Metatarsalgia is a general term that is used to refer to
pain in the metatarsal heads of the foot. This is the area of the metatarsal
that forms the proximal half of the metatarsal-phalangeal (MTP) joints, which
are the joints that connect the toes to the rest of the foot. Pain underneath the second metatarsal head is
a common clinical presentation.
Pain in the second metatarsal most commonly occurs in the
presence of hallux limits. Hallux
limitus is a condition in which the first metatarsophalangeal joint (the joint
that connects the big toe to the rest of the foot) does not have the
appropriate amount of motion required for normal function. When there is not enough motion available in
the first MTP joint, the ground reactive forces are transferred to the lateral,
smaller MTP joints. Most often, it is
the second MTP joint that takes the brunt of this force.
If the second toe has a hammer digit deformity, in which the
joints of the small toe remain contracted, it can exacerbate the problem. When a hammer toe is present, the metatarsal
head is pointed down towards the ground, or plantarflexed. This plantarflexed position of the metatarsal
adds to the amount of force. Equinus
deformities, in which the ankle joint is tight, can also contribute to the
problem by placing additional pressure on the forefoot. The pain will be especially great when the
patient walks down stairs, as they lead with their toes.
When this second metatarsalgia is present for a long period
of time, a condition known as predislocation syndrome may occur. This is most commonly described in the second
toe, though it may be seen in any of the lesser digits. Predislocation syndrome occurs when the
plantar plate, which is a portion of the joint capsule, becomes damaged. This damage can attenuate, or thin out, the
structure. This attenutation can lead to
joint instability, and can cause the second toe to end up pointing upwards and
medially or laterally. Thus, the condition
is also sometimes referred to as a crossover toe deformity, as the second toe
may overalp the first or third toes.
The diagnosis of predislocation syndrome is largely made
using clinical judgement, though x-rays are necessary to rule out any underlying
pathology, such as fractures or complete dislocations. An MRI may also be ordered, though it is not
always necessary. The MRI will show the
ordering physician whether the plantar plate is torn, attenuated, or if there
is any other potential pathology causing the deformity.
Initial treatment typically involves icing the affected
area, rest, and the use of non-steroidal anti-inflammatory medications. Orthotics may be used to manipulate the
position of the foot while walking or running, and various strapping and
padding methods may alleviate some of the pain.
Surgery becomes warranted if there is a failure of
conservative therapy. Typically surgery
will address any bony deformities of the foot first, such as hammer digits,
metatarsals that are functionally too long, or other problems. In the case of concomitant hallux limitus,
procedures of the first MTP joint may be required to restore normal function to
that joint and to take pressure off of the second MTP joint.
When the plantar plate is ruptured or damaged, that too can
be repaired with a direct approach. This
has traditionally been done through an approach through the bottom of the foot,
though it has recently been described as being repaired through the top of the foot.
101 6th Street N.W.
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Phone: 863-299-4551
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