Metatarsalgia
(Pain in the ball of the foot)

Topics Discussed In This Section:

  • Metatarsalgia

  • Plantarflexed Metatarsal

  • Excessively-Long Metatarsal

  • Capsulitis

  • Turf Toe

  • Synovitis

  • Periostitis

  • Ligament Damage

  • Dislocated Joint

  • Cartilage Damage

  • Arthritis

  • Bone Bruise

  • Stress Fracture

  • Avascular Necrosis

  • Sesamoiditis

  • Neuroma

  • Tendinitis

  • Tendinosis

  • Neoplam

 

What is metatarsalgia?

Metatarsalgia is the name doctors give to describe pain in the ball of the foot.  The word is derived from the fact that the metatarsal bones make up the ball of the foot, and the suffix  -algia  added to the end of a word is the Greek word for pain.  Hence, metatarsal + algia = metatarsalgia. 

What are the metatarsals?

 

 

  These are the toe bones, or phalanges. 

 

 

These are the metatarsal bones.  Pain in this area is called "metatarsalgia".

Because the word metatarsalgia simply describes the general symptom of pain in the ball of the foot, regardless of its cause, it is not really a diagnosis.  The diagnosis is made after one figures out the cause of metatarsalgia.  Thus, if you go into a medical office with a complaint of pain in the ball of your foot, and come out told the diagnosis of metatarsalgia, you haven't really learned much about your condition.  All you now have is a Latin translation of the symptom you already knew you had.   

What exactly is metatarsalgia?

There are many possible conditions that occur under the general heading of metatarsalgia, and they may not be easily differentiated.  But as each condition may have a different treatment and a large number of potential causes and associated factors, it is important to be carefully examined by someone who treats a lot of feet.

We'll review some of the most common types and causes of metatarsalgia: 


Capsulitis

The thickened soft-tissue covering surrounding a joint is termed "capsule".  It's the same kind of white connective tissue you'd see if you've ever pulled a part a turkey or chicken leg and looked at the soft tissues holding the bones together.  Adding the suffix -itis to the end of a word means inflammation, so it follows that capsulitis means an inflammation of the joint covering. 

Capsulitis is very common in the ball of the foot.  Indeed, this is probably the most common cause of metatarsalgia.  Unfortunately, it is also one of the most overlooked diagnoses, which is too bad, because if your metatarsalgia is caused from capsulitis, it can usually be resolved fairly quickly.

Symptoms include aching discomfort, but it is frequently experienced as a sharp pain with pressure and with movement of the toe.  As the capsule surrounds all sides of the joint, pain may develop on either the top or bottom of the foot, or both.  But most people find the majority of their discomfort on the bottom of the foot.  

Capsulitis is most common when the bone in the ball of the foot is plantarflexed or "dropped," meaning relatively lower than the others, elongated, (both discussed above), or if it is somehow irritated with activity.  Bunions, excessive mobility in adjacent joints and bones, connective tissue disorders, arthritis, (particularly rheumatoid arthritis and osteoarthritis), equinus, sudden trauma, excessive weight, poor shoe choices (especially tight toe box and high heels), repetitive irritation from weight bearing activities, age, gender (females get this condition more, especially if they've had children), working or exercising on hard surfaces, and a host of other factors are associated with this condition.  

When capsulitis involves the great toe joint, it is sometimes known as "Turf Toe."

When the damage is severe enough, the capsule may even rupture, usually on the bottom of the foot, destabilizing the entire joint and causing a dislocation of the joint, (discussed below).  Indeed, such a rupture can be a cause of a hammertoe

There are several possible ways to treat the acute symptoms of capsulitis:  rest, ice, anti-inflammatory medications, steroid injections, massage, physiotherapy, shoe changes, and padding are just a few.  Orthoses designed to redistribute weight away from a prominent bone is likely best for chronic capsulitis. 

Surgery to repair ruptured joint capsule, or to lift, shorten, or otherwise alter a prominent bone may be indicated at times. 


