Metatarsalgia

MedicalContinuing Education

CLINICAL PODIATRY

Objectives 1) To determine the etiology of plantar keratosis, diffuse callosities, callus under the first, second, and fifth metatarsal heads as well as to distinguish between diffuse and discrete plantar keratosis. 2) To describe the symptoms experi- enced by the patient with structural or mechanically induced metatarsalgia. Metatarsalgia: 3) To be aware of the nature of associated digital deformities. 4) To review the biomechanics of metatarsalgia. Diagnosis 5) To be aware of common conditions resulting in pain in the forefoot which may be in the differential diagno- and sis for structural metatarsalgia. 6) To update the recent research on the etiology of structural metatarsalgia. 7) To update recent research on the Management effectiveness of metatarsal pads, insoles and custom foot orthoses in the treatment of metatarsalgia. Etiologies and differential diagnoses. 8) To be aware of the variety of prefabricated commercial paddings, insoles, and foot orthoses in the management of metatarsalgia. 9) To know the pedorthic management for patients with metatarsalgia.

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By Ellen Sobel, D.P.M., Ph.D., C.PED. & forms the subject of this Continuing metatarsalgia. Although there are Steven Levitz, D.P.M. Podiatric Medical Education Article. numerous etiologies of metatarsal- The isolated complaint of gia,4,5 very few patients present with ain under metatarsal heads metatarsalgia, with pain under the Freiberg’s disease, let alone Tetralo- with callus formation is an ex- metatarsal head, has been called gy of Fallot as a cause of plantar tremely common reason for “primary” metatarsalgia,1,2 pressure forefoot pain. This CME article will P 3 seeking podiatric treatment and metatarsalgia, or structural Continued on page 79

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 77 Continuing

Medical Education

FIGURE 2A. Second metatarsal head shows sharp plantar FIGURE 1. The normal plantar fat pad with fibrous septa. lateral condyle responsible for metatarsal callosity.

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Metatarsalgia... be thought of as a pinched nerve (Figure 2B). Intractable plantar keratoses tend to occur focus on the most common structural causes of under metatarsal heads two, three, and four, which metatarsalgia, and provide several examples of fre- may or may not be associated with hallux valgus. They quently occurring differential diagnoses and the practi- are deep and painful, however, when an individual has cal management of this common problem. multiple IPK’s and they may not all hurt. Debridement reduces pressure to the ball of the foot 30%. After de- Plantar Keratosis Callosities bridement moleskin padding can be placed over the Plantar callus or tyloma is the most common cause callus for two to three days. Some patients will even of metatarsalgia. Pain limited to the bathe with the moleskin in place. head of the metatarsophalangeal ar- Normally, the dorsal angle of the ticulation with callus formation be- metatarsophalangeal joint is about 16 neath the metatarsal head is a sign of Plantar callus 160°. In a hammertoe deformity this abnormal weight bearing pressure. angle may be reduced to 90°, at which The stress of the body weight results or tyloma is the most angle the base of the proximal pha- in an inflammation on the plantar common cause lanx articulates with the dorsum of surface of the head of the metatarsal the head of the metatarsal. A hammer- bone as well as at the metatarsopha- of metatarsalgia. toe deformity causes the proximal langeal articulation.6 The plantar fat phalanx to push down on the dorsal pad has been thought to atrophy with aspect of the metatarsal head, causing aging in some people and fails to pro- the metatarsophalangeal joint to vide adequate cushioning, producing generalized dis- stretch and the glenoid plate to degenerate. This pro- comfort beneath the metatarsal heads (Figure 1).7 cess can occur very quickly. Hyperkeratosis or callus is a thickening of the skin caused by hyperplasia of the keratin layer, histological- Fifth Metatarsal Head Callus ly similar to a corn.8,9,10,11 It is found most frequently Callus on the fibular side of the fifth metatarsal under one or more of the lesser metatarsal heads in the head occurs because the head of the fifth metatarsal is forefoot12,13 especially under subcutaneous tissue Continued on page 80 thinned by continuous and excessive pressure.14 Metatarsal callosities are divided into large diffuse keratosis and well localized intractable plantar keratosis (IPK). DIFFUSE PLANTAR KERATOSES lack a discrete central core and are usually one to two centimeters in diameter.15 They may be caused by a relatively long or plantar-flexed second metatarsal. The Morton’s foot, consisting of a short first metatarsal, causes increased stress under the second metatarsal and subsequently a large, diffuse keratosis. In patients with significant hallux valgus deformity, the stress-absorbing function of the first metatarsal diminishes and a so-called transfer lesion develops under the second metatarsal.

