Metatarsalgia

Symptoms

The pain of metatarsalgia is usually described as sharp, although sometimes it may be a burning or [Page 868]tingling sensation at the ball of the foot. The most common areas are usually the second, third, or fourth metatarsals. Patients may complain of worsening of the pain with walking or running, usually during the midstance or push off phase. The pain may improve with rest or non–weight bearing. There may also be pain with just standing. Pain is usually worse when associated with barefoot walking on hard surfaces.

Usually, the pain develops gradually and is not necessarily associated with any trauma. Sometimes, if a neuroma is involved, there may be numbness of one or multiple toes.

The history should also include a thorough training history, either increases in mileage or intensity. The type of terrain can play a role if the athlete mostly trains on hard surfaces such as concrete. Age of training footwear (generally recommended to be replaced every 300–500 miles [mi; 1 mi = 1.61 kilometers]) can definitely play a role. A new shoe that may not be appropriate to the athlete's foot mechanics can also contribute to the pain; for instance, a motion control shoe on an athlete with pes cavus and supinates may not provide enough shock absorption.

Causes

Metatarsalgia is often seen in the context of increases in training. Increased training increases the repetitive load, increasing the risk for stress fracture, fat pad atrophy/contusion, sesamoiditis, and breakdown of shoe cushioning.

Certain physical characteristics also increase the risk for metatarsalgia. A longer second toe than the first one shifts more weight to the second metatarsal head. Weight gain can obviously increase the load on the metatarsals. Hammertoes (flexed, curled toes) due to high heels or shoes that are too small cause depression of the metatarsal heads. Bunions (hallux valgus) result in a hypermobile and weak first toe, which offloads pressure to the second metatarsal. Fat atrophy from aging can be a risk for the elderly.

Shoe wear can definitely play a role in the development of metatarsalgia. As previously stated, old shoes that have lost their cushioning ability will more directly transmit shock. Toe boxes that are too narrow can irritate a neuroma due to constant compression. Daily wearing of high heels will place extra load on the metatarsals. Shoes that are too small can be a common problem, especially in new marathoners who do not take into account the swelling caused by long hours of running.

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