Synovitis 

Synovitis is a condition of inflammation of the joint fluid known as synovium.  Yes, the fluid inside the joint can get inflamed just like the surrounding tissues. 

As the synovium is produced by the joint capsule, this condition may be closely associated with the condition of capsulitis described above, and the causes are often the same.  But trauma, infection, certain types of arthritis and other problems can, at times, inflame the synovium directly. 

If associated with capsulitis, synovitis may be treated in similar ways as describe above.  But if a result of infection, arthritis or other causes, synovitis may need very different treatment than would capsulitis.  Such treatment may even include antibiotics and surgery.  


Periostitis

Once the joint capsule passes over the joint and attaches to the bones on each side of the joint, it thins out, enveloping each bone.  This tissue--really a continuation of the capsule--is known as "periosteum", and periosteum may also become inflamed and tender, causing metatarsalgia.  Periostitis has many of the same causes as capsulitis and synovitis, but it is more closely associated with injury to the bone, itself, than the joint.  Stress fractures, discussed below may begin as periostitis.  


Ligament Damage

Each joint consists of two bones, with soft tissues holding them together.  There are various types of soft tissues that help hold bones together--including fascia, tendons, periosteum, and capsule--but ligaments, most of all, are directly responsible for this duty. 

Ligament damage may occur for many of the same reasons as the conditions above, but it is probably most frequent with sudden trauma than repetitive irritation.  

When ligaments surrounding the toe joints are damaged in some way, (irritated, stretched, or ruptured), symptoms can range from aching discomfort to deviated or misaligned toes.  

Conservative measures like rest, ice, immobilization, and anti-inflammatory medications may help, but when instability is chronic, the ligaments may be repaired surgically.    


Dislocated Joint

When the capsule and ligaments holding the joint together become compromised enough, a joint may become dislocated--where the bones making up the joint are no longer aligned.  This is particularly true with trauma.

This is more frequently seen in sudden, acute trauma or in chronic conditions is where those soft tissues are compromised enough to allow for a a subluxation (a partial dislocation), when the joint is under stress (such as being maximally flexed.  Diagnosis of this condition is more difficult because the bones may only "pop" out of alignment only occasionally.   This condition is commonly associated with the development of a hammertoe.   

Surgical intervention is usually warranted in these cases.


Cartilage Damage

The two opposing bony surfaces of a joint are covered with a smooth, glistening, pearly-white, covering known as "articular cartilage".  This is what keeps the bones from rubbing against each other.  

Sometimes this articular cartilage may become damaged from sudden trauma or from slow, repetitive trauma from misaligned metatarsal bones.  In each case, this can cause metatarsal pain (metatarsalgia).  


Arthritis

These joint surfaces can also be damaged from one of the many forms of "systemic" arthritis.  When the arthritis involves the joint where the toe attaches to the foot, it can give you pain the metatarsal area.  The symptoms from arthritis are usually more of a dull, aching type, though the pain can be severe.  Creaking motion in the joint may also develop. 

Some types of arthritis, like rheumatoid arthritis, are more likely to develop in this area of the body than other types of arthritis, like osteoarthritis.  If X-rays are suspicious for arthritis, blood work may be ordered.   

Conservative measures like rest, ice, physiotherapy, anti-inflammatory medications, range of motion exercises, shoe changes, padding, innersoles and orthoses may be helpful treatments.  Surgery, too, may be indicated.  Excision of loose cartilage, drilling of subchondral bone (the bone where the cartilage was torn away), artificial joints and other procedures may be considered.  

Arthritis and its treatments are reviewed in greater detail on another page of this website. 

Click on the X-ray of metatarsals  

to go to the Arthritis web page

 


Bone Bruise 

All of the above discussion concerned itself with various soft tissue injuries--the joint covering, the joint fluid, the joint surfaces, the supporting ligaments and tendons--but it's also quite possible that the metatarsal bones, themselves, may be injured.  This may begin as periostitis, discussed above.  