Intractable Plantar Keratosis (IPK) The cause of the discrete IPK is an enlargement of the plantar lateral condyle of the metatarsal head (Fig- ure 2A).10 The condylar process on the fibular side is always the larger of the two. Pain produced by an IPK is caused by trapped nerves and capillaries (redipegs) resulting in neuritic FIGURE 2B. Entrapment of capillary and pain. nerve within the IPK. The enlarged plantar Therefore lateral condyle is protruding. an IPK can

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 79 Metatarsalgia... Continuing the most prominent point on the outer border of the Medicalforefoot. Education16 Case Presentation 1: This 50 year old male maintenance worker had severe pain under the fifth metatarsal head for the past several years. Physical examination revealed a scar over the dorsum of the foot from removal of Morton’s Neuroma (Figure 3A), with moderate callus formation under the fifth metatarsal head (Figure 3B). Numerous foot orthoses were of no help, despite the careful dispersion under the callus (Figure 3C). Careful palpation revealed a small fibroma on the slips of the lateral band of plantar fascia inserting into the fifth metatarsal (Figure 3B). One of the authors (SL) has removed three of these fibromas The first metatarsal in patients who could not get re- normally carries lief with debride- FIGURE 3A. Dorsum of the foot showing old surgical scar from removal of Morton’s Neuroma. approximately ment and foot orthoses. tibial sesamoid becomes a weight-bearing focus and twice as much causes a keratotic lesion. The keratotic lesion produced weight as each lesser First Metatarsal by the tibial sesamoid is a discrete, localized keratosis Head Callus with a dense keratotic center. When this lesion is de- metatarsal. A special case brided, a punctate keratotic focus is identified. is that of the callosity under the Biomechanics of the Metatarsal Heads first metatarsal All of the metatarsals sustain the body’s weight.17,18 head, which most commonly occurs under the tibial One-half of the body weight passes through each ankle sesamoid. Hyperkeratotic lesions beneath the first minus the weight of the foot. Half of the force on the metatarsal head are caused by an enlarged or malformed foot passes to the five metatarsal heads and the remain- tibial sesamoid, or excessive plantar flexion of the first ing half passes to the heel. If plantar weight bearing is ray. The tibial sesamoid normally assumes more of the divided into 12 units, 6 units will pass to the heel and 6 weight-bearing function transmitted to the head of the units will pass to the forefoot. Of the six units under first metatarsal. During weightbearing the first metatarsal the metatarsal head, each of the lesser metatarsals takes assumes a valgus torque and the lesser metatarsal heads one unit and the first metatarsal head takes 2 units. assume a varus torque. This is another reason why the Therefore the first metatarsal normally carries approxi- tibial sesamoid is more subject to excessive weightbearing mately twice as much weight as each lesser metatarsal. under the first metatarsal head, and the lateral plantar Viladot18 describes a first ray insufficiency syndrome condyles are more subject to weightbearing under the in which the first metatarsal cannot bear its share of lesser metatarsal head. the weight. Conditions such as hallux valgus, short first Hallux valgus deformity frequently results in the metatarsal, metatarsus adductus, and proximal place- first metatarsal head slipping off the sesamoid and the ment of the sesamoids result in reduced weightbearing for the first ray and place increased pressure under the lesser metatarsals. Flatfoot with resultant forefoot supinatus indirectly reduces the weightbearing under the first metatarsal head. Relaxation of the capsuloligamentous structures prevents the firm tight contact of the first metatarsal to the ground, resulting in an up- ward or dorsal tilt of the first metatarsal. Conversely, first ray overload syndrome, chiefly exemplified by hallux rigidus and sesamoiditis, places too much pressure on the first ray with possible clinical symptoms (callosity and pain) under the first metatarsal head. Morton18 proposed that the cause of metatarsalgia was a structural shortness of the first metatarsal which had to be compensated via lateral weight distribution. A functional shortness of the first metatarsal manifest- ed with hypertrophy of the second metatarsal head and cortex, metatarsal-cuneiform split, and proximally dis- Continued on page 81

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Metatarsalgia... vation, beneath the first metatarsal pad caused metatarsalgia, the head, to redistribute weight. thickness of the plantar fat pad placed sesamoids. Observation of It has been hypothesized that in- under the second and third only one of these radiographic find- creased pressure under the metatarsals was measured using ul- ings was considered evidence of a metatarsal head results in fat pad at- trasound in 50 patients with hypermobile first ray. The treatment rophy which then causes pain under metatarsalgia and varying degrees of for this malady was a Morton’s artic- the metatarsal heads.9,19,20 However, fat pad atrophy. Atrophy of the ulating insole, which consisted of in a recent study to determine plantar fat pad was not associated an insole with a 1/8 to 1/4 inch ele- whether atrophy of the plantar fat with increased severity or frequency of metatarsalgia.21

Subluxation of the 2nd Metatarsophalangeal Joint A common cause of painful IPK’s under the 2nd metatarsal head is subluxation and dislocation of the 2nd metatarsophalangeal joint with crossover deformity of the second toe.22 The most important stabilizing structure of the MTP joint is the FIGURE 3C. Numerous foot orthoses and ad- justments were unsuccessful in alleviating plantar plate, which is pain because the pain was due to a small fi- formed by the plantar FIGURE 3B. Man with pain under fifth broma which could be palpated in the slips aponeurosis and the plan- metatarsal head as shown by arrow. of the lateral band of plantar fascia. Continued on page 82

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 81 Metatarsalgia... FIGURE 4A (left photo). 39-year-old Continuing male with a 2.5 inch short left leg sec- tar capsule.23 Metatarsophalangeal ondary to trauma when he was Medicaljoint Education instability can be produced by pushed off train tracks. He suffered se- damage of the joint capsule, collat- vere muscle loss of the left lower ex- tremity with weakness of all left ex- eral ligaments, articular cartilage, or tensor muscles and a fused right knee. subchondral bone as a result of repetitive microtrauma (i.e., walking), or inflammatory, metabolic, and infectious diseases.24 The use of high-heeled shoes may produce chronic hyperextension forces at the metatarsophalangeal joint that may cause stretching of the plantar aponeurosis and capsule with even- tual instability of the metatarsophalangeal joint.23 Chronic repetitive microtrauma disrupts the plantar plate and collateral ligaments. Syn- ovitis from rheumatoid arthritis can also disrupt the plantar metarsopha- langeal joint ligaments and capsular structures.24 Once this joint stability is com- promised, the intrinsic interosseous and lumbrical muscle, which flex FIGURE 4B. 2.5 inch short left leg re- the MPJ and extend the PIPJ and sults in deep IPK’s submetatarsals 1 Continued on page 82 and 5 on the left.

