Metatarsalgia

Metatarsalgia is pain under the ball of the foot. The part of the foot that is behind the toes and is on the ground when you lift your heel off of the ground. When you say that you are walking on your "tippy-toes" (and who doesn't say that?) you are actually walking on your metatarsal heads. Too much of this can lead to pain in the metatarsals, ergo the name metatarsalgia.

If the swelling goes on long enough it can damage the joint between the 2nd toe and the foot: the 2nd metatarsophalangeal joint (2nd MPJ). when this happens the second toe can actually dislocate (see photo below) and start to either float or move to one side or the other. For this reason the condition of the swelling of the 2nd toe is often called

Here are two pictures of the ball of Marla's foot. On the left foot (the right picture) the ball of the foot is quite flat. The ball of the foot is smooth

with no bulging. On the picture on the left (the right foot) there is a perceptible swelling behind the 2nd toe (counting from the big toe). This is a very typical finding in metatarsalgia.

The cause is usually due to a weight distribution problem where the normally strong first metatarsal is not pulling its fair share. For one reason or another the weight is being shifted to the second metatarsal. This little bone is designed to only take so much pressure. The extra weight on this guy takes its toll and the joint begins to swell. The swelling can be due to several factors.

CAPSULITIS - There is a tough covering that holds all joints together called the capsule. Think of it as the Duct Tape of the body. It is lined with cells that produce joint fluid. The fluid is called synovial fluid and the cells that produce it are called synovial cells. If the covering of the capsule is inflamed the problem is capsulitis, If the cells inside the capsule are inflamed the problem is called SYNOVITIS.

When the capsule gets "too swollen" it can actually tear. when this happens the toe can actually start to deviate to the side away from the tear.

This is a picture of a severe dislocation of the 2nd toe. The toe is sitting up so high that it allowed the bog toe to move over under the place where the 2nd toe should be. This patient also had a big lump under the 2nd metatarsal head. This is a frank dislocation of the 2nd metatarsophalangeal joint. These are very difficult to treat. If your foot doctor says that your 2nd toe is starting to elevate, and you have a bit of a bunion, please do yourself (and your foot surgeon) a favor and consider a bunion surgery before this happens to your big toe.

This is an example of a case where a 2nd MPJ pain and swelling went on to elevate and move toward the big toe. Fixing this will require repair of the bunion, the hammertoe 2nd (with an implant, fusion or flexor tendon transfer) and a reduction of the dislocated 2nd mpj (with fixation)

This is another view of the picture above. You can clearly see how the 2nd toe is elevated and crossing over the big toe.

TENOSYNOVITIS - Below the capsule and the joint there is a tendon that runs to the tip of the toe. The purpose of the tendon is to pull the toe down. This structure can get inflamed when it gets "squished" (another medical term) due to that old problem: excess weight bearing.

BURSITIS - The body is great at padding pressure points, One of the common mechanisms is the use of little pillows called bursae (bursa is singular). If you over-stress a bursa it becomes inflamed, a condition called bursitis. Bursae are fluid filled and increase and decrease in size just a little with changes in temperature, pressure and humidity. This swelling is what leads some people to say that they can predict the weather.

Treatment is both short term and long term and addressed in the answer to a letter I received on March 17, 2001

Dear Dr. Zapf,
I found your information on pre-dislocation syndrome on the Internet,
and am very grateful for your explanation of the condition. I would greatly appreciate if you could answer a few questions. For the past 19 months, I have been trying to get help for this problem. I have had injections, which only seemed to aggravate the condition. I have tried total rest, a walking cast, orthotics, physical therapy, ice, various metatarsal pads. Still, my second toe is lifting, and my big toe is moving over to the left, underneath the second toe. I have been advised at this point to have surgery: flexor tendon transfer, to stabilize the second MTP joint, and an Akin procedure to get the big toe out of the way. Do you have any thoughts on this as an appropriate solution? Any thoughts on other possibilities that may have been overlooked? Thank you so much for your time.

I find that 2nd metatarsal / pre-dislocation syndrome a difficult problem. The best theory that I have heard is that there is a tear or disruption on the so-called "plantar plate" which is the fibrous band of tissue that connects the bones of the 2ne toe to the metatarsal. It is often called the bottom part of the joint capsule. If the capsule - or plantar late- is torn on the side of the big toe the 2nd toe will deviate toward the 3rd toe. If it is torn on the side of the 3rd toe, the 2nd toe will move toward the big toe. If is torn dead center the toe will just rise straight up (as in the photograph above). In addition to the deviation of the toe the 2nd metatarsophalangeal joint often swells and can become a very visible (and touchable) lump under the foot (as in the photograph at the top of this page). Rest, walking casts, physical therapy, cortisone injections and ice can calm down the inflammation but they do nothing about the tear in the capsule or plantar plate.

