Pain and overload of the metatarsal head region has been termed metatarsalgia. The etiology is often complex, with body habitus, foot deformity, muscular imbalance, training style, training surface, chosen sport, and shoe wear all contributing to the problem. The addition of heavy equipment to the player also increases risk of metatarsalgia.

By definition, metatarsalgia is pain under the metatarsal head, and for this discussion, we concentrate on the second through fifth metatarsals. Pain under the first metatarsal head is often a sesamoid problem and is discussed subsequently.

Generally, the patient will present with complaints of pain with ambulation. It is important to take a complete medical history from the patient, as rarely an underlying inflammatory

Turf Toe Syndrome
Figure 71-5 Turf toe injury with irreducible dislocation of the first metatarsophalangeal joint. Anteroposterior (A) and lateral (B) radiographs of a turf toe injury with an irreducible dislocation. The sesamoid complex is disrupted, and the metatarsal head is buttonholed through the plantar plate.

arthropathy (like rheumatoid arthritis) or neurologic abnormality (such as Charcot-Marie-Tooth syndrome) will present as metatarsalgia. It is also important to obtain a complete description of the pain and aggravating and alleviating factors. Some patients will have pain alone; others will present with pain, intermittent numbness, a burning sensation, and varying degrees of plantar callus making it very difficult in some cases to differentiate between metatarsalgia and nerve entrapment on physical examination alone, and the history often gives the best clues to the diagnosis. Most patients with metatarsalgia will describe an insidious onset of symptoms. It often starts as a feeling of a marble, pea, or a swollen feeling under the forefoot. Pain generally increases with activity, although some runners will describe that an area hurts initially, then goes "numb" after a certain point during their run, and then later hurts more. Almost universally, however, patients will report that the pain is worst barefoot on hard surfaces (in the shower, for example) and feels better in a padded shoe and/or on carpet. Often their good athletic shoes feel the best on the foot, and dress shoes (especially heels) make it worse. Unlike nerve entrapments, patients with metatarsalgia do not report that they remove their shoe and walk barefoot to relieve the pain.

All patients should have weight-bearing radiographs. On a weight-bearing radiograph, the functional position of the foot is most apparent. The angle of hallux varus, intermetatarsal angle, and presence of abnormalities can be most correctly identified.

Physical examination is directed toward identifying the source of the pain. Again, it may be difficult to differentiate metatarsalgia versus a nerve problem on examination alone. Patients with metatarsalgia will be tender directly under the metatarsal head, at the level of the metatarsal phalangeal joint. They are nontender, or minimally tender, in the web spaces associated with the joint. The joint may be swollen, and a Lachman's test to evaluate dorsal-plantar stability should be performed. The position of the toes should be noted. It is important to evaluate dorsiflexion, plantarflexion, lateral deviation, and the presence or absence of fixed angulation of the toe joints. There may be varying degrees of callus formation, from broad diffuse callus to small punctate keratoses. Often patients will have associated deformities causing the metatarsal overload. Hallux valgus and metatarsus primus varus lead to elevation of the first ray and commonly to an overload of the second metatarsal head. Patients with hammertoes and claw toes will have more metatarsalgia, as the metatarsal head is pushed plantarward in these deformities. Congenital deformities can also increase the risk of metatarsalgia, including metatarsus adductus and cavo-varus feet.

An additional predisposing factor to metatarsalgia that may be overlooked is tightness in the gastrocsoleus complex and hamstrings. This inflexibility leads to increased forefoot pressures and often metatarsal pain.16

Treatment of metatarsalgia is initially conservative. As previously described, heel cord and hamstring stretching may be quite helpful. Shoe modification is essential. A simple felt pad that sticks to the liner of the shoe may be enough, or a more complex custom orthosis may be indicated (Fig. 71-6). Metatarsal bars are not useful in the athletic population. It is important to examine the athlete's training shoe. In cyclists and soccer players, the shoe may be too small or too stiff, contributing to the problem. These patients should be encouraged to choose wider shoes with better padding in the forefoot and deeper toe boxes. In addition, patients should be instructed to

Figure 71-6 Metatarsal pad.

pumice or file their calluses frequently, as the thicker skin often increases pain.

Surgery is rarely indicated for metatarsalgia. When performed, it should be directed at the deformity causing the problem: correction of hallux valgus, hammertoe, claw toe, or plantar condyle prominence. Surgery to shorten or elevate the metatarsal alone is fraught with difficulty and has a high risk of transfer metatarsalgia or other problems.

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