Metatarsalgia: A burning issue





By Michael Zapf, DPM

I just received an e-mail question on my Website asking about a problem that’s becoming epidemic in the world of foot doctors: metatarsalgia and predislocation syndrome. I know that’s a mouthful, so I will just call it PDS.


This condition is felt as pain and swelling on the ball of the foot behind the second toe. I know many of my Acorn readers have this condition, so I want to discuss it in some depth.


The Master Designer tried to carefully spread our weight across the foot from the heels to the toes. Each part of our foot was designed to carry only so much weight. If a given part is asked to carry more than what it was designed for, it rebels with pain and swelling. This is most obvious just behind the second toe. The second metatarsal head was designed to carry about 10 to 15 pounds. Even for a 200-lb. person this may not have been much of a problem in the past, when we walked on sand, grass and dirt. Now that we walk on unforgiving hard surfaces, often in unforgiving nonpadded shoes, and have added a few extra pounds to our frames, we might just be reaching the weight-bearing design limit of the second metatarsal head. PDS will result. I call metatarsalgia a disease of affluence. At least in the Conejo it seems that the more money we make, the harder our floor surfaces become.


If, on top of all that, you have a mechanical imbalance, say from a bunion or a hammertoe, the second metatarsal head cries "uncle" and the pain and swelling of PDS results. When I observe people with this condition, I often see a swollen knot on the ball of the foot (you can see a picture of this on my Website) that hurts to touch. If the swelling gets out of hand, the soft tissues around the joint can rupture and the toe lifts up and no longer rests on the floor. Often the toe starts to curl and forms a hammertoe. Sometimes the toe moves over the big toe, giving a pedal version of the good luck sign. By definition, when the toes cross, the joints are partially dislocated. Until that point the condition goes by the name of "predislocation syndrome"—hence the name of the condition.


In the office the joint can be examined with a diagnostic ultrasound to see the presence or extent of joint damage. Sometimes there is a swollen nerve, called a neuroma, next to this joint that can be visualized with the ultrasound. If a swollen nerve is discovered with the ultrasound, it can be treated in a variety of ways.


The primary treatment for PDS is taking weight off of the second metatarsal. Avoiding hard floors in bare feet or shoes without padding is the first step. Perhaps a soft mat could be placed at the workbench or at the sink to further pad the floor surface. In-shoe orthotic devices, specially designed to take weight off of the second metatarsal, are often helpful. Cortisone injections will reduce the inflammation temporarily but at the possible expense of weakening the joint further. If structural problems like bunions, hammertoes or a long second metatarsal are contributing factors, they might need to be addressed as well.


For PDS, treatment is never easier than prevention. The first time you have pain in the ball of your foot, start to lighten the load on your feet or cushion them as much as you can. If you see swelling on the ball of the foot behind the second toe, visit a podiatry office. Listen to your podiatrist. If he or she recommends orthotics, consider getting them even if your insurance balks. And think twice about getting rid of those carpets.


Dr. Michael Zapf has offices in Agoura Hills and Thousand Oaks. For more information, please see his Website, www.conejofeet.com, or call his office at (818) 707-3668 or (805) 497-6979.



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