In my mind the best non-surgical procedure is the use of well designed orthotics and or various pads. This well designed orthotic can be worn virtually all the time by some people and redistribute weight from the 2nd metatarsal head. Unfortunately, there are a lot of people for whom an orthotic does not fit into their life style. For these people a surgical choice is often their only choice.

Surgery can be done "from the top" or "from the bottom". The surgery "from the bottom" is made through an incision directly under the 2nd metatarsophalangeal joint. Through this incision the joint capsule / flexor plate is reached and the tear in the capsule is made directly. To minimize scarring patients should remain non-eight bearing (crutches) for a month after the procedure. As of this date (March 2001) This is a relatively new procedure in podiatry and I know of only a few people who are doing "plantar plate repair". I have done the procedure on cadaver specimens twice but not yet on a live patient. I want to get feedback from other foot surgeons on their rate of success before I venture into making an incision on the bottom of the foot for this repair. Instead I make the incision "from the top" like most foot surgeons.

The incision from the top usually involves two steps: the almost always accompanying hammertoe (with often a flexor tendon transfer) and reduction of the dislocation of the 2nd metatarsophalangeal joint, often with fixation to hold the toe straight. If the big toe has moved out of position and is now sitting where the 2nd toe should be, then it needs to bye put back into position. This is, by definition, a bunion correction. An Akin is one method to get the big toe back where it belongs.

From you description I would say that your doctor is planning the exact procedure I would do. If it fails (and it does fairly often) you can always do the flexor plate repair "from the bottom" at a later date.

Thank you very much for your response to my question regarding
treatment of Pre-dislocation Syndrome. One further question about this is that my specific pain is at the metatarsal head, between the 2nd and 3rd MTP joints, not beneath the 2nd. The pain began specifically after doing dancing which placed excessive weight on the ball of my foot, and there was a visible spot of discoloration between those two joints which lasted many months, but no visible swelling. The lifting of the second toe did not occur until months had passed following the initial injury. Given the need to stabilize that toe and move the big toe out of the way, I will go ahead with the surgery. I am wondering, however, if you have any thoughts on whether the surgery will address the original pain, which is still the most significant part of the problem. Thank you again for your help. I am extremely grateful. Sincerely, Judy F

You bring up an excellent point. Many times the swelling under the 2nd metatarsal seems to "leak over" and cause significant irritation to the nerve that runs up the second interspace and between the 2nd and 3rd toes. This gives the impression of a not-too-common 2nd interspace neuroma. Until I understood the pathology of predislocation syndrome I believe that I incorrectly diagnosed several 2nd interspace pains as neuromas instead of nerve irritation from the joint swelling. You can have an actual neuroma between the 2nd and 3rd toes, but if there is a 2nd toe deviation and a 2nd hammertoe I would look very closely at these being the cause. Have your foot surgeon examine the 2nd interspace for a tell tale "click" when palpating this area. A positive click is one sign of a neuroma.

Whew! Your letter is a web page in itself. I am going to start of with saying that trying to fix a 2nd toe pathology without addressing the bunion that caused it seem to me difficult at best and probably impossible. Does your foot look something like the picture of the crossover toe above? If so, there is no way to get the 2nd toe where it belongs without addressing the bunion. If, as you state, the collateral ligament [the one on the side of the joint] is damaged then the toe will necessarily deviate to the other side. This all is part and parcel of the predislocation (in your case actual dislocation) syndrome.

When it comes time to repair the 2nd mpj the controversy I alluded to above comes into play. Traditionally most foot surgeons do pretty much the same procedure. We do a hammertoe correction on the 2nd toe at the proximal interphalangeal joint (PIPJ) that involves either a fusion of the joint, the use of a little implant or an arthroplasty procedure where a piece of bone is just removed. All of these are designed to "unbuckle" a hammertoe and either let it fly, give it partial stability (implant) or complete stability (fusion). The next step is to go back to the metatarsal phalangeal joint (the joint where the toe meets the foot (the very joint that has damaged collateral ligaments in your foot). Using an instrument that is a scoop-like spoon called a McGlamry elevator all of the soft tissue connections between these two joints are cut and severed. The toe is now brought own into a correct position. This position is held in place by passing a coat-hanger thick K-wire from the metatarsal, through the bones of the toe and out the tip of the toe. Obviously it is difficult to pass this wire through an implant, so if one is used sometimes the toe-metatarsal joint is stabilized differently - maybe by using an absorbable pin that passes just between the metatarsal and the base of the toe bone.