Bone bruises can develop from sudden, one-time trauma, and it can occur from chronic, repetitive injuries, like with excessive walking or running.  It may begin as periostitis, discussed above.  Shoes can also play a role in this injury, as hard-soled shoes may not absorb enough shock, and high-heels may increase weight onto these bones.

Early on, the injury consists of the bone simply being bruised.  X-rays are normal, and the diagnosis is usually made upon clinical examination. 

When the problem is acute, common treatments for this condition include rest, ice, physiotherapy, anti-inflammatory medications, shoe changes and padding.  Soft over-the-counter inserts may also help matters by cushioning the painful bone. 

When the problem is chronic, however, custom-made orthoses are helpful to redistribute weight away from the painful region.  Surgery is rarely indicated, unless the problem is a result of a misaligned or malformed bone that doesn't respond to conservative treatments. 

It is best to try to deal with this situation early, as a bone bruise may progress, eventually causing a tiny crack to develop in the bone, known as a stress fracture.  (More on this below.)


Stress Fracture

When a bone bruise (see above) gets bad enough, a tiny crack (a break) may develop in the metatarsal bone.  This is known as a "stress fracture."  

Stress fractures usually occur over periods of overuse.  Common with a sudden increase in activity, stress fractures are seen with people in high-activity jobs, Christmas shoppers, individuals starting a new exercise regimen and army recruits in basic training.  (In the military, these fractures are often referred to as "March Fractures", as they can result from long marches common in the military.

Because stress fractures are just cracked and not completely broken and misaligned, diagnosis can be difficult.  Podiatric physicians can often surmise a stress fracture is developing upon clinical examination, but definitive diagnosis, usually requires X-rays or a bone scan.  Stress fractures sometimes look normal on X-ray, however, especially when early in the process.  But they tend to become visible on X-ray when the bone begins to heal.  Bone scans are much more sensitive in showing this injury earlier than X-ray, but these tests are more invasive to the patient, and they're much more expensive. 

When the problem is acute, treatment for this condition is rest, ice, immobilization, padding and anti-inflammatory medications.  After the condition has healed enough to return to more regular activity levels, shoe changes, padding and soft over-the-counter inserts may speed recovery.  

If there is a biomechanical or structural problem, or when the problem is chronic, custom-made orthoses are helpful to redistribute weight away from the painful region.  Surgery is rarely indicated, unless the problem is a result of a misaligned or malformed bone that doesn't respond to conservative treatments, or if the stress fracture progresses to a complete, displaced fracture. 


Avascular Necrosis

When repetitive trauma to a bone like the metatarsals gets bad enough, sometimes the circulation gets disrupted, and a portion of the bone may begin to degenerate and collapse.  This condition is known as "avascular necrosis", which translates to death from lack of blood supply.  Protection of the bone and surgical intervention are commonly-employed treatments.  


Sesamoiditis

The word "sesamoid" is Greek, and it means "like a sesame seed".  The term "sesamoid" refers to any of a series of small bones that exist in some joints.  And adding the suffix  -itis  to the end of the word means that the sesamoid is inflamed. 

The number of sesamoids each of has is variable from person to person, but with rare exceptions, there are some consistencies.  For example, each of your thumbs has a couple of these bones, as do each of your big toe joints.  And many people have other sesamoids in other joints around their body, quite commonly in their metatarsal region. 

The purpose of these small bones is to help make the pull of a tendon more direct, improving biomechanical function.  In fact, even your knee caps can be looked at as a type of sesamoid bone, helping the pull of the thigh muscles (Quadriceps) become more efficient. 

Because sesamoid bones are found on the bottom of the foot, where you bear weight, they can become injured, either from direct pressure, or from chronic, excessive pull of the tendons they're assisting.

Initially, the sesamoids can become bruised, just like I described under the section "Bone Bruises".  And like the metatarsals, sesamoids can develop fractures. 

