Metatarsalgia Foot Pain

A Series of foot Conditions

Rheumatism is as meaningless as arthritis, failing to convey the origins or cause. Similarly, metatarsalgia is meaningless unless it implies that pain exists under the ball of the foot. So this is not a foot disease in itself. Technically, algia is Greek for pain, so it means metatarsal pain

Metatarsalgia contributes to several conditions, and the reader should appreciate the complexity involved in making a diagnosis. If you have been to see someone and the pain has not cleared up, you might wonder if they have failed. The chances are that you have one of several conditions.

Why not read more about Morton's Neuroma on this site?

Rest easy, for the most part, the diagnosis is straightforward. I have taken the following article from my current book, Morton's Neuroma. Podiatrist Turned Patient, launched in October, although I have added some supplementary material. There is much you can do yourself for Morton's neuroma, also known as plantar digital neuroma, for reasons that fall outside the scope of this article. Take a look at this diagram to see where we are on the foot.

The location of metatarsalgia is across the metatarsal heads, which form a joint with the toe bones (phalanges).

What are Metatarsals?

These are the longest bones in the feet and give rise to the end closest to the toes, upon which we pivot when we walk as the heel lifts. Suffice it to say, the end of the metatarsal takes a good deal of weight across its five metatarsal heads.

There are five metatarsals, which are the longest bones in the foot.

You have foot metatarsalgia. Now, which type of pain do you have?

Is it obvious - blister, wart or callus? Have you stepped on something and it has become buried, like a splinter? The chances are you have looked so that we can rule out an external effect. However, even small corns, dog hairs, and foot warts (verruca) can cause unbelievable pain, and once cleared up, walking returns to the comfortable state you had expected.

Foreign bodies include any non-human biological material that finds its way into the foot. Hair, wood and glass are all contenders for the cause. Once the skin closes over the foreign body, visualising the problem becomes difficult.

A 45-year-old woman presented with neuroma pain. Upon examination, I removed a small shard of glass that was lodged deep in the second interspace. After its removal, the nerve did not recover as anticipated, necessitating a second surgery to address the nerve. Unfortunately, the aim of being minimalistic fell short in this case.

This is a well-established callus appearing directly over the metatarsal head of the second metatarsal.

In essence, pain varies between different conditions, so some discomfort arises from nerve impingement (neuroma) or burning sensations. The tell-tale is what brings the discomfort on, and how long has it been present?

 A list of differential diagnoses

There is more than one condition that can cause metatarsalgia, foot pain.

• Arthroses.

• Metatarsal bone pad bruising.

  • Metatarsal lipoatrophy

• Foreign body. (see text above.)

• Fracture metatarsal.

• Arthritis.

• Osteochondroses (Freiberg's)

• Plantar digital neuroma.

• Plantar plate tear

• Bursae.

• Referred pain (tarsal tunnel syndrome).

Arthroses

Commonly known as arthritis, the joint condition is associated with inflammation. Osteoarthritis is less common between the metatarsals and phalanges (toe bones) than simple inflammation, due to overuse. However, when we undertake bunion surgery, joint damage associated with cartilage loss is commonly identified. This is wear and tear and not osteoarthritis, the disease.

A common form of arthrosis affecting the ball of the foot is transient synovitis or capsulitis. Like any part of the body that has repeated stress, the joint rebels. Transient synovitis can press on digital nerves, setting off a sensory change because the swelling of the lining takes up space where a nerve might travel. The nail of the affected toe may feel as though something is localised, and yet on examination, there is nothing to see. If left, erosive changes could take place in the cartilage.

The least common forms of arthritis are associated with gout and psoriasis. Rheumatoid arthritis is on par with psoriatic arthritis, while gout is more common than both. Modern diagnostic blood tests and early use of medication can reduce what once were horribly deformed feet under the ball.

Bone development fault: A fault in growth can affect the second and third metatarsals, suggesting pain under the ball of the foot. In the latter case, these are known as osteochondroses, such as Freiberg’s disease, related to the second metatarsal and Kohler II affecting the third metatarsal. As these effects are more noticeable in younger people, it is usually easier to spot them on an X-ray. Be aware that the long-term effects of Freiberg's disease in patients can occur in over fifty-year-olds. Neither is a disease. (I've used Wikipedia for the reference here as it provides good insight and shows the X-ray of the metatarsal head.)

