Together, these structures assist with the transfer of force through the big toe joint while walking or running and help bend the big toe joint for propulsion. Because of the anatomical location and function, the sesamoids are subjected to large amounts of force, which can result in inflammation.
Fat pad atrophy
This refers to the thinning out and/or displacement of the fat pad underlying the plantar forefoot area. The metatarsal fat pad functions to cushion the bones, ligaments, tendons and neurovascular structures in the forefoot. Metatarsal heads affected by fat pad atrophy may appear prominent due to the loss or shift of the fat pad. It can often result in very painful and sensitive feet, making barefoot walking quite a painful experience!
03
Treatment for forefoot pain
At Shellharbour Podiatry accurate diagnosis of the underlying cause of your metatarsalgia is the essential first step. Once this is determined, we use a combination of the following to address and treat metatarsalgia.
Anti-inflammatories: Oral non-steroidal anti-inflammatory medications (ibuprofen) or cortisone injections may provide short term relief, but do not address the underlying issue. Anti-inflammatories are not suitable for all types of metatarsal conditions.
Metatarsal domes: Strategically placed in your shoes to lift up the transverse metatarsal arch reduce forefoot pressure and open up the intermetatarsal spaces
Deflective in-shoe padding: To offload particular metatarsal heads.
Exercises: To address muscular imbalances and tightness, may include intrinsic foot muscle strengthening and calf stretches.
Footwear: Supportive footwear with adequate width and depth in the toe box is important for forefoot issues.
Orthotics: This will address underlying biomechanical issues that may be contributing to abnormal forefoot loading.
