Metatarsalgia is a generic term used to describe non-specific forefoot pain in the region of the metatarsal bones.  Most clinicians agree that metatarsalgia is actually pain from the metatarsal bones that is the result of overuse, overloading or use of inappropriate shoes for a particular activity.  Metatarsalgia may be considered a precursor to a stress fracture of the metatarsal bones.  The 'algia' or pain of the metatarsal bones is a symptom of stress or fatigue of the bone.  Therefore, if we consider metatarsalgia to be an overuse syndrome, cases of metatarsalgia that fail to repair themselves over time may result in a stress fracture of the metatarsal bone.
 

Treatment of metatarsalgia
Metatarsalgia can be due to a number of different biomechanical conditions of the foot.  And in many cases, the foot is simply predisposed to developing metatarsalgia.  Luckily, the conservative treatment of many forefoot problems is the same. Metatarsalgia can be treated with a metatarsal pad, arch support with metatarsal pad, increased cushion of the forefoot in the shoe. Forefoot rockers soles (seen at right) are an important shoe modification used by pedorthists to decrease the load to the forefoot.  And lastly, stiffening the shank of the shoe tends to carry load more effectively past the metatarsal bones to the ball of the foot.  Stiff shank shoes and boots are helpful, or a stiff carbon graphite inner sole called a spring plate, can help.

Oral and injectable anti-inflammatories, such as cortisone, can be helpful in cases of metatarsalgia.  But it's important  to recognize that metatarsalgia is a mechanical problem.  It's a problem that occurs again and again with each step.  Anti-inflammatories may help to decrease pain, but they don't specifically target the primary mechanical problem contributing to the pain of metatarsalgia.  Therefore, effective treatment of metatarsalgia must focus on correcting the pathomechanics of the foot.

Anatomy

There are five metatarsal bones in each foot that run from the midfoot (arch) to the metatarsal phalangeal joints (toe joints). Each metatarsal is a long shaft with cartilage on both ends to form articulation with the midfoot and toes.

The size of the metatarsals vary. The first metatarsal is always larger and more stout. The lesser four metatarsals are typically close in size. Any increase in metatarsal size may be suggestive of an increase in the long term load bearing of the individual metatarsal bone.

Biomechanics

The metatarsal bones reach the ground at a 20-30 degree angle as they travel from the midfoot to the toes. The overall length of the metatarsal is very important in diagnosing cases of metatarsalgia related to one or two isolated metatarsals.

When viewing an AP X-ray (from the top of the foot to the bottom) the overall length of the metatarsals is referred to as the metatarsal parabola. The typical parabola is 2,1,3,4,5 meaning that the length of the metatarsals is the second as longest, the first and third as a close second and the fourth and fifth close behind. To understand the importance of metatarsal length, or parabola, consider this simple example;

Let's say you have two bamboo poles, one 5 feet in length and the other 10 feet in length. You hold the poles under your arms level to the earth and slowly lower them. Obviously the ten foot pole is going to hit the ground before the five foot pole. This is exactly what happens with long metatarsals, over and over again with each step. Eventually, metatarsalgia develops as a result of the over loading of the 'ten foot' pole.

Much of the treatment of the biomechanical factors found in metatarsalgia relate to correcting the imbalance of the metatarsal length.

Symptoms

The symptoms of metatarsalgia can be acute or chronic in nature. Symptoms may include dull ache and sharp pain on the bottom of the foot. Typically, symptoms of metatarsalgia increase with the amount of time spent on the feet and are relieved by rest. The picture to the right shows the area most commonly effected by metatarsalgia. Symptoms may vary in severity and location