A variation in this technique is to use the flexor tendon for 2nd toe for stabilization. This tendon runs up the bottom of the toe and can be freed from its insertion at the tip of the toe and brought up to help hold the proximal phalanx (the toe bone closest to the metatarsal) in correct alignment. It is thought that transverse deviations from dam age to the collateral ligaments can be corrected with this technique because all the collateral ligaments are cut and new scar tissue is formed with the toe held in correct position. This is the so-called step-by-step correction of the dislocated 2nd mpj with internal fixation. Unfortunately it does not do such a great job in the very long run (long dance?)

A Boston podiatrist, Dr. Jolly (great name, huh?) You can probably find reference to his articles on MPJ surgery through a MEDLINE search - find MEDLINE from the page: www.refdesk.com) recognized the shortcomings of the traditional approach and has been promoting a technique that approaches the metatarsal phalangeal joint from the bottom. This technique identifies the "flexor plate" on the bottom of the joint. He can see if and where there is a tear of the plantar plate and repairs it using tiny little sutures that are attached to little anchors that go into the bone. He believes that in every case where there is damage to the joint that will cause the toe to deviate there is a tear in the transverse plate that will correct the problem. When he is done he puts his patients on crutches for several weeks while this heals without undue stress placed on the joint be walking. This is probably what your orthopedist also plans to do with the tendon graft from the hand. I do not know what technique will give the greater stability but at least this one does not require a hand surgery.

I have not yet done Dr. Jolly's approach because I do not want to put a potentially bothersome scar on the bottom of the foot until I know the long-term results of his procedure. I suspect that his procedure is better than mine but I do not know, yet. Since I know the complications of my procedure (AKA the traditional procedure) and I do not know the long term risks or benefits from his I have chosen just he old standby for now.

Dr. Jolly is a great surgeon and you can look him up in Boston. He is a podiatrist associated with Harvard Medical Center and, I believe, Deaconess Hospital. He might be able to give you more insight to your mpj pathology.

So in summary, I do not see how you can fix the 2nd mpj without addressing the bunion. If you can, make sue you address the transverse (leaning to the side) pathology of the 2nd mpj and not just the up and down pathology of the joint.

P.S. You are right that my numbers for first MPJ range of motion are a little low. I based them on the need for 30 degrees of dorsiflexion to walk and 60 degrees to run. I added 10 degrees for safe measure and called 70 normal. Clearly most people are born with more than 90 degrees of dirsi9flexion but I did not want to make people who only had 70 or 80 feel bad. They have enough dorsiflexion for most activities in most circumstances.

Dear Dr. Zapf: I want to congratulate you on your website - although the site's a little "rough around the edges" there's a tremendous amount of good information there. I have been experiencing metatarsal pain for the past few years (although for a long time, I couldn't really figure out where the pain was coming from exactly). I finally got an appointment with a local (NYC) podiatrist and when he manipulated my foot and pressed his thumb into the metatarsal - Whoa! - I quickly realized where the source of my foot pain was. He proceeded to give me three cortisone injections in each foot over the course of the next few weeks and I had some blissful relief for a while. Now the pain is back (seems worse perhaps!). My problem is that I don't feel entirely confident in this doctor and wondered if you'd be able to recommend someone here in New York City (Manhattan). At this point, I'm pretty sure that my best shot at long term relief (although apparently from everything I've read or heard - there are definitely no guarantees in this field) may be surgical correction. The doctor tells me that my bunions are candidates for surgical correction - although he didn't perceive them as being severe (yet!) and they aren't nearly as severe looking as the ones depicted on your website. This doctor also mentioned orthotics as a possibility and seems to take the approach of working his way through the various treatments, with surgery as the final possibility. But regardless of the appearance of my bunions, the pain is very real. I'm loath to have to go through the hassle and inconvenience not to mention the pain and financial cost of surgery - with a chance that it won't eliminate the pain. But at this point I feel like I've got no choice. I've been trying to use adhesive pads under the balls of my feet (thick "mole-skin" with a piece cut out where the tender part of the foot is), soft-gel metatarsal pads, etc., etc. - with limited success and a lot of frustration and hassle. It's been particularly tough for me since I'm pretty athletic (I'm 41) and like to exercise/jog regularly. My latest trick I stumbled across through a recommendation by a salesman at a surgical supply house where I was trying to track down some foot pads or insoles, has been wrapping Elastikon tape around the metatarsal region a few times (snug, but not too tight). For some reason, this provides a fair amount of relief - more so than most of the other methods I've tried. I wondered if you were familiar with this "trick" and whether you perceive any risks or other problems with it. In any case, I don't feel as though wrapping my feet with tape every day is a reasonable long-term solution. Sorry for the length of this, but my frustration runneth over, I guess...hope you can help. Thanks. Sincerely, Jeff H.