82 PODIATRY MANAGEMENT • MARCH 2002 www.podiatrym.com Metatarsalgia... Continuing DIPJ, are overcome by the stronger Medicalextrinsic Education muscles (EDL, EHL and FDL). This results in hyperextension of the MPJ and flexion of the PIPJ and DIPJ, producing hammertoe deformity.

Cavus Foot Structural deformities such as cavus foot place increased pressure on the first and fifth metatarsal heads.25,26 Contracted digits, atrophy of the fat pad, and rigidity tend to occur in the cavus foot type and ex- acerbate plantar pressures under the metatarsal heads. The plantar flexed metatarsals of the cavus foot also result in increased weightbearing pressure on the metatarsal heads.

Limb Length Difference After walking for prolonged peri- FIGURE 5A. Clinical presentation of ods of time with significant limb metatarsal fracture—pain and FIGURE 5B. Plain radiographs show length discrepancy, the shorter leg will swelling over the dorsum of the right healing of stress fractures of the 3rd compensate with rigid ankle equines, foot localized to the shaft of the sec- and 4th metatarsal necks. The 4th Continued on page 84 ond metatarsal. metatarsal fracture is impacted.

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Metatarsalgia... therefore increasing weightbearing stress on the forefoot and the metatarsal heads. This results in callus formation (Figure 4A/B).

Trauma Metatarsal fractures are a common cause of metatarsalgia.27-30 The most common stress fracture in the human body occurs in the second metatarsal neck, and is usually caused by excessive weight-bearing demand on this metatarsal bone (Figure 5A/B).27-30 However, isolated fractures of the fourth metatarsal base are very uncommon and FIGURE 6A. This man fell down some should indicate suspicion of Lis- stairs and reported to the emergency Franc fracture dislocation. room. The diagnosis was fracture of Case Presentation 2: This 35 the base of the 4th metatarsal. year-old dentist fell down several stairs and sprained his foot. Radio- FIGURE 6B (photo right). However, DP graphs taken at a local emergency radiograph shows abnormal space be- room revealed a fracture of the base tween the 1st and 2nd metatarsal and of the fourth metatarsal (Figure lateral malalignment of the second metatarsal over the intermediate 6A). The DP view of the same foot cuneiform, which is evidence of LisFranc revealed a LisFranc fracture disloca- fracture dislocation, which was missed tion, which was missed at the ini- by the emergency room physician. Continued on page 86

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 85 Metatarsalgia... quela of a probable third metatarsal to the metatarsals have been shown Continuing fracture, which healed with a split to be reduced in military recruits who tial presentation (Figure 6B). metatarsal head (Figure 7). wore soft custom foot orthoses.31,32 Medical EducationMetatarsal fractures may result The incidence of stress fractures in healing in such a way that the Prior surgery metatarsals are misshapen, more Patients who have had previous plantar flexed, creating additional surgery on a metatarsal, especially pressure and callus formation in the Atrophy of the plantar removal of a metatarsal head, are forefoot. fat pad was not likely to have painful callus on the Case Presentation 3: This 65 year- adjacent metatarsal head. old female had painful callus under associated with increased Case Presentation 4. This 55 year- the third metatarsal head. She remem- severity or frequency of old female presents with chief com- bered previously injuring her foot plaint of painful callus located about a year ago, but claimed that her metatarsalgia. under the second metatarsal head foot had healed. Radiographs revealed (Figure 8A). Physical examination a split third metatarsal head as a se- Continued on page 88

TABLE 1 EFFECTIVENESS OF MECHANICAL TREATMENT OF METATARSALGIA-REVIEW OF THE LITERATURE

STUDY N TREATMENT MEASUREMENT RESULTS

Holmes & Timmerman, 10 healthy volunteers soft metatarsal pads Pedograph Reduction in plantar pressure for 1990 5 females; 5 males (no other details) woman 12% to 60% men 14% to 40%

Chang, Faraj, Harris, et al., 10 healthy male Plastazote insoles Interlink (Santa Barbara, Significant increases in peak 1994 subjects (6.4 mm thick) CA) pressure sensors pressures, contact durations, rubber metatarsal in portable in-shoe pressure-time integrals at pads-6 cm long data acquisition system. metatarsal shaft region with 5.2 cm wide, metatarsal pad use. .8 cm thick Mild decrease in mean peak Distal margins 5 mm pressure under 1st & 2nd met proximal to metatarsal head. Contact duration heads. decreased at all met heads; worn in P.W. Minor pressure-time integrals Extradepth shoes decreased at mets 1-4.

