Forefoot Metatarsalgia

In this episode of PodMD, Australian trained orthopaedic surgeon Dr Gayle Silveira will be discussing the topic of Forefoot pain or metatarsalgia, including what metatarsalgia is, what GPs should do before referring, the management of the condition and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMd studio Dr Gayle Silveira, Dr Silveira is an Australian trained orthopaedic surgeon, specialising in keyhole and general foot and ankle surgery.

    She consults at Ashford and Western Hospitals as well as in Modbury and Salisbury. She operated at Ashford, Western and Calvary North Adelaide Hospitals.

    Today, we’ll be discussing the topic of Forefoot pain or metatarsalgia.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Gayle, thanks for talking with us on Pod MD today.

    Gayle: Thank you for having me

    Question 1
    The topic of today’s discussion is Forefoot pain or metatarsalgia. Can you quickly explain to us what this is?

    Gayle: Uh metatarsalgia is sense of pain under the forefoot, and this can be associated with a deformity of the toes including things like bunions and hammer toes. It refers to a very localized or sometimes can be a generalized pain in the region of the metatarsal heads. Often this pain is on the plantar surface, so underneath the forefoot, beneath the metatarsal heads and arises from either a mechanical or artogenic causes.

    Question 2
    I imagine a patient presenting with forefoot pain and deformity of the toes may not always be straightforward in their presentation, so what should GPs should be looking for?

    Gayle: Uh, it’s important to understand that there’s various causes of metatarsalgia, um, broadly they’re divided into primary, secondary and nitrogenic causes primary metatarsalgia is mainly due to a mechanical imbalance in the forefoot, for instance, uh, uh, in severe hallux valgus, a Bunyan deformities, uh, leading to an incompetent first surgery and pressure transfer over the other lesser toes, uh, leading to less at or metatarsalgia. This can also be due to a discrepancy in the length of the metatarsal, uh, where you have a long, second metatarsal, uh, causing a transfer of load onto that metatarsal head. Uh, in essence, it’s described as a change in the bio or pathomechanics of the forefoot.

    Tight calves as well can sometimes cause excessive, uh, for, fore foot loading. Secondary metatarsalgia On the other hand is due to more generalized disorders like, um, metabolic disorders, um, for example, gout. Systemic disorders like rheumatoid arthritis and other inflammatory arthritis can also cause these symptoms, um, Morton’s neuroma, tassels, Donaldson arms are some examples of neurological causes for, fore foot pain, uh, Freiberg’s disease, or, um, also known commonly as avascular necrosis of the head of the second metatarsal is also one of the causes and the last group, which is mainly allergenic metatarsalgia, uh, is due to surgical complications from failed, uh, forefoot surgery either, um, uh, failed hallux, valgus surgery, or a failed, um, uh, uh, uh, fusion of the big toe.

    Question 3
    Is there anything GPs can do before metatarsalgia or bunions get to a surgery stage to manage or prevent them?

    Gayle: I think it’s important to first try and fit these into one of the two categories that I’ve just mentioned, uh, above our thing. If, If a direct cause has been identified and then treating it either by, um, uh, medical, uh, forms of treatment or referring them to a podiatrist, uh, to offload, uh, any mechanical symptoms of the forefoot could certainly help.

    Question 4
    Is there any imaging a GP should be doing before referring?

    Gayle: Plain weightbearing x-rays of the foot, uh, should be a routine initial investigation for most foot and ankle conditions. Uh, if a GPS worried about a more generalized, um, uh, condition like rheumatoid arthritis, then a basic set of blood tests, which include inflammatory markers would also be helpful at this state.

    Question 5
    What is the management of forefoot metatarsalgia and how does minimally invasive surgery help?

    Gayle: The management of forefoot metatarasalgia again, depends on what, uh, uh, category of cause Uh, we have, um, uh, placed this patient into. Non-operative management is always the first line where you can organize blood tests and appropriately medically diagnose a patient as well as refer them to a podiatrist, uh, for, um, custom orthotics, as well as metatarsal domes to offload, uh, the, uh, fore foot. Uh, we could also consider referring them to a physiotherapist for calf stretching exercises if the cause has been identified as a gas stroke or Keely’s tightness.

    In case of failure of non-operative management, surgery to correct, for instance, a bunion deformity with keyhole techniques, uh, could be utilized. Uh, we could also consider surgery for the lesser tool deformities, uh, including wilds, osteotomies, and tendon transfers to correct deformities of claw or hammer tools in the forefoot. Minimally invasive or key hole uh forefoot surgery has a low complication rate with faster or quicker wound healing times and reduced swelling of the forefoot.

    Question 6
    When should a GP refer?

    Gayle: A GP should refer a patient on, um, for failed non-operative management or if they remain concerned about the diagnosis or off, uh, forefoot pain, uh, they should also refer if they’re concerned about a particular forefoot condition that needs more advanced imaging, like an MRI scan, which is commonly used to diagnose, um, contemplate tears, um, Morton’s noodle Memorial lively than an ultrasound, and, uh, also intermetatarsal bursitis.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Forefoot pain or metatarsalgia

    1. Uh for generalized or diffused number one would be for generalized or diffused fore foot pain and swelling. It is mandatory to rule out inflammatory pathology, including rheumatoid arthritis and gout.
    2. Number two would be to consider early intervention for bunion and lesser tore deformities. It is all too common for me, uh, to see, uh, bunions, uh, being managed quite late, uh, with less satisfactory results.
    3. Number three would be the absence of calluses under the forefoot on examination as well as pain, but direct pressure should alert the GP to consider another cause, uh, for fore foot pain and perhaps organize an ultrasound of the forefoot, uh, which does include, uh, the tarsal tunnel, which should include, sorry, the tarsal tunnel as well.

    Thanks for your time and the insights you’ve provided.

    Gayle:Thank you for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.