In the U.S., forefoot injuries, including metatarsalgia, are common in athletes who participate in high-impact sports.
Athletes who take part in high-impact sports involving running or jumping are at high risk of forefoot injury. While track and field runners are exposed to the highest level of traumatic forces to the forefoot, many other athletes, including tennis, football, baseball, and soccer players, often have forefoot injuries.
SYMPTOMS AND CAUSES
The primary symptom of metatarsalgia is pain at the end of one or more of the metatarsal bones. The pain is typically aggravated when walking or running. Athletes who participate in high-impact activities and may also have an inflammatory condition such as bursitis often have diffuse forefoot and midfoot pain.
Most often, the pain comes on over a period of several months, rather than suddenly.
A condition known as Morton's neuroma (interdigital neuroma) produces symptoms of metatarsalgia due to irritation and inflammation of a nerve at the site of pain. People with Morton's neuroma may experience toe numbness in addition to pain in the forefoot.
The foot can be injured during sports activities. As with many other overuse injuries, the condition may be the result of an alteration in normal biomechanics that has caused an abnormal weight distribution.
Persistent stress can lead to chronic irritation and inflammation of the bone covering and adjacent tissues, such as ligaments and tendons.
The following factors can contribute to excessive localized pressure over the forefoot:
- High level of activity
- Prominent metatarsal heads
- Tight toe extensors (muscles)
- Weak toe flexors (muscles)
- Hammertoe deformity
- Hypermobile first foot bone
- Tight Achilles tendon
- Excessive pronation (side-to-side movement of the foot when walking or running)
- Ill-fitting footwear
Some anatomical conditions may predispose individuals to forefoot problems. They include:
- A high arch
- A short first metatarsal bone or a long second metatarsal bone is often seen in people with a Morton toe; the normal forefoot balance is disturbed, resulting in the shift of an increased amount of weight to the second metatarsal.
- Hammertoe deformity
Any or all of the above musculoskeletal problems may contribute to forefoot trauma in athletes.
X-rays may be helpful in excluding other causes of forefoot pain.
A bone scan can pinpoint places of inflammation.
Ultrasound can help identify conditions such as bursitis or Morton neuroma that can be causing pain in the metatarsal region of the foot.
The doctor may also ask for an MRI to help detect and diagnose many causes of pain in the metatarsal and midfoot regions. These can include traumatic disorders, circulatory conditions, arthritis, neuroarthropathies, and conditions that result in biomechanical imbalance.
The doctor may also ask for other tests and procedures to help in the diagnosis and in determining the proper treatment.
Initial treatment includes regular icing and application of a pressure bandage. The doctor may also recommend not putting weight on the foot for the first 24 hours. After the first 24 hours, the doctor may start passive range of motion (ROM) and ultrasound treatments. Using metatarsal pads and other orthotic devices can help provide relief, even in the early phases of treatment. At this point, a change in footwear is recommended.
Rehabilitation begins on the first day of injury with the goal of restoring normal range of motion, strength, and function. Semi-rigid corrective devices worn in supportive shoes are an effective treatment for metatarsalgia. Supportive shoes worn alone, with or without soft corrective devices, may not provide adequate pain relief.
It's important to not disrupt the healing process. Stretching and strengthening exercises should be done carefully, and returning to a higher-level activity should be gradual and done with caution to prevent re-injury. The health care provider will likely discourage an athlete from trying to continue activities that cause pain.
If there is a callus, the doctor may shave it down to provide temporary relief. It is, however, important to avoid bleeding from excessive debridement and the use of acids and other chemicals. In addition to shaving down the callous, it is important to determine the cause of the callous, which is a response to pressure.
If symptoms are acute but don't last long, abnormal pronation of the subtalar joint in the ankle can be the primary cause. The doctor may recommend using orthotic devices in these cases. Chronic symptoms respond better to a metatarsal bar that can be added to the running or athletic shoe.
Individuals with a high arch who experience pain from metatarsalgia respond well to an orthotic device. Patients with a Morton neuroma respond well to a rigid orthotic with an extension underneath the first metatarsal bone.
The primary focus of treatment is restoration of normal biomechanics and relief of pressure in the symptomatic area. Therapy needs to allow the inflammation to subside or resolve by relieving the repeated excessive pressure.
Once the athlete is pain-free, isometric, isotonic, and isokinetic exercises will be started for strengthening. Passive range of motion exercises will progress to active exercises as the inflammation disappears.
Alternate forms of conditioning and training during healing should be encouraged. For example, swimming is an excellent exercise for maintaining physical conditioning while the patient is in a restricted weight-bearing phase of healing.
Patients with an interdigital neuroma can benefit from a nerve block in combination with long-acting steroids. Individuals with primary metatarsalgia receive little benefit from these types of injections.
As inflammation subsides, an orthotic device often is the only intervention required to maintain normal mechanical function. These devices are necessary to distribute force away from the site of injury. At the very least, regular replacement of shoes, especially for runners, can help to maintain support for the foot.Patients should continue self-mobilization exercises, including long-axis distraction and dorsal/plantar glides as directed by the practitioner.
Shoe modification with an orthotic may be the only treatment required, although in severe cases, surgical realignment of the metatarsal bones may be required.
A patient may be referred to an orthopedic or podiatric specialist if the condition is not improving or is worsening.
Return to Play
Returning to play for most injured athletes exposes them to the same traumatic conditions that resulted in the original injury. Therefore, the individual must be completely healed, free of symptoms, and prepared for resuming the stress and trauma inherent to his or her sport. Proper selection of running and training shoes is critically important to prevent re-injury.
Preventing re-injury means eliminating abnormal friction or pressure. Orthotics, metatarsal pads, and callus care can be used to prevent muscular and stress imbalances. Callus care includes razor debridement and buffing, which enhance tissue elasticity.
Some foot problems may not be caused by disease but by improper footwear. Proper positioning of the foot within the shoe depends upon appropriate fitting, as no two feet are the same. Athletes who perform on hard surfaces should make certain that new shoes have adequate cushioning. Rubber heels and soles that absorb shock better than other materials are helpful for athletes who perform repetitive running and jumping on hard surfaces.
Prognosis generally is good, with the treatment described in the Treatment section.
Athletes who suddenly and dramatically increase training activity are at risk of forefoot injury. Whether the increase is in time or intensity, athletes should increase their levels of activity gradually and never exercise through the pain.
Long-distance runners, women, and athletes who diet to qualify for certain weight divisions may experience bone loss from nutritional deficiencies, predisposing them to foot injury. A well-rounded diet is necessary for healthy tissues.
The selection of footwear and orthotic devices is an important part of foot care and injury prevention. Warm-up and passive stretching increase vascular supply and flexibility.