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What is a Metatarsalgia (stone bruise)?

Metatarsalgia, also known as stone bruise, is a type of pain and inflammation that occurs in a part of the foot known as the metatarsal (ball of foot). It often occurs in the metatarsal heads - where the three middle toes meet the ball of the foot. It is a common problem which can affect the bones and joints of the metatarsals.

Most commonly, the first metatarsal head is affected - the ball of the foot just behind the big toe.

A lot of physically active people suffer from this condition as it can be caused by high impact of the foot which is a product of running, jumping etc. Sometimes, the condition can be caused by badly-fitting footwear, or even an underlying medical condition.

The severity of the pain can vary and may affect just one or two toes - sometimes the whole foot or even both feet might be affected. Metatarsalgia can worsen when weight is put on the foot, as may be the case when standing, walking, or running.

Metatarsalgia can affect males and females of all ages, but is most common in middle aged females.

Although the condition is not considered as serious or life-threatening in any way, the patient may be sidelined by it. Fortunately, symptoms usually respond well to plenty of rest, the application of ice, and some other conservative treatments.

What are the signs and symptoms of Metatarsalgia ?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

Symptoms of pain can range from mild to severe, and usually become more noticeable and unpleasant when the individual stands of moves. Some describe it as a burning sensation, while others complain of shooting pain, tingling or numbness in their toes. "It is like walking on pebbles."

  • A burning pain
  • Sharp aching
  • Pain in the ball of the foot, this is the metatarsal region, which is just behind the toes
  • Pain that can occur near the toes
  • Pain that increases when walking in bare feet, and even more so when walking on a hard surface
  • Pain that worsens when standing or moving around but decreases when the weight is taken off the feet.
  • Shooting pain in the toes
  • Tingling sensation in the toes

These symptoms usually develop slowly, however they may sometimes develop abruptly. Especially if there is an increase in exercise that may put strain on the feet, such as running or jumping.

What are the Causes of Metatarsalgia?

In the foot there are small toe nerves between the metatarsal bones. When the head of one metatarsal bone is pressed against another, the small nerve is caught between them and starts to become inflamed, thus causing metatarsalgia. The condition can worsen as weight is put on the foot, because with each step the metatarsal bones rub together more and more, which causes the inflammation of the nerve to increase.

There are many things that can cause metatarsalgia, such as particular medical conditions; however, the pain can be brought on by anything that puts too much stress on the ball of the foot. Any of the below can cause or be factors in the development of metatarsalgia.

  • Footwear that doesn't fit properly - footwear that is tight around the toes or has high heels that can add pressure on the ball of the foot as it is forced into a tight space.
  • Overweight people - may suffer this pain as the excess weight can put strain on the foot.
  • Age - the pad of fat that protects the foot can get thinner as a person ages; metatarsalgia can subsequently develop as the foot has less protection from the strain of impact and load.
  • High impact exercise - people who run or play high impact sports are at risk of metatarsalgia. When we are running our feet absorb large amounts of force.
  • Shape of the foot and toes - having a high arch in your foot or a second toe longer than the big toe can add to the pressure on the metatarsals.
  • Stress fractures - these are small breaks in the toe bones or metatarsals. They can cause pain when weight is put on the foot - the individual compensates by changing the way they put weight on his/her foot.

The following are medical conditions which can cause Metatarsalgia:

  • Bunion - this is a painful swollen bump that occurs at the base of the big toe. It weakens the big toe, which results in increased stress on the ball of the foot. This condition can be caused by wearing shoes that are too small, or can be inherited. It is more common in women than men.
  • Rheumatoid Arthritis - swelled joints in the foot, or gout can cause Metatarsalgia.
  • Build up of fluid in the foot.
  • Morton's neuroma - this is a growth of fibrous tissue of one of the nerves between the metatarsal heads.Morton's neuroma has very similar symptoms to Metatarsalgia and can cause further stress to the metatarsals.
  • Diabetes - the small nerves in the foot can become irritated, thus causing Metatarsalgia.

Who is most at risk of developing Metatarsalgia?

  • People who wear high heels or shoes that don't fit properly
  • Individuals with foot problems
  • Obese or overweight patients
  • Athletes or people who partake in high impact sports

What are the complications of Metatarsalgia?

If left untreated Metatarsalgia can cause:
  • The pain to spread to other parts of the foot or even the other foot.
  • Pain somewhere else on the body due to limping caused by the foot pain.

How is Metatarsalgia Diagnosed?

If the patient's first point of call is a GP (general practitioner, primary care physician), they may be referred to a podiatrist (specialist foot doctor). It is important to accurately assess and diagnose the condition right from the start so that the patient can receive effective treatment.

The doctor will examine the patient's foot and ask some questions, such as:
  • The patient's medical history
  • The patient's lifestyle
  • What type of footwear the individual has
  • Hobbies
  • When the pain began
  • How frequently the pain comes on; when the pain happens, where the pain happens..
  • Is the pain becoming worse?
  • Is there any pain in other parts of the body?

Gait - the patient may be asked to walk on a treadmill or pressure plate so that his/her gait can be assessed. This helps identify which parts of the foot are receiving pressure.

The following diagnostic tests may also be ordered:
  • Imaging tests - this may be an X-ray, an MRI (magnetic resonance imaging) or ultrasound scan, usually to see whether there are any bone fractures.
  • Blood tests - these may reveal underlying conditions which are linked to a higher risk of metatarsalgia, such as gout, arthritis or diabetes.

What are the treatment options for Metatarsalgia?

The following approaches may help ease discomfort and/or pain:
  • Apply ice to the area several times a day each time for approximately 15-20 minutes. Wrap the ice in something to protect your skin - do not let the ice touch the skin.
  • Take over the counter (OTC, no prescription required) anti-inflammatory medicines such as ibuprofen, this will reduce the inflammation and relieve the pain.
  • Avoid high impact sports and exercise that puts pressure on the feet. Try something lighter on the feet, such as swimming or cycling.
  • Try to keep pressure off the feet, when resting try putting your feet up.
  • Be sure to exercise your ankle and keep stretching the Achilles tendon.
  • Use fitted insoles (orthotics) as these will reallocate pressure, improve foot function and guard the ball of your foot.
  • Use metatarsal pads as they reduce pressure from the metatarsal bones.
  • Use shock absorbing insoles to relieve pressure when walking.
  • Arch supports may be recommended by your doctor if fitted insoles were not effective. There are various sizes which can be bought over the counter, or you can have ones custom made to fit your foot.
  • Change to better fitting flat headed shoes.

For more severe cases a doctor may recommend:

  • Steroid injections to reduce pain and swelling. The patient may initially experience some pain and swelling at the injection site, which should go away within a few days.
  • Foot surgery may be recommended if other therapies were not effective, to:
  • Reshape the metatarsal bones
  • Release/remove an affected nerve which may be trapped or irritated
  • Straighten the hammer toe (a deformity of the proximal interphalangeal joint of the second, third, or fourth toe causing it to be permanently bent).

How can Metatarsalgia be prevented?

The following measures may help significantly reduce the risk of developing metatarsalgia:
  • Proper footwear - avoid high heels and shoes that are too tight. A shoe should also provide adequate support and cushioning. A wide toe-box is better.
  • Arch supports or cushioned insoles - they help prevent pain of metatarsalgia. If pain develops they can help relieve it.
  • Bodyweight - remember that slim people have a significantly lower risk of developing metatarsalgia. Try to maintain a healthy bodyweight.
  • Recovery time - people who are recovering from injuries should make sure they comply with doctor's recommendations regarding when to resume strenuous activity.
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