|
Metatarsalgia
(Pain in the ball of the foot)
|
 |
Topics Discussed In This Section:
|
|
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 (metatarsal pain).
What are the metatarsals?
|
|
|
These
are the toe bones, or phalanges. 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 Greek translation of the symptom you already knew you had.
Then what condition 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 is a tough, cylindrically-shaped connective tissue that completely surrounds both the metatarsal and toe bones as they come together to form the joint. |
You can get a good idea of what capsule looks like the next time you see a turkey or chicken leg. Joint capsule is one of those thick, tough, white soft tissues holding the bones together.
As we've mentioned before, the suffix -itis means inflammation, so it follows that adding it to the word capsule (forming the new word
capsulitis) refers to the 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.
In other words, if you bend the toe upwards or downwards, you may re-create the painful symptoms, because you're stretching the capsule.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 common when the bone in the ball of the foot is plantarflexed or "dropped," meaning relatively lower than the others. It is common, too, when the inflamed metatarsal is excessively long. Trauma, too, whether of a gradual onset or a sudden onset, may create the problem.
The presence of 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) hammertoes (Contracted Toes).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 may be indicated when it's torn. If the metatarsal bone is "dropped" or too long, surgery may be considered to lift or shorten the bone. Over a dozen procedures may be considered for this, but two commonly employed for this procedure are the
Jacoby Osteotomy (a "V"-shaped bone cut made from top to bottom, allowing the bone to elevate) or a Weil Procedure (an oblique bone cut that allows the bone to be elevated and shortened.)Synovitis
Most people don't realize it, but the joint fluid can get inflamed just like the surrounding tissues. This joint fluid is known as "synovium", so inflammation of the synovium is known as "synovitis".
|
|
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.
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.
|
|
As you can see from the picture on the left, the two bones are being held together by a white, connective tissue marked "MCL" (for Medial Collateral Ligament). It should be easy to see how much the joint would be compromised if that ligament were to rupture, and this is exactly what can happen. |
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.
|
Of course, a sudden, severe trauma may cause the toe to become completely dislocated, (as with the picture to the right). But the same problem to a lesser degree may also develop. A joint may become partially dislocated, deviated, or misaligned--or it may become so only intermittently--particularly when the joint is under stress, such as being maximally extended. This type of problem is usually a result of minimal but repetitive trauma that causes the joint covering (capsule) to weaken, and eventually tear or rupture. |
|
Diagnosis of this condition may
be complicated because the bones may only "pop" out of alignment only
occasionally. This condition is commonly associated with the
development of a
hammertoe.
Surgery is required in these cases, though it needs a unique surgical repair
compared to a typical hammertoe.
Cartilage Damage
|
The two opposing bony surfaces of a joint are covered with a smooth, glistening, pearly-white, covering known as "articular cartilage" or "hyaline cartilage". This is what keeps the bone surfaces 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 (cartilage) 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 |
Periostitis
Where the joint capsule attaches
to the bone, it thins out and envelopes the bone. This tissue--really a continuation of the
capsule--is known as "periosteum", and periosteum may also become
inflamed and tender, and thereby be a cause of 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.
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. Bone bruises can develop from
sudden, one-time trauma, and it can occur from chronic, repetitive
injuries, like with excessive walking or running. 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.
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 may require 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. The fracture may develop what appears to be a cloud of "fluffy"-looking bone around the fracture site. This appearance is evidenced on the X-ray to the right.
|
|
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
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.
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 one of the most common concerns patients have, and they are reviewed in more depth on a separate page on neuromas.
Tend
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 tendinitis in greater detail.
Tendinosis
Tendinosis is a more severe 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.
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 benign growths like fibromas (fibrous tissue growths), lipomas (fatty tissue growths), and ganglions (fluid filled growths usually coming from a joint or tendon sheath), and many other types of growths, are much more common. Neoplasms of bone are also common.
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
orthotics 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.
_________