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metatarsalgia (forefoot pain)
Etiology: (differential diagnosis)
1) 1st metatarsal pain
- bunion/hallux valgus
- hallux limitus/rigidus
- sesamoiditis
- Morton's foot
2) other
- neuroma (interdigital or Morton's neuroma)
- sprain
- calluses or warts
- stress fracture
- posterior tibial nerve entrapment
3) general
- arthritis
- diabetic neuropathy
- infection
- peripheral arterial disease
Clinical manifestations:
1) paresthesias suggests neurologic origin
2) great toe pain on tiptoeing suggests hallux rigidus or sesamoiditis
3) atraumatic hot, swollen 1st toe, with gnawing or throbbing pain suggests gout or infection
4) stocking distribution to pain suggests diabetic neuropathy
5) pain only with weight-bearing suggests stress fracture
6) tenderness may be present
7) decreased plantar/dorsiflexion at 1st metacarpal suggests hallux rigidus/limitus
8) lateral protuberance from a bunion
9) hyperesthesia in web space of toes suggests neurologic origin
10) positive Mulder's sign
Laboratory:
- joint aspiration if gout, pseudogout or joint infection suspected
Special laboratory:
1) electromyography (EMG)
2) nerve conduction velocity
3) a 3 mm skin punch biopsy of distal calf can reveal small fiber neuropathy [2]
Radiology: plain radiograph of foot
Management: R: rest from pain-eliciting activities I: ice for 20 minutes several times/day while area is swollen C: compression with padding & a wrap E: elevation above level of heart to reduce edema D: non-steroidal anti-inflammatory Drugs (NSAIDs) for pain & inflammation if not contraindicated
1) avoid constrictive footwear
2) neuroma:
a) metatarsal pad
b) corticosteroid injection
c) physical therapy
d) surgery
3) hallux limitus/rigidus
a) padding to shift weight laterally
b) hard sole shoe
c) joint injection with corticosteroid/anesthetic
d) surgery
2) urgent referral to orthopedic surgeon if acute neurovascular impairment
Related
Morton's foot
Mulder's sign
General
foot pain
References
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 751-52
- Journal Watch, Mass Med Soc 20(1):11 (Jan 1) 2000
- Wu KK.
Morton neuroma and metatarsalgia.
Curr Opin Rheumatol. 2000 Mar;12(2):131-42.
PMID: 10751016