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Metatarsalgia is a symptom complex of pain localized to the forefoot.
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There are many etiologies to metatarsalgia.
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Hammer toe, mallet toe and claw toe are lesser toe deformities created by an imbalance between the extrinsic and intrinsic musculature of the foot.
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Most conditions of the forefoot can be treated successfully with shoe modifications and off the shelf appliances to alleviate areas of pressure.
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When conservative treatment is unsuccessful, referral to a foot and ankle specialist is
Metatarsalgia, Lesser Toe Deformities, and Associated Disorders of the Forefoot
Section snippets
Key points
Metatarsalgia
Metatarsalgia is a term attributed to pain localized to the forefoot region. While there are many conditions that create pain in the forefoot, the term metatarsalgia serves to differentiate such conditions from pain in the area under the second, third, and fourth metatarsal heads.1
Pain localized to the forefoot may be associated with disorders of the hallux and lesser toes. It is also important to recognize that in addition to these entities there are conditions of the hindfoot, ankle, and leg
Lesser toe deformities
Lesser toe deformities can create a considerable amount of pain for an individual and negatively affect one’s quality of life.10 Deformities of the forefoot can have multiple causes, which may include a traumatic event, improper shoe wear, neuromuscular disorders, and inflammatory and metabolic diseases. These conditions lead to alterations in the normal anatomy, which ultimately create an imbalance in the muscle-tendon units that control the positioning of the lesser toes.
When the foot is
Associated forefoot deformities
In addition to the aforementioned lesser toe deformities, 2 additional conditions can be considered along a continuum of progression of lesser toe abnormality: monarticular nontraumatic synovitis and instability, subluxation, and dislocation of the MTP joint.
Monarticular synovitis is characterized by swelling of an isolated MTP joint, which can be seen in the absence of a traumatic event or inflammatory disease.21 The etiology is thought be related to proliferation of inflammatory synovium.
Disorders of the plantar skin
Discrete intractable plantar keratoses and diffuse plantar keratoses are conditions of the plantar skin associated with hyperkeratotic disorders of the skin. A discrete plantar keratosis is typically seen under a singular metatarsal head, and can be a significant source of pain and disability.23 These “seed corns” are characterized by a core of avascular tissue that is tender to direct pressure. It is typically localized under a metatarsal head, and may be associated with a prominent fibular
Interdigital neuralgia (Morton neuroma)
Interdigital neuralgia (IDN) is also a common form of forefoot pain, commonly referred to as Morton neuroma. Morton described an affliction of the fourth MTP joint and the lateral plantar nerve and its treatment, which included methods of surgical resection, blood letting, and anodyne treatment.24 Common descriptions are inaccurate in that it does not represent a nerve tumor.25
Summary
Forefoot disorders can be a considerable source of pain and dysfunction. Obtaining a careful history and performing a focused examination will help identify the cause of the pain. Once the cause is identified, treatment can be instituted. Treatment with shoe modifications, appliances, and the judicious use of corticosteroids is successful. When conservative measures fail, surgical intervention should be entertained and a referral to a foot and ankle specialist should be made.
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Cited by (37)
Shoe and Bracing Considerations for the Insensate Foot: Shoe considerations for diabetic foot
2022, Physical Medicine and Rehabilitation Clinics of North AmericaCitation Excerpt :This study found that Charcot feet were more likely to have mid-foot ulcers. Feet with compensated forefoot varus tended to have ulcers under the second, third, or fourth metatarsal heads, whereas feet with uncompensated forefoot varus or forefoot valgus had ulcers under the fifth or first metatarsal heads, respectively.17 The Achilles tendon and plantar fascia are also frequently found to be abnormally thick in diabetic patients with neuropathy which contributes to the rigid confirmation of the foot leading to poor shock absorption during landing.18,19
Diabetic Ulcer Prevention
2022, Physician Assistant ClinicsCitation Excerpt :With the intrinsic muscles weakened and unopposed the extrinsic muscles strength can lead to the subsequent hammering of the digits.14 Additionally, the metatarsal heads can become more prominent and closer to the skin’s surface.50–53 Common examples of foot deformities can be seen in Fig. 2.
Incidence of thyroid disease in patients with forefoot deformity
2020, Foot and Ankle SurgeryCitation Excerpt :Finally, MTP joint instability may be an important contributor to forefoot deformity. Specifically, it may contribute to the development of hallux valgus and lesser toe deformities or present clinically as metatarsalgia [8,25,26]. The high coincidence of these conditions in our study may suggest a central role for MTP synovitis as a potential link between thyroid disease and forefoot disorders.
Scientific Evidence in the Treatment of Metatarsalgia
2019, Foot and Ankle ClinicsCitation Excerpt :Steroid infiltration in patients with metatarsalgia has been proposed in cases with metatarsophalangeal instability.51 However, whereas steroid infiltration into the intermetatarsal web space may help to differentiate pain between a Morton neuroma and the metatarsophalangeal joint, destabilization of the joint with deterioration of the plantar plate may be accelerated and therefore infiltration must be indicated with caution.52 As well as infiltration using corticosteroids, injection with alcohol-sclerosing agents, hyaloron and Botox, has been proposed.