Metatarsalgia

Definition

Metatarsalgia can be literally translated as pain under the metatarsal (= metatarsal bones) heads.

Symptoms
This pain is typically found at the bottom of the tip of the foot, where the toes begin. It is a stress-related pain, which is due to a pressure at that specific place. Callus formation is often a sign and can be present very locally, e.g. under the second metatarsal head, or more spread over the entire forefoot. Most patients get pedicures or podiatric care for a while, but the callus returns again and again.

As long as the overpressure, and thus the cause, is not handled, the callus will always redevelop. So, some overpressure problems are treated as warts. To speak of metatarsalgia, callus does not need to be present.

The overpressure may also manifest itself in other ways, but they are always variations on the broad term “metatarsalgia”: a stress fracture of the metatarsal or phalanx, a rupture of the stabilizing plantar structure of the metatarsophalangeal joints:, a dislocation of the toe, the formation of hammer toes,…

Causes
Multiple causes may underlie this problem. The overpressure may be due to a shortened Achilles tendon : a metatarsal which is anatomically too long or to steep compared to the other, an age-related sagging of the forefoot, often in combination with hallux valgus, in certain high arched feet, in certain neurological disorders,…


Medical treatment

The treatment is primarily non-operative and should be adressed to the metatarsalgia producing pathology.  The pressure on the forefoot can be reduced by performing stretching exercises at the level of the lower limb, mainly of the Achilles tendon. Custom-made orthopaedic or podiatric insoles might as well redistribute the pressure under various metatarsal heads. The shoewear can be modified by using a rocker-bottom sole to relief the metatarsal heads from punctual overload.

Sometimes, in very specific cases, an infiltration, followed by several weeks of taping, can bring some comfort.


Surgical treatment

If these treatments are not sufficient, surgery may be considered, depending on the defects and causes. In any case, the entire foot has to be taken into consideration:
           -        Lengthening of the Achilles tendon, or of a part of it;
           -        Transfer of a flexor tendon to the top of a toe;
           -        Suture of the stabilizing plantar structures;
           -        In case of hallux valgus or varus, they also should be surgically corrected.
           -        The most common procedure is an osteotomy, in which the metatarsal bone (one or several), responsible for the overpressure, is relieved by making it a few millimetres shorter, or by slightly lifting it up. After such an osteotomy, a screw or some kind of osteosynthesis is usually placed, to make sure that the predetermined shortening is maintained. After the operation, one may in fact immediately lean on a specifically designed postoperative shoe.


Post-operative care

Depending on the kind of surgery that was done, the postoperative course consists of partial weightbearing for up to 6 weeks in a   special postoperative shoe .

The surgery can take place in day hospital or in cases of more complex surgery also in combination with a short in hospital stay.

Today we often use some kind of nerve blockade to keep the patient painfree in the initial time periode after surgery, usually for the first 24- 48 hrs after the operation.

Physiotherapie including lymphdrainage is recommended for the first 4- 6 weeks after surgery. In cases of preexisting venous insufficiency or chronic lypmphatic edema the use of compression stockings for a longer time periode may be favorable.