metatarsalgia (forefoot pain)

Etiology

(differential diagnosis)

• 1st metatarsal pain
  • bunion/hallux valgus
  • hallux limitus/rigidus
  • sesamoiditis
  • Morton's foot
• other
  • neuroma (interdigital or Morton's neuroma)
  • sprain
  • calluses or warts
  • metatarsal stress fracture*
  • posterior tibial nerve entrapment
• general
  • arthritis
  • diabetic neuropathy
  • infection
  • peripheral arterial disease

* suspect stress fracture when 2nd, 3rd or 5th metatarsal involved

Clinical manifestations

• paresthesias suggests neurologic origin
• great toe pain on tiptoeing suggests hallux rigidus or sesamoiditis
• atraumatic hot, swollen 1st toe, with gnawing or throbbing pain suggests gout or infection
• stocking distribution to pain suggests diabetic neuropathy
• tenderness may be present
• decreased plantar/dorsiflexion at 1st metacarpal suggests hallux rigidus/limitus
• lateral protuberance from a bunion
• hyperesthesia in web space of toes suggests neurologic origin
• positive Mulder's sign
• pain only with weight-bearing & point tenderness over bone suggests metatarsal stress fracture

Laboratory

• joint aspiration if gout, pseudogout or joint infection suspected

Diagnostic procedures

• electromyography (EMG)
• nerve conduction velocity
• a 3 mm skin punch biopsy of distal calf can reveal small fiber neuropathy

Radiology

• plain radiograph of foot (may be normal with stress fracture)
  • MRI if stress fracture suspected

Management

R: rest from pain-eliciting activities I: ice for 20 minutes several times/day while area is swollen C: compression with padding & a wrap E: elevation above level of heart to reduce edema D: non-steroidal anti-inflammatory Drugs (NSAIDs) for pain & inflammation if not contraindicated

• avoid constrictive footwear
• neuroma:
  • metatarsal pad
  • corticosteroid injection
  • physical therapy
  • surgery
• hallux limitus/rigidus
  • padding to shift weight laterally
  • hard sole shoe
  • joint injection with corticosteroid/anesthetic
  • surgery
• urgent referral to orthopedic surgeon if acute neurovascular impairment

More general terms

• foot pain

Additional terms

• Morton's foot
• Mulder's sign