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Metatarsalgia (Forefoot Pain)

Metatarsalgia is a generalized term indicating pain in the front of the foot (the forefoot). Traditionally these pains were reflected to be athletic conditions due to high impact loading during sports, it is obvious now that metatarsalgia is house to all conditions in the forefoot affecting people from all walks of life, not just athletes.


Primarily, metatarsalgia is pain around one of more of the metatarsal heads, aggravated with walking, specifically at the midstance and propulsion phases of gait (when the toes bend). Pain may be gradual or acute and can feel dull or sharp in nature depending on the underlying cause. Some patients describe it as ‘walking on pebbles’. Pain may be worse when walking barefoot, wearing shoes with thin soles or wearing high heels.


Metarsalgia may be caused by inflammation, fracture, overload, degeneration, neoplastic lesion, etc.

Assessment is needed to determine the correct treatment for this complex condition. During assessment it may be found that the problem is originating from another area of the foot and not the actual site of pain, this is a referred pain syndrome.


Metatarsalgia may occur because patients wear the wrong size shoe, excessive weight gain causing increased pressure on the forefoot, fat pad atrophy (reduced fatty cushioning) as a person ages, participation in high impact activity or increased activities. There is a genetic factor to consider as there is an increased prevalence of metatarsalgia in patients with longer 2nd toes and higher arched feet.


Leaving the pain without treatment often results in worsening pain across the entire foot or developing problems elsewhere on the body due to limping with the painful foot.

Conditions within the umbrella of Metatarsalgia:

There are 5 metatarsal bones in the foot with one nerve running between these bones before branching into the toes plantar and dorsal nerves. Patients will experience inflammation, numbness, and pain in the location of the bones compressing the nerve.


  • 2nd metatarsal head overload / Freiburg’s Disease / Osteonecrosis

Very often patients present with longer 2nd toes, this is a genetic predisposition to conditions such as 2nd metatarsal overload, Freiburg and osteonecrosis. Patients do not necessarily need a predisposition to such conditions, they can just appear from daily lifestyle and walking habits. Excessive pressure on the forefoot can lead to degeneration.


  • Stress fracture / spiral fracture

Fractures occur from acute trauma or repetitive strain on the bone. Fractures of any sort should be evaluated immediately to avoid long-term bone damage. Offloading and clinical treatment for bone healing may be necessary, more severe foot and ankle fractures may require orthopaedic surgical evaluation.


  • Plantar plate / ligaments / Toe Deformities (Hammer, Retracted, Clawed, Elevated)

Bones are held together by ligaments (thick, tough tissue). The bones can often be subjected to stresses that may strain, fray, tear or rupture the ligament. Once a ligament is painful or weakened, patients need to undergo clinical therapy to reduce the pain and strengthen affected tissue. If a ligament ruptures it needs surgical correction. Toe ligament injury leads to toe deformities such as hammer toe, plantarflexed metatarsals, retracted or overlapping toes.


  • Capsulitis

This is inflammation of a joint, the space between two bones, most commonly affecting the 2nd toe joint as this traditionally takes the most pressure. Evaluation of the capsulitis is needed as it may be caused by overuse or an underlying autoimmune condition such as rheumatoid arthritis, inflammatory arthritis or reactive arthritis.


  • Interdigital bursa / Ganglion Cyst

Bursa’s and ganglion cysts are conditions that appear in the foot, they are like each other but different physiologically. Bursa’s are fluid-filled sacs that help to offload a bony prominence, they often develop on areas of high pressure. Ganglion Cysts are soft tissue lumps found to grow out of a joint or high-pressure area.


This is a common overuse condition of the tendon (tissue that connects bone to the muscle). Tendonitis is inflammation of the tendon and is the beginning stages of tendinopathy or degeneration of the tendon tissue.


  • Rheumatoid Arthritis

Progressive inflammatory disorders result in forefoot structural changes and bony damage. Patients who are diagnosed with RA should see a podiatrist for foot deformity prevention. Podiatrists work to ensure patients are not overloading their forefoot joints which can speed up deformity formation. Most RA patients will wear orthotic controls to reduce forefoot pressure.


  • Foreign body

Singapore’s weather means that patients favour open toe, slip on sandals compared to the covered, protective shoes recommended. Open toe shoes, and walking barefoot, leave room for patients to step on foreign objects. Objects can be as small as a fibreglass in a house renovation to a pin sized object or larger. Clinical assessment and treatment should be carried out to ensure they have not embedded themselves within the layers of skin.


  • Arthritis / Bone Erosions / Gout

Joint degeneration and bone erosions can come from arthritic diseases such as osteoarthritis (wear and tear) or gout-related conditions where the joint is worn away due to internal factors. Erosions can also come from the joint spaces narrowing due to excessive pressure i.e. hallux limitus or flat foot, both of which are easily managed non-surgically by podiatry.


Two small bones that sit under the big toe (1st metatarsal head). These bones sit within the flexor halluces longus tendon, they function to allow the tendon glide and function optimally, along with helping to balance or redistribute body weight across the forefoot.


Many people think bunion is extra growths of bone at the big toe region. Bunions are actually a medial rotation of the 1st metatarsal with a secondary subluxation of the phalangeal bones of the toe. This rotation puts a lot of stress on the big toe joint and mis-shapes the forefoot region.


Callus and corns are reactions to high pressure, high friction areas. Treating the skin condition without addressing the underlying cause results in recurrent, often painful corns. These conditions are associated with high pressure over a pinpoint area of bone. Permanent solutions involve orthotic control.


Warts are medically termed ‘verrucae’, they often present with a ‘cauliflower’ appearance, sometimes with little black dots inside. Warts can easily be mistaken to be a splinter and so patients will try to ‘dig out’ the lesion. Warts are highly contagious, they can spread to other parts of the body or another person. They should be treated promptly.  Most commonly they are picked up when a person’s immune system is low or around warm, moist environments.


Chronic conditions such as diabetes affect the peripheral and sensory nerves of the feet. Pain, tingling and numbness are common complaints about diabetic patients, particularly those who were diagnosed many years ago or have uncontrolled diabetes. Any pain in a diabetic foot must be investigated promptly.

As noted above, forefoot pain worsens over time if it is not addressed promptly and can result in pain spreading the other areas of the foot or requirement of surgical correction if it is not adequately treated. Changing footwear is not adequate to resolve underlying forefoot problems as the inflammation or damage within still needs to be addressed. If you suspect that you have any of the above conditions, please see a podiatrist today.


Non-Surgical Solution

Conservative treatment solutions are possible with the use of therapeutic medical devices such as shockwave or ultrasound offering immediate relief and long-term prevention of recurrence with ideal footwear and support with the use of foot orthotics are possible.




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