Metatarsal Pad Bruising

As with heel bruising, see my article, the fat pad and underlying tissues can become inflamed. It does not take long before you start limping. Reduced activity, ice, local anti-inflammatory gels, and a soft insole or pad can help relieve the discomfort over a few weeks. Thicker soled shoes with more cushioning are best. For exercise, use a bike rather than a treadmill. This advice applies to most cases of metatarsalgic pain.

Lipoatrophy, not to be confused with lipodystrophy, can arise in the foot for different reasons unrelated to genetic disease. The loss of fat padding under the metatarsal heads increases pain during walking.

Fractures

We must rule out apparent features such as a metatarsal fracture. The problem with foot (metatarsal) fractures is that they can remain obscure and hidden as a cause of pain for months. I have seen patients walk into the clinic not knowing they've fractured their metatarsal. In many cases, stress fractures will settle, while X-rays do not show up for several weeks. Clinically, these can easily be missed.

The neck of the longest bone (second metatarsal) is most exposed and cracks around the thinner area of the neck of the bone, without displacement.

Check out my article on broken foot bones — Foot Bones Most at Risk.

Plantar Digital Neuroma

The foot has dividing branches of nerves, and the gap between the second and third metatarsals, as well as the gap between the third and fourth metatarsals (Morton's neuroma), can lead to nerve pinching. A neuroma is a swelling of a section of nerve. With time, the nerve deteriorates until it no longer functions normally. This means nerve signals alter - hence, symptoms change.

The third to fourth space between the metatarsals is associated with the classic foot neuroma. Taken from my book - Morton's Neuroma Podiatrist Turned Patient.

The nerve is compressed over time, and symptoms include shooting pain and electric shocks. Diagnosis is made from scans such as MRI and ultrasound with a high degree of sensitivity. The scans do not show early signs, which can take months to form the classic nerve swelling.

I have devoted a whole book to Morton's neuroma, not least as I suffered from this problem myself and had surgery.

Morton's Neuroma 2nd Edition with expanded treatments, more self-help tips and self-diagnosis methods. eBook, paperback and hardback.

A word about tumours:

Although rare, tumours (Greek for swelling) other than neuromas can develop within the foot and indeed compress nerves. Most foot tumours are non-malignant; however, I would always advise anyone with a suspicious swelling to consult a clinician for guidance, even if it is not painful. If the toes are separated, they can be influenced by a tumour, although, mostly, one of the toes is likely to be dislocated and out of alignment. Bursa is the most common tumour, alongside a neuroma.

Bursa

A bursa can coincide in the metatarsal spaces and confuse the clinical and radiological signs. This is a sac of fluid with an organised capsule. An inflamed bursa in the intermetatarsal space can, therefore, be considered one form of metatarsalgia.

Bursae (plural) are not only located between the metatarsals but can also develop beneath the ball of the foot. Once organised, these are more obvious and appear as soft, squishy swelling.

These flattened sacs form within the fat pad, become inflamed, and fill with specialised healing cells that combat the inflammation, often failing to shrink or disappear. Symptoms resemble those of a neuroma but can typically be distinguished, as a squashing sensation is felt under the foot. Furthermore, some of these inflamed bursae may extend across all three central metatarsals.

Nine per cent of my cases, taken from 91 histology reports, showed symptoms associated with bursae due to a damaged nerve. Among those reported, 13% had mixed neuromas and bursae^[1].

Referred Pain

Pain that is not directly located in a specific site can arise from a different area. This includes the spine where nerves branch out. The commonest form of metatarsalgic pain originates from a large nerve around the ankle, which is associated with tarsal tunnel syndrome (TTS).

Because the subject of referred pain is vast, you can read my article on this site for further information. If your foot feels as if it is bursting, consider consulting a specialist (orthopaedic surgeon or podiatrist [2]) who can run tests and start a programme of treatment.

Thanks for reading 'metatarsalgia foot pain' by David R. Tollafield.

ConsultingFootPain is part of Busypencilcase Communication & Publishing. Est. 2015.

^[1] Tollafield –Histology collection of reports from foot surgery ~ unpublished; 1996-2001.

[2] Not all podiatrists are equipped to treat TTS, so it is best to ask when making an appointment. The NHS has podiatry specialists in musculoskeletal (MSK) problems, and some NHS Trusts have podiatric surgeons who can assist, or you can refer to an orthopaedic surgeon specialising in the foot & ankle.