Metatarsalgia (MET – tuh tar – SAL – juh) is a catch-all term used to describe a number of conditions which cause pain in the ball of the foot. “Metatarsal” is the name for the long bones in the foot and the suffix “algia” means pain. This term appropriately describes the condition of pain in the metatarsal area. The heads of the central metatarsals, 2, 3 and 4, make up what most consider the ball of the foot and they are the most commonly affected. Due to excess pressure, overuse and/or microtrauma, one or more of the heads of the metatarsals become inflamed and painful.
Symptoms: The pain is generally deep, dull and achy with rest but may be sharp and stabbing with walking. There may be shooting pain or tingling in the toes. A feeling of a “bunched up sock” under the foot or walking on a lump or pebble is common. The pain is generally worse with walking and especially painful when pushing off of the forefoot. Activities such as running, jumping or squatting will worsen the pain. Certain shoes, especially tight or constricting shoes, will also worsen the pain. Rubbing or massage may alleviate the pain, but only briefly.
Causes: Metatarsalgia is caused by a combination of faulty foot mechanics, poor footwear and overuse.
- Faulty Foot Mechanics: The common biomechanical causes of metatarsalgia are tight calf muscles, overpronation and hypermobility of the 1st ray. Many times these three occur together. When the calf muscles are tight, the heel lifts early during walking, shifting the weight from the heel to the forefoot. This places excess stress on the forefoot. Over-pronation is a motion described as “rolling in” of the foot and collapse of the arch. This motion commonly occurs with hypermobility of the 1st ray. This means that as the arch collapses and the foot rolls in, the 1st metatarsal and big toe joint are forced upward. The result is a shift in pressure from the big toe joint to the lesser metatarsals. The great toe is designed to carry a substantial amount of body weight during the “push off” phase of gait. When the great toe does not carry it’s fair share of the load, the lesser metatarsals, which are much smaller and more narrow, are forced to carry the extra weight and force.
All of these factors contribute to excess weight, force and repetitive stress on the ball of the foot. The metatarsal heads and the metatarsal phalangeal joints (MPJs) respond by becoming inflamed and painful. Athletes, especially runners, have a high risk of developing metatarsalgia because of the impact on the forefoot. Hill climbing in particular, places a substantial amount of pressure on the forefoot. When a runner changes their training regimen or adds hills or sprints to their training, excess pressure can cause pain and inflammation at the metatarsal phalangeal joints. Poor quality shoes which do not offer enough support, or enough shock absorption can also contribute to the development. More on faulty foot mechanics as a cause of common foot problems.
- Structural deformities: Hammertoes can cause pain under the ball of the foot because their crooked shape cause retrograde pressure on the metatarsal head. As the toe cocks-up, the metatarsal head is pushed down. The bone is now prominent on the bottom of the foot and susceptible to increased force and pressure with every step. A bunion is a structural deformity at the big toe joint. As the metatarsal bone moves centrally, the big toe moves toward the little toes. This position causes the big toe joint to not function properly, shifting the weight to the lesser metatarsals. Individuals with cavus feet (very high, rigid arch) place excess stress on the ball of the foot as well.
- Ill-fitting shoes: One of the more common reasons for the development of metatarsalgia. Shoes which are too tight at the forefoot compress the metatarsals together. This impairs normal function of the forefoot during walking, increasing rub and irritation in the area and resulting in pain and swelling. More on shoes.
- Overweight: Excess weight on the body, or in the form of carrying a newborn, can place excess stress on the entire foot contributing to heel, arch or forefoot problems. Overweight individuals with faulty foot mechanics, as mentioned above, or wearing poor shoe gear may develop metatarsalgia. More on weight loss.
Other causes of pain in the ball of the foot include infections, arthritis and nerve disorders. A neuroma is an inflamed nerve in the bottom of the forefoot which cause sharp pain in the ball of the foot with shooting pain and tingling in the toes. A neuroma can be confused with metatarsalgia. Although some of the treatments may be the same, distinguishing a neuroma from a problem at the joint is important.
Treatments: Identifying the cause of the problem is the most important step in treatment. If metatarsalgia is caused by faulty foot mechanics, orthotics may be prescribed. If metatarsalgia is caused by improper shoe fit or poor quality shoes, a change should be made immediately. It’s a common mistake to think that the softer the shoe and the more cushioned the shoe the better the shoe. A shoe with a rigid sole, which flexes only at the toes, has at least 1/2 inch wedge at the heel and adequate shock absorption is the best shoe for this condition. The more flex in the shoe and at the toes, the more weight that is placed on the ball of the foot. Although high heels, over 2 inches, will place excess stress on the ball of the foot, a shoe without a heel doesn’t allow for adequate weight distribution and may actually increase the pressure in the ball of the foot. Tight calves will cause the heel to lift early and increase pressure on the ball of the foot. To address this cause, calf stretching exercises and a heel lift will distribute the pressure more evenly. Training regimens for athletes should be modified slowly, gradually introducing hills or stairs. Hammertoes and bunions should be treated appropriately. Lastly, there are many types of metatarsal pads to help distribute pressure and alleviate stress on the metatarsal heads.
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