Metatarsalgia - hillingdongp.org.uk

Metatarsalgia
Htwe Zaw FRCS (Tr&Orth)
Orthopaedic Foot & Ankle Consultant
Hillingdon Hospitals NHS Foundation Trust
Painful foot
• common in general population
(17.4% Hill et al. J Foot and Ankle Research 2008 )
• more common in women
• Steven Raikin MD (Rothman Institute, Philadelphia)
– 1” heels: 22% forefoot pressure
– 2” heels: up to 57%
– 3” heels: up to 76%
Metatarsalgia
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‘pain in the forefoot’
multiple aetiology
pain under metatarsal heads
pain between heads
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footwear advice (1st line treatment)
orthotics
chiropody
physiotherapy
steroid injection
surgery
Assessment
• Symptoms
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mechanical vs non-mechanical
neuropathic
shoewear related
functional deficit (e.g. stairs)
• Examination
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site of maximal tenderness
dorsal/plantar callosities
hammer/mallet/claw toes & subluxed MTPJ
mid/hindfoot malalignment (flatfeet, high arch)
gastroc-soleus tightness (Silfverskiold’s test)
Gastrocnemius-soleus complex
Imaging
• Weight-bearing views (AP, lateral, oblique)
Treatment
• dependent on aetiology
 footwear education - high & wide toe box shoes
 orthotics – offloading insoles & splints
 chiropody – regularly shave callosities
 physiotherapy - eccentric stretches
 ultrasound-guided steroid injection
 surgical correction
Shoe modification
• ‘high & wide toe box’
• bespoke orthotic shoes
• high street brands
(Ecco, Clarks, Hotters, Coolers)
• rocker-bottom shoes
(MBT, Sketchers)
• supportive sandals
(Birkenstock, FitFlop)
offloading orthotics
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‘metatarsal shelf/dome’
+/- heel raise
+/- arch support
+/- hindfoot correction
Nighttime splints
Ankle dorsiflexion splint
Strassburg sock
US-guided injections
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steroid + LA
ultrasound-guided: diagnostic & therapeutic
avoid alcohol/sclerosants
?pulsed RF ablation
Ian Garnham et al. A Prospective Study on Ultrasound-guided Steroid injections for Morton’s
Neuroma: Does the Size of the Lesion Matter? J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XLIII 4
Henry Slater et al. Effectiveness of Ultrasound-Guided Corticosteroid Injection in the Treatment
of Morton's Neuroma. Foot & Ankle International May 2008 vol. 29 no. 5 483-487 (Sydney)
Aetiology
Hallux metatarsalgia
Lesser metatarsalgia
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hallux valgus
hallux rigidus
sesamoiditis
forefoot overload
cavus
turf toe
gout
interdigital (Morton’s) neuroma
intermetatarsal bursitis
MTPJ pathology (capsulitis/subluxn)
forefoot overload
transfer lesions
Freiberg’s
stress fracture
Morton’s Neuroma
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‘perineural fibrosis’
mechanical irritation of plantar digital nerves
pain, burning, numbness, tingling
typically females (4:1), unilateral, 3/4 webspace
better barefoot, worse in constrictive shoes
Mulder’s click (compression test)
 wide toe box shoes, offloading insoles, us-guided
steroid injection, surgical excision
Mulder’s click
Plantar MTPJ pain
 plantar fat pad displacement (e.g. hammertoes)
S Bus, M Maas, P Cavanagh, R Michels, M Levi (AMC), Diabetes Care 27:2376 –2381, 2004
Dorsal MTPJ pain
 MTPJ instability/capsulitis/Freiberg’s/tenosynovitis
 Lachman test:
Transfer Lesions
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relatively long lesser MTs
defunctioned 1st ray (e.g. HV)
iatrogenic (post-surgical)
neurological conditions
Charcot arthropathy
What to look for
• Check for gastrocnemius tightness?
– eccentrics, dorsiflexion splints/socks OR ?heel raise
• Lesser metatarsalgia (mtpj vs webspace)
– eccentrics, offloading insole, chiropody, consider USS ± injection
• Hallux metatarsalgia
– refer early (hallux valgus, rigidus, sesamoid, turf toe, cavus)
– eccentrics, offloading insoles, rocker-bottom/wide toe-box shoes
When to refer
 failed conservative Mx
 pt wants to consider surgery
 pain is primary symptom
 lesser toe deformities
 impending or active ulceration
 hallux metatarsalgia
 associated mid/hindfoot deformities
 previous surgery (altered biomechanics)
Thank you