Dear Jeff,

For some reason this topic attracts the longest letters. If readers have read this far they must be very interested in this topic. Metatarsalgia of the 2nd metatarsal bone and predislocation syndrome in general are terrible problems. There are no easy solutions if a cortisone injection or two do not help you. And obviously a cortisone injection by and of itself in the absence of changing something, is not likely to work.

The original problem is a weight bearing one, that is, the second metatarsal is bearing more weight than it was designed for. Redistributing this weight is the long term goal. This redistribution can be done by walking on a softer surface. A softer surface can be a softer shoe or can be walking on a carpet rather than tile, wood, marble or concrete floors. A softer surface can be achieved with a properly designed orthotic that takes weight off of the second metatarsal bone. I use one called the "slot orthotic" from ProLabs orthotic labs near San Francisco. Your podiatrist can call them and look into this device. I am sure he or she thinks that any accommodative orthotic can do the trick, but they have a couple of variations on he orthotic that are very slick. A final solution is a surgery designed to recreate an ideal weight bearing pattern between all 5 metatarsals. This is trickier than it sounds. Too much lifting of the second metatarsal creates a transfer of weight to the 3rd metatarsal. Your doctor has to know what he or she is doing. If the second metatarsal bone is too "down" or to "long" then he or she might consider a shortening osteotomy of the 2nd metatarsal. A nifty way of doing this is with an "Offset V" described in the Foot and Ankle Journal a couple of years back. One of the designers of this technique is Glen Weinraub, D.P.M. who has a web site on the internet that you can find with a search engine. If the 2nd toe is deviated toward the big toe or the 3rd toe then, be definition, there is damage to the joint capsule around the 2nd metatarsal. There are starting to be a number of doctors around the country that are doing a Flexor Plate Repair as described 9above0 by Dr. Jolly. You can probably learn a lot about your local doctors by calling their offices and see if they are doing a "flexor plate repair". Most will probably not know what you are talking about. Some will know but not do it. Only a rare few do it. As long as they know about it and see its value you are dealing with someone "up on the literature" of this pathology. Use the phrase of "flexor plate repair" as a litmus test as to your doctor's knowledge of 2nd metatarsal pathology.

Another method of getting weight and pressure off of the 2nd metatarsal is to change exercise habits. Repetitive stress activities involving the forefoot make matters worse. A treadmill with an incline is worse than a flat treadmill. A flat treadmill is worse then a bicycle. A bicycle is worse than swimming. And so on an so on.

You mention that you have a bunion. Most of the time fixing a bunion aggravates 2nd metatarsal pain. Your doctor must understand this and tell you specifically what he or she will do to reduce the likelihood of shortening the first metatarsal during a bunion surgery. Shortening the first metatarsal in a bunion surgery is very common. This "side effect" will make the metatarsalgia worse. This is another litmus test to see if your surgeon understands this pathology. The correct answer on the part of your doctor is that he or she will either try to lengthen or plantarflex (move down) the first metatarsal head at the time of surgery.

I have not tried the Elastikon trick but I will. I make a similar removal metatarsal pad for my patients with 1/8" felt and Elastoplast (a similar material).

As far as doctors in New York I cannot help you. Elsewhere in this site there are references to the American College of Foot and Ankle Orthopedics and Medicine (ACFAOM) and the American College of Foot and Ankle Surgeons. You can link to their web sites complete with doctor directories at the following:

The American Board of Podiatric Orthopedics and Primary Care Medicine

and

The American College of Foot an Ankle Surgeons.

Send mail to (zfootdoc at doctor dot com) with questions or comments about this web site. Copyright � 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M. Last modified: February 24, 2008

Send mail to (zfootdoc at doctor dot com) with questions or comments about this web site.
Copyright � 2000 Michael A. Zapf, D.P.M., F.A.C.F.A.S., F.A.C.F.AOA.M.
Last modified: February 24, 2008