Metatarsalgia

What is it?

Metatarsalgia is pain located under the forefoot. It has many causes and a specific clinical examination usually determines its aetiology and a targeted treatment can then be proposed.

The body’s weight is distributed between the five metatarsals (bones in the midfoot, linking with the toes). The first bone, linked to the big toe, receives 2.5 times more weight than the others. The rest of the weight is then divided among the other metatarsals. Any imbalance of this relationship causes a cascading change meaning that an extra burden falls onto one or more of the other metatarsals. Pain then develops specifically under the overburdened metatarsals.

métatarsalgies et premier métatarsien court

Fig. 1

Normal foot
Pressure is distributed equitably between the different metatarsals (in blue)
Fig. 2

First short metatarsal that does not bear enough weight and therefore transfers its burden to the adjacent metatarsals, which are painful (in red)

Bony protrusions can be felt when palpating the plantar region, at the base of the toes; these protrusions correspond to the heads of the metatarsals and are a specific representation of the painful area.

Clinical presentation

There are many causes but they are all characterised by an overloading of the forefoot. The problem is always located under the metatarsal heads, and protrusions can be easily palpated at the base of the toes.

Traditionally, the second metatarsal is the first affected. Pain is experienced when walking and when standing for prolonged periods; the pain improves with rest and increase when wearing high heels.

When should you consult a specialist?

If the pain persists despite restricting the excess burden or if the pain becomes incapacitating, it is advisable to consult a specialist. A comprehensive and specific clinical examination will help make an accurate diagnosis and offer the appropriate treatment.

The examination is generally completed by a radiological evaluation, to refine the diagnosis and determine the cause of the condition.

Non-surgical treatment

There are just as many treatments as there are causes. The solution often involves wearing custom-made soles or receiving targeted physiotherapy, depending on the basic problem.

It is important to limit the stresses by, for example, avoiding wearing high heels or choosing the correct footwear.

If this treatment is not enough, specific surgical support may be required.
Surgical treatment

This depends on the problem causing the metatarsalgia, hence the importance of obtaining an accurate diagnosis, which can be difficult. It usually involves “biomechanical” metatarsalgia and the principle is to restore a harmonious architecture to the foot and a normal distribution of the loads. X-rays are used to guide the type of treatment required.

For cases of imbalance of the metatarsal length or sagittal alignment, only a procedure on the bone will restore the correct support. The most common technique is called a Weil osteotomy. The aim of this procedure is to shorten and/or elevate the overloaded heads.

Fig. 3: Here metatarsals 2 and 5 require shortening to provide a harmonious curve. Fig. 4: “Weil” osteotomy, with a shortening and elevation of the metatarsal head. Fixation by screw.

More recently, percutaneous surgery has changed these bone sections (called osteotomies) through an absence of fixations, systematic treatment of the three central digits and a different theoretical approach. In fact, the released heads move when walking, until they reach a balance corresponding to a uniform distribution of loads. It is therefore the body’s own biomechanics and not the surgery that will determine the optimal position of the metatarsal heads. This technique is called DMMO (Distal Minimally invasive Metatarsal Osteotomy).

Naturally, other static or dynamic disorders can respond to correction surgery. Classic examples are the treatment of hallux valgus, hammertoe, elongation of gastrocnemius or treatment for Morton’s neuroma.
Post-surgical follow up

After any procedure on the metatarsal bones (classic Weil osteotomy or percutaneous surgery), a special orthopaedic shoe is usually required for 6 weeks. The foot may remain swollen and sensitive for 1-3 months. Discomfort decreases rapidly once the bone cuts heal; x-ray confirmation is required during follow-up consultations.

Less energetic sports such as swimming or riding a bike can start 6 weeks after surgery; running or contact sports can resume after 3 months.

Driving can resume after 6 weeks. When only one foot has been operated on, driving is allowed after a shorter time, on condition the car is an automatic one.

A period of around 2 to 9 weeks off work is generally required, depending on the type of job.
Risks and complications
Besides the possible complications after any type of surgery (thrombosis, infection <1%, algodystrophy <1%), the following complications may occur after a metatarsal osteotomy:
- Delayed or absence of bone consolidation (very rare)
- Persistent swelling of the foot lasting for longer than 6 weeks (common) usually spontaneously regressive
- Persistent pain (rare)
The possible risks or complications during other procedures are specific to the type of surgery and your specialist will provide full information to you.

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Metatarsalgia

What is it?

Clinical presentation

When should you consult a specialist?

Non-surgical treatment

Surgical treatment

Post-surgical follow up

Risks and complications

MAKE AN APPOINTMENT