Poon & Love, 14 patients with Custom “metatarsal F-scan 13% reduction in forefoot 1997 metatarsalgia dome” foot orthoses Visual analog pain scale plantar pressure 71% reduction in pain as measured by visual analog scale.

Postema, Burm, Zande, et al 42 patients with Custom molded insole EMED System Rockerbar decreased peak 1998 metatarsalgia & rockerbar added pressure under forefoot 15% 41 females depth shoe Custom molded insole decrease 1 male (Patient casted full pressure under forefoot by 18% weightbearing) Metatarsal pad was 5 mm thick and 40mm long

Kelly & Winson, 1998 33 patients Viscoped Insole Musgrave Footprint Viscoped-6/18 patients rated (Bauerfeind, UK) system. much improved Langer Blueline Visual analogue pain Langer Blue group 12/15 rated orthosis (Langer, score. much improved Deerpark, NY) Langer Blue Line group reduced for 8 weeks forefoot plantar pressures significantly better than Viscoped insoles

86 PODIATRY MANAGEMENT • MARCH 2002 www.podiatrym.com Metatarsalgia... thing is to observe whether a callus is present.34 The sub- Continuing jective findings include pain under the metatarsals of a reveals a short third toe (Figure 8B). X-rays revealed burning and cramping nature.6 The objective findings in- Medicalsurgical Education removal of the 3rd metatarsal head (Figure 8C). clude a plantar callus under the head of the metatarsal, often with indi- Neuromuscular Disease vidual or multiple Neuromuscular disease may result in pronounced contracted digits. muscle imbalance leading to particularly thickened The most common There may be painful metatarsal calluses (Figure 9A/B).33 tenderness over stress fracture the plantar sur- Brachymetatarsia in the human body face of the Brachymetatarsia disrupts the smooth metatarsal occurs in the second metatarsals. parabola resulting in uneven weightbearing with pain- There may also ful metatarsalgia. metatarsal neck. be a depression Case Presentation 5: This 20 year-old female had a on the dorsum history of removal of a pituitary gland tumor several over the head of years previously, which caused her to require taking the metatarsal large doses of hormone therapy. This resulted in prema- bone. There may be decreased passive range of motion of ture closure of the growth plates with brachymetatarsal- the involved metatarsophalangeal joint. gia (Figure 10). Associated Deformities Clinical Presentation The contracted digital deformities are hammertoes, When a patient complains of forefoot pain the first mallet toes, and claw toes. A hammertoe is a flexion contracture at the proximal interphalangeal joint. A corn frequently develops on the head of the proximal phalanx. Extrinsic pressure of the hallux against the second toe owing to restrictive shoe gear results in hammertoe deformity or subluxation or dislocation of the second metatarsal phalangeal (MTP) joint (crossover deformity).22 A mallet toe is a flexion contracture of the distal interphalangeal joint making the distal aspect of the toe point toward the ground. A hard corn develops on the tip of the toe. A clawtoe is a flexion contracture at both the proximal and distal inter- phlangeal joints.35 Clawed digits may be associated with neuromuscular disease.36 Hard corns (heloma durum) are an accumulation of several layers of epidermis over a bony prominence generally found on the lateral side of the fifth toe and on the dorsum of the toes as the skin rubs against the FIGURE 7. Patient clinically had 3rd metatarsal callus. X-rays 37 showed that a metatarsal fracture sustained about a year shoe. They are the body’s attempt to protect the skin ago healed with split metatarsal heads. One of the over the bony prominence. Because there is no mois- metatarsal heads was directed plantarly, causing pain and ture in these locations, the corn remains hard. Soft callosity with ambulation. corns (heloma molle) occur intertriginously most frequently in the fourth interspace in either the web space or the medial or lateral borders of the lesser digits. The soft corn retains the moisture of the interspace, which is responsible for its macerated soft texture.38

Differential Diagnosis A study of metatarsalgia in 98 patients revealed 23 distinct diagnoses.1 Scranton1 divided metatarsalgia into structural, systemic, and miscellaneous forefoot pain categories. Structural and postoperative etiologies were the most common causes of forefoot pain; however, rheumatoid arthritis, Morton’s neuroma, and sesamoiditis were also relatively common. Although the great percentage of pain in the forefoot, especially under the metatarsal heads, is caused by callosities, the most common of these diagnoses will be considered. Continued on page 89

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Metatarsalgia... der when it is squeezed from medial The third common digital to lateral and bleeds easily when de- nerve is vulnerable to damage Verruca Plantaris brided. Plantar keratosis can be easi- due to excessive motion between It is important to distinguish ly pared down fairly deep and will Continued on page 90 verruca plantaris from plantar ker- not bleed if debrided carefully. atosis. The keratosis is mistakenly treated with anti-wart chemical ap- Morton’s Neuroma plications until keratosis breaks Morton’s neuroma is a well-doc- down and ulcerates or leaves a per- umented clinical entity which is manent scar. A plantar wart is ten- most probably a mechanically-induced degenerative neuropathy that predilects for the third common digital nerve in middle-aged women.39-43

FIGURE 8A. Patient presents with chief complaint of painful 2nd metatarsal FIGURE 8B. Clinically there is a short FIGURE 8C. X-rays reveal surgical re- head callus. 3rd toe. moval of the 3rd metatarsal head.