But sesamoid bruises and fractures are usually more difficult to treat.  This is primarily because the circulation to the sesamoid bone, is not great, and circulation is required for any tissue to heal. 

Treatment for sesamoiditis is initially similar to treating a metatarsal bruise or fracture.  Rest, immobilization, anti-inflammatory medications, ice, shoe changes, padding and soft, over-the-counter inserts may speed recovery.   If chronic, custom-made orthoses are helpful to redistribute weight away from the painful region.

Chronically-inflamed sesamoids are somewhat more likely to require surgical intervention than other damage to other bones like the metatarsals.  Surgery for chronic sesamoid pain and fractures usually consists of simple excision of the sesamoid.  This doesn't usually affect function greatly, but it can cause the toes to become crooked at times, so other procedures are sometimes performed along with sesamoid excision. 


Neuroma 

A neuroma consists of scar tissue surrounding a nerve in the foot, as a result of chronic irritation.  Usually this is caused from friction of the nerve between adjacent bones in the foot.  Symptoms usually consist of numbness to burning, electric pain that may shoot into the toe, or up the foot or leg. While neuromas are common, particularly between the third and fourth toes, many times this diagnosis is hastily made to describe any pain in the ball of the foot.

The topic of neuromas and how they're treated is reviewed in more depth in another section of this website. 

 

Click on the X-ray of metatarsals  

to go to the Morton's Neuroma web page

 



Tendinitis

Each toe has a lot more tendons attaching to it than you may think.  

In most cases, there are two tendons to pull the toe up, two tendons to pull the toe down, not to mention the dorsal interosseous muscles, the plantar interosseous muscles and lumbricale tendons, which exist primarily to stabilize the toe and help make the pull of the major tendons more efficient.  

With so many tendons attaching into one relatively-small structure like the toe, it may seem rather surprising these structures don't get injured more than they do.  But tendons are strong and not easily injured.

Symptoms of tendonitis include pain with pressure, joint motion (particularly against resistance), and if chronic enough, misaligned toes may develop.   

Because tendons don't have great circulation, however, when they do get injured, they can be slow to heal. 

Conservative treatment includes rest, ice, immobilization, physiotherapy, and massage.  Surgical intervention is rare, unless the tendon has become ruptured, in which case, it is better to fix the problem earlier, rather than later. 

This website has a web page that covers tendonitis in greater detail.

Click on the X-ray of metatarsals  

to go to the Tendinitis web page

 


Tendinosis

Tendinosis is a more sever form of tendinitis, one where actual degeneration of the tendon occurs.  While conservative measures may be adequate to resolve this condition, surgical intervention is more common with tendinosis than with tendinitis.  



Neoplasm

The word neoplasm refers to an abnormal growth of a tissue.  Cancer, which is very rare in the foot, is a type of neoplasm, but much more common are benign growths like fibromas (fibrous tissue growths), lipomas (fatty tissue growths), and ganglions (fluid filled growths usually coming from a joint or tendon sheath) are the most common lesions, although there are many other types of growths possible.  

Lesions can seem very hard or soft.  It can be mobile (moveable) under the skin, or fixed.  While we can often make an accurate, educated guess as to the nature of the lesion, the best way to know for certain what kind of lesion is present is when your podiatric physician sends a sample of the lesion, or the lesion in its entirety, to a pathologist, who can identify the lesion by examination under a microscope.    

Treatment of neoplasms varies, depending upon the type of lesion.  Sometimes a needle can be used to draw out the material inside a growth.  Sometimes a soft cushion in the shoe or an orthosis to redistribute weight will resolve matters.  Surgical excision of these lesions is very common, however. 


By discussing just a few of the common causes of metatarsalgia, you may be able to see why a diagnosis of metatarsalgia is not specific.  It really doesn't tell you which tissue is irritated, what mechanism caused it to be injured (and what activity needs to be avoided in the future), or how it should be treated.

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S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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