Metatarsalgia is common term employed in medicine and the sports/footwear industry to describe pain under the forefoot. As the term is an umbrella diagnosis there are many specific clinical diagnoses which comprise this term.

Unfortunately, making a more specific clinical diagnosis in cases of metatarsalgia can be tricky for many clinicians as the forefoot is a complex area of speciality within orthopaedics and scans need to be read and interpreted with significant clinical experience.

For persistent or disabling cases of metatarsalgia, it is recommended to book an appointment with an experienced orthopaedic ankle and foot surgeon to get an accurate diagnosis prior to commencing further treatment.

Circle Health is able to offer short notice appointments with foot and ankle specialists following injury or following a gradual onset of pain. Our experts are able to give our clients an accurate diagnosis and appropriate management plan based on expert history taking, physical examination and clinical experience. Diagnostic scans as needed can be booked without delay as needed prior to any follow up appointment.

The most common cause of metatarsalgia is a simple pressure related problem through the forefoot which is unrelated to any structural problems to the joints and soft tissue in the area i.e. diagnostic scans may be normal. More specific causes of metatarsalgia are outlined further.

Morton’s neuroma describes a formation of scar tissue in the nerve which runs between the base of the third and fourth toes. When weight bearing through the forefoot while wearing tight fitting footwear the neuroma can be compressed between the toes, leading to pain and tingling.

Lying between the skin and the bones at the base of our toes there is a fluid filled protective pad known as a bursa. In some cases this bursa may become painful itself leading to swelling and inflammation.

Lastly the joints of the forefoot known as the metatarsal-phalangeal joints (MTPJ’s) may be a source of forefoot pain due to a variety of reasons. Age related changes to these joints or acquired deformity elsewhere in the foot leading to angulation or excessive pressure the the MTPJ’s may contribute.

In most cases of metatarsalgia, there is an underlying biomechanical cause. Common biomechanical causes can include:

  • High arch foot which causes excessive pressure towards the heel and forefoot
  • Deviated big toe (hallux valgus) which is often genetic and may squeeze the other toes leading to deformity
  • Stiff calf muscles which leads to greater pressure through the forefoot when walking
  • Wide forefoot which leads to squeezing of the toes in normal footwear

Specialist x-ray views of the lower leg, ankle and foot may be requested in a weight bearing position to give further information on any structural problems which may be causing metatarsalgia.

For detailed anatomical views of the forefoot area the scan normally requested is an ultrasound scan which is able to give excellent images of any morton’s neuroma as well as locate any areas of inflammation.

Depending on the specific diagnosis being managed the most effective diagnostic tests may not aim to help with a specific diagnosis but may give useful information concerning biomechanical problems which may be causing the metatarsalgia.

Circle Health is able to offer a comprehensive biomechanical review with a podiatrist or orthotist who work closely with our orthopaedic ankle and foot specialists. Force plates, motion camera technology as well as pressure pads placed inside footwear enable the download of useful data concerning pressure points and any abnormal foot postures which occur during walking and running.

In many cases, the first line of management will involve the production of insoles (orthotics) which are aimed at correcting any underlying biomechanical problems identified during the clinical examination force plate/motion camera analysis. The orthotics will be tailored to each patient and several pairs are sometimes needed to fit with each type of footwear needed.

Some cases of morton’s neuroma and bursitis may not settle entirely with appropriate orthotics. As such, ultrasound guided corticosteroid injections may be advised in specific circumstances by an orthopaedic consultant.

Finally, if pain and disability persist an ankle and foot consultant surgeon may offer surgical solutions to treat metatarsalgia. Surgical management of forefoot problems can range from being very simple procedures such as a morton’s neurectomy (removal of a morton’s neuroma) to highly invasive procedures such as midfoot, forefoot and toe joint fusions and corrections to the angle of the ankle and foot.

A common surgical practice aimed at relieving some forms of metatarsalgia involves straightening the big toe to reduce pressure on the subsequent toes and forefoot. The most common way of achieving this is through an operation known as a scarfe osteotomy.

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