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 89 Metatarsalgia... transverse intermetatarsal ligament cessive intraneural and juxtaneural Continuing and weightbearing forces from high reparative fibrosis significantly en- the third and fourth metatarsals, heeled shoes. Over long periods of large the nerve, making it even Medicalcompression Education by the large overlying time, nerve fiber degeneration, ex- more vulnerable to compression. The metatarsal squeeze test is a clinical diagnostic test for this disorder.

Systemic Arthritis The metatarsophalangeal joints are the first areas of the foot to be involved in rheumatoid arthritis.44 An x-ray of the foot with estab- lished and advanced rheumatoid arthritis shows characteristic sub- luxations at the metatar- sophalanageal joints, but FIGURE 9B. AFO padded with felt and a special foot x-rays in the early diag- plate with cut out for the first metatarsal was nec- essary to alleviate this patient’s symptoms from the nosis of rheumatoid excess pressure of the callus. arthritis are not helpful.

FIGURE 9A (photo left). IPK under the first Treatment metatarsal head with contracted digits. Patient had The treatment for a gunshot wound to the spine result in muscle im- plantar callosities be- balance, which led to the digital contractures. Continued on page 92

90 PODIATRY MANAGEMENT • MARCH 2002 www.podiatrym.com Metatarsalgia... plied to affected skin twice per day and rubbing the Continuing cream into the skin until completely absorbed. gins with debridement of diffuse callosities with Medicalenucleation Education of intractable plantar keratoses (IPK’s). A Metatarsal Pads surgical scalpel with a number ten surgical knife is Metatarsal pads are pear-shaped pads which are used for debridement. A number fifteen surgical knife placed just proximal to the metatarsal heads to transfer may be used for enucleation. Lubrication and hydra- and distribute tion to maximize skin tone is essential. Callus debride- body weight ment in one recent study found no significant differ- to necks and ence in peak forefoot pressure before and after callus shafts of the removal;45 however, in another report, plantar forefoot metatarsals.47 pressures were reduced after debridement of calluses Metatarsal in diabetic patients.46 pads have A hyperkeratolytic agent such as Carmol®-40% Urea been found to Cream (Doak be effective in Dermatologics, reducing pres- Fairfield, N.J), sure under the or Amlactin® metatarsal 12%-(12% am- heads. Soft monium lac- FIGURE 11A. Prefabricated wool felt metatarsal tate), may be metatarsal pads (Hapad, Inc., Bethel pads were ef- helpful when Park, PA) with adhesive backing. fective in re- hyperkeratosis ducing pres- is particularly sure under the metatarsal heads in ten asymptomatic thickened. volunteers as measured by pedobarograph.48 Subjects These agents walked barefoot with the metatarsal pad taped to the provide enzy- foot. This study found that metatarsal pads were more matic debride- effective in reducing plantar pressures in females than ment of callus- in males possibly because of previous use of high- es. Urea gently heeled shoes or because of the smaller size of the fe- dissolves the in- male foot. The authors concluded that simple inexpen- tercellular ma- sive metatarsal pads were an effective treatment for trix, which re- metatarsalgia, especially in female patients. sults in loosen- In a more recent but similar study, ten male asymp- ing the horny tomatic volunteers walked in 6.4mm thick plastazote layer of the skin insoles with rubber metatarsal pads worn in P.W. Minor and shedding shoes.49 Metatarsal pad use resulted in peak load in- scaly skin at creases in the midfoot region and mild decreases in the FIGURE 10. This 20 year old female had regular inter- forefoot region under the 1st and 2nd metatarsal heads a history of removal of a pituitary gland vals, softening and slight increases laterally. Contact durations de- tumor several years previously which caused her to require taking large doses hyperkeratoses. creased at all metatarsal head locations. Therefore ® of hormone therapy, which resulted in Carmol -40% metatarsal pads seemed to redistribute pressure away premature closure of the growth plates Urea Cream is from the metatarsal head more proximally into the with brachymetatarsalgia. topically ap- metatarsal shaft. The authors concluded that insoles with metatarsal pads were an effective treatment for metatarsalgia. Prefabricated wool felt metatarsal pads are available from Hapad, Inc. (Bethel Park, PA) (Figure 11A). These metatarsal pads have adhesive backing and are designed to be placed directly inside the shoe (Figure 11B). When a shoe is worn, the inside of the shoe can Continued on page 93

FIGURE 11B. Prefabricated wool felt metatarsal pads (Hapad, Inc. Bethel Park, PA) with adhesive backing are designed to be placed directly inside the shoe and last the life of the shoe.

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Metatarsalgia... tion in plantar pressure of 7% to 9% under be examined for pressure areas in the metatarsal heads.51 the metatarsal region usually indi- In one study with sev- cated by dark spots. The front of the eral interesting conclusions pad is placed just proximal to the it was found that custom dark spot pressure area. While fit- molded insoles and a ting the pad in the shoe, only a rockerbar were found to be small portion of the adhesive on the effective in reducing central back of the pad should be shown so forefoot pressure in 42 pa- that the pad can be placed in differ- tients with metatarsalgia.52 ent spots until the patient feels It was determined that the comfortable in the shoe. custom molded insole re- Special prefabricated metatarsal duced central forefoot pres- bandages are available from Apex FIGURE 12. Metatarsal bandage (Apex Foot Health sure by 18% and the rocker Foot Health Industries (Hackensack, Industries, Hackensack, New Jersey). bar contributed to reduc- New Jersey), which slide easily on the In another study, fourteen pa- tion in forefoot pressure by approxi- foot and do not take up as much tients with metatarsalgia wore mately 15%. In this study, custom metatarsal dome orthoses with a fol- molded insoles reduced forefoot low-up of 15.5 weeks.50 At the time pressure better than prefabricated in- of follow-up there was found to be a soles. However, reduction in pain It is important to 13% decrease in mean forefoot plan- was not related to a reduction in distinguish tar pressure and a 71% reduction in pressure. Similarly, walking speed pain as measured by a visual analog and body mass were found to be un- verruca plantaris scale, with 90% of patients wearing related to plantar forefoot pressure from plantar their orthoses most of the time. And in this study. The authors recom- in yet another similar study, custom mended prescribing the custom keratosis. moulded inserts resulted in reduc- Continued on page 94

TABLE 2 room as an insole or foot orthosis and can be worn in virtually any shoe TYPES OF ROCKER BOTTOM SOLES with complete comfort (Figure 12). (Adapted from Janesse D: Introduction to Insoles & Foot Orthoses Pedorthics, Pedorthic Foot Wear Insoles or accommodative foot orthoses assist in rebalancing to re- Association, Columbia, Maryland, 1998) distribute and disperse calluses and are made of soft materials such as plastazote, PPT, felt, foam rubber, TYPE ROCKER INDICATION sponge rubber, plastics, leather, Spenco®, and Sorbothane. Insoles Mild Rocker Sole Relieve metatarsal pressure and custom foot orthoses have been Typically found on running shoes shown to reduce forefoot pressure and pain in patients with Heel-to-toe Rocker Sole Digitial deformities such as metatarsalgia (Figure 13A/B). hammer toes A number of studies have com- & claw toes pared the effectiveness of various Calcaneal ulcers kinds of insoles on the relief of Midfoot amputation metatarsalgia and reduction of forefoot pressure. In a comparative study on the effectiveness of plasta- Toe-only rocker sole Hallux rigidus zote/PPT versus silicone insoles, plantar forefoot pressure was low- Severe angle rocker For extreme relief of ulcerated ered in all patients. However, reduc- metatarsal heads tion in forefoot plantar pressure was 84% for those wearing the plasta- Negative-heel rocker Rigid calcaneus deformity zote/PPT insoles for eight weeks ver- Painful metatarsal heads sus 34% forefoot pressure reduction for those wearing silicone insoles for Double rocker sole Midfoot charcot foot the same time period.3

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 93 Metatarsalgia... rheumatoid arthritis, foot orthoses ly more than flat inserts.53 Continuing have been effective in reducing fore- Twelve rheumatoid arthritis pa- molded insole and rocker bottom foot pressure and relieving tients with second metatarsal head Medicalshoe Education together.52 metatarsal pain. In diabetic patients, pain were treated with four different In patients with foot problems custom foot inserts lowered foot orthoses which included prefab- due to diabetes mellitus and metatarsal head pressure significant- ricated, standard custom molded, custom molded with metatarsal dome, custom molded with metatarsal bar and a shoe-only control.54 Results revealed that all orthoses significantly reduced pressure beneath the first and second metatarsal head compared to the FIGURE 13A. A variety of insoles for relief of shoe-only control metatarsalgia. Top left 3/4 Comf-Orthotic® of wool FIGURE 13B. Variety of metatarsal pads and P.Q. as measured by felt with metatarsal lift and arch support (Hapad, Lady’s dress shoe comfort inserts with special ball Bethel Park, PA). Bottom left Soft Plastazote PPT of the foot cushion. The insole is made of a spe- the EMED Pedar combination insoles (Langer Biomechanics Group, cial 3-layer material consisting of a top cover of system. However, DeerPark, New York). Top right Sorbolite shock ab- smooth nylon, midlayer of SbR for shock absorp- the custom mold- sorbing Comfort Insole (IEM Medical Technologies, tion and a bottom layer of 1/8 inch pure PQ Visco ed orthosis with a Inc, Ravenna, Ohio). Bottom right Hapad full length elastic polymer for extra shock absorption (Rieck- metatarsal dome Comf-Orthotic® (Hapad, Inc., Bethel Park, PA). en’s Orthotic Laboratory, Evansville, Indiana). Continued on page 95

94 PODIATRY MANAGEMENT • MARCH 2002 www.podiatrym.com MedicalContinuing Education

Metatarsalgia... Use of ready-made insoles in the treatment of lesser was the most effective design mettarsalgia: A prospective ran- for rheumatoid arthritis pa- domized controlled trial. Foot tients with painful second Ankle 19: 217-220, 1998. 4 Albert SF, Jahnigen DW: metatarsal heads.54 Treating common foot disorders in older patients. Geriatrics 38: Footwear 42-55, 1983, June. Shoes should be well- 5 Pack LG, Julien PH: Differ- padded, have rubber soles to ential diagnosis of lesser cushion and absorb shock metatarsalgia. Clin Podiatr Med and have a relatively low Surg 7(4): 573-7, 1990. heel. Depth inlay orthope- 6 Hauser EDW: Diseases of the dic shoes have a large upper foot. W.B. Saunders Company, to accommodate hammer Philadelphia, 1941. pp. 311-314. 7 Mann RA: Metatarsalgia digits and are large enough Common causes and conserva- to fit an insole. A shoe with FIGURE 14. Budin splint to stretch toe and pad metatarsal heads. tive treatment. Postgraduate a rocker bottom sole has the Medicine 75:150-67, 1984. anterior half of the sole curved up- thicker than 3/8 of an inch. The 8 Helfand A: Nail and hyperkeratotic ward toward the end of the shoe metatarsal bar should be located problems in the elderly foot. AFP: 39(2) with the apex of the curve just prox- proximal to the metatarsal heads of 101-110, 1989. imal to the metatarsal heads allow- the foot. 9 Helfand AE Lesser metatarsalgia in the ing for a smooth transmission from Treatment of associated ham- geriatric patient. Clin Podiatr Med. Surg. heel to toe during stance phase of merdigits consists of observation if 7(4): 743-749, 1990. 10 gait. Shoes with rocker-bottom soles not symptomatic. Shoe wear with Mann RA, DuVries HL: Intractable plantar keratosis. Orthop Clin North Am have been shown to reduce pressure higher toe box, low heel, depth 41: 67, 1973. under the metatarsal heads and are inlay shoe is recommended. De- 11 Mann RA: Keratotic disorders of the a frequently recommended external bridement of the associated corn plantar skin. In Surgery of the Foot and and plantar callosity is always help- Ankle, ed by RA Mann, St. Louis, CV ful. Silicone toe sleeve may be Mosby Company, 1986. Chapter 7. pp. placed directly on the affected ham- 180-198. Metatarsal pads mered digit. A Budin splint (figure 12 Calliet R: Foot and Ankle Pain. F.A. have been found 14), or silicone gel metatarsal cush- Davis Company, Philadelphia, 1982, edi- ion (Apex Foot Health Industries, tion 2. 13 to be effective in Hackensack, NJ (Figure 15) may be Friedman SL: “Palliative Care,” In JM Robbins: Primary Podiatric Medicine. W.B. applied to extend a flexible ham- reducing pressure Saunders Company, Philadelphia, 1994, merdigit. Surgical referral is rec- under the Chapter 13, 167-82. ommended if the problem is ex- 14 Klenerman L, Nissen KI, Baker H: The metatarsal heads. tremely painful and does not re- Foot and Its Disorders, Blackwell Scientific spond to conservative treatment. Continued on page 96 For high-heeled dress shoes thin shoe modification for metatarsal- lightweight prefabri- gia.55,56 Of the six types of rocker-bot- cated foot orthoses tom soles (Table 2), the mild rocker with a spring arch sole is the most commonly used and design are available is effective in relieving metatarsal from the Eneslow pressure.57 Since the mild rocker is Foot Comfort Cen- frequently found on running shoes, ter (New York, New the heavy cushioning of the better York) (Figure 16). men’s running shoes in conjunction with the rocker sole makes this an References excellent choice for patients with 1 Scranton PE: metatarsalgia. Metatarsalgia: Diagnosis A metatarsal bar, not to be con- and Treatment. J Bone fused with a rockerbar, is another Joint Surg. 62A: 723-32, 1980. external shoe modification which 2 Scranton PE: works as a fulcrum to reduce Metatarsalgia: A clinical metatarsophalangeal extension review of diagnosis and forces creating a negative heel ef- management. Foot fect.57 The bars are made from Ankle 1: 229, 1981. FIGURE 15. Anti-Shox® Gel Metatarsal Cushion (Apex Foot leather or crepe and should be no 3 Kelly A, Winson I: Health Industries, Hackensack, New Jersey.)

www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 95 Metatarsalgia... 46 Young MJ, Cavanagh Continuing PR, Johnson TG, Murray Publications, 1976, pp. 131-63. MM, Boulton AJM: The ef- Medical Education15 Silfverskiold JP: Common foot prob- fect of callus removal on lems. Postgrad 89(5) 183-8, 1991. plantar foot pressures in dia- 16 DuVries HL: Surgery of the Foot. C.V. betic patients. Diabetic Med Mosby Company, St. Louis, 1959. 9: 55-7, 1992. 17 Morton DJ: The Human Foot, New 47 Milgram JE: Office York, Columbia University Press, 1948. measures for relief of the 18 Viladot A: Metatarsalgia due to painful foot. J Bone Joint biomechanical alterations of the forefoot. Surg 46A 1095-1116, 1964. Orthop Clin NA 4: 165-178, 1973. 48 Holmes GB: Timmer- 19 Chairman EL: Restoration of the man L: A quantitative assess- plantar fat pad with autoliptransplantation. ment of the effect of J Foot Ankle Surg. 33: 373-379, 1994. metarsal pads on plantar 20 Hlavac H: The plantar fat pad and pressures. Foot Ankle 11: some related problems. J Am. Podiatr. FIGURE 16. Walking Balance Orthotics especially de- 141-145, 1990. 49 Assoc. 60: 151-155, 1970. signed to wear with high heeled shoes (Eneslow Foot Chang A, Abu-Faraj 21 Waldecker U: Plantar fat pad atro- Comfort Center, New York, NY.) ZU, Harris GF, Nery J, Shereff phy: A cause of metatarsalgia? J Foot Ankle MJ: Multistep measurement Surg 40(1): 21-27, 2001. Prevention of stress fractures using custom of plantar pressure alterations using metatrsal 22 Weinfeld SB: Evaluation and man- biomechanical shoe orthoses. Clin Orthop pads. Foot Ankle Intern 15: 654-660, 1994. agement of crossover second toe deformity. Rel Res. 360: 182-190, 1999. 50 Poon C, Love B: Efficacy of foot or- Foot Ankle Clin 3(2) 215-228, 1998. 32 Milgrom C, Giladi M, Kashtan H, et thotics for metatarsalgia. The Foot, 202- 23 Coughlin MJ: Subluxation and dislo- al: A prospective study of the effect of a 204, 1997. shock-absorbing orthotic device on the in- 51 Bennett P, Miskewitch V, Duplock L: cidence of stress fractures in military re- Analysis of the effects of custom moulded cruits. Foot Ankle 6: 101-104, 1985. foot orthotics. Gait Posutre 3, 183, 1994. Shoes with 33 Sobel E, Giorgini R: Problems and 52 Postema K, Burm PET, Zande ME, management of the rearfoot in neuromus- Limbeek JV: Primary metatarsalgia: Influ- rocker-bottom soles cular disease. A report of ten cases. J Amer ence of a custom moulded insole and a have been shown Podiatr Med Assoc 89 (1): 24-38, 1999. rockerbar on plantar pressure. Pros Orthot 34 Coughlin MJ; Common causes of intern 22: 35-44, 1998. to reduce pressure pain in the forefoot in adults. Review arti- 53 Lord M, Hosein R: Pressure redistribution cle. J Bone Joint Surg 82B: 781-9, 2000. by moded inserts in diabetic footwear A pilot under the 35 Sands AK, Byck DC: Idiopathic study. J Rehab Res Dev 31: 214-221, 1994. metatarsal heads. clawed toes. Foot Akle Clin 3(2): 245-58, 54 Hodge MC, Bach TM, Carter GM: Or- 1998. thotic management of plantar pressure and 36 Teasdall RD: Neuropathic clawed pain in rheumatoid arthritis. Clin Biomech toes. Foot ankle Clin 3(2): 229-43, 1998. 14(8): 567-575, 1999. cation of the second metatarsophalangeal 37 Astion DJ: The fifth toe hard corn. 55 Nawoczenski DA, Birke JA, Coleman joint. Orthop Clin North Am 29: 535-551, Foot Ankle Clin 3(2): 305-11, 1998. WC: Effect of rocker sole design on plantar 1989. 38 Donley BG, Gates NT: Interdigitial forefoot pressures. JAPMA 78: 455-60, 1988. 24 Mann RA, Mizel MA: Monoarticular corns. Foot Ankle Clin 3(2): 293-303, 1998. 56 Schaff PS, Cavanagh PR: Shoes for the nontraumatic synovitis of the metatrsopha- 39 Oliver TB, Beggs I: Ultrasound in the insensitive foot: The effect of a “rocker bot- langeal joint: A new diagnosis. Foot Ankle assessment of metatarsalgia: A Surgical and tom’ shoe modification on plantar pressure 6: 18-21, 1985. Histological Correlation. Clin Radiol 53: distribution. Foot Ankle 11: 129-140, 1990. 25 Jimenez AL, Martin DE, Phillips AJ: 287-9, 1998. 57 Janisse D: Introduction to Pedor- Lesser metatarsalgia evaluation and treat- 40 Quirk R: Morton’s neuroma. Aus- thics. Pedorthic Footwear Association, ment. Clin Podiatr Med Surg 7(4): 597-618, tralian Fam Phys 16(8): 1117-20, 1987. Columbia, Maryland, 1998. 1990. 41 Williams JW, Meaney J, Whitehouse CME Exam on page 100 26 Subotnick SI: The Cavus Foot Phys GH, et al: MRI in the Investigation of Mor- Sport Med 8(7): 53-5, 1980. ton’s Neuroma: Which Sequences? Clin Ra- 27 Childers RL, Meyers DH, Turner PR: diol 52: 46-9, 1997. Lesser metatarsal stress fractures: A study of 42 Younger ASE, Claridge RJ: The role of 37 cases. Clin Podiatr Med Surg 7(4): 633- diagnostic block in the management of 44, 1990. Morton’s neuroma. Can J Surg 41(2): 127- 28 Kaye Ra: Insufficiency stress fracture 30, 1998. of the foot and ankle in postmenopausal 43 Wu KK: Morton neuroma and women. Foot Ankle Int 19: 221-224, 1998. metatarsalgia. Curr Opin Rheumatol 12(2): 29 Shereff MJ: Complex fractures of the 131-42, 2000. (Published posthumously, metatarsals Review Article: Foot and Ankle Dr. Wu died November 25, 1999.) Series. Orthopedics 13: 875-82, 1990. 44 Sobel E, Caselli MA, McHale K: Pedal 30 Spector FC, Karlin JM, Scurran BL, Sil- Manifestations of Musculoskeletal Disease. vani SL: Lesser metatarsal fractures Inci- Clin Podiat Med Surg. 15: 435-480, 1998. dence, management, and review. J Am Po- 45 Potter J, Potter MJ: Effect of callus re- Drs. Levitz and Sobel are professors in diatr Med Assoc 74(6): 259-64, 1984. moval on peak plantar pressures. The Foot the Department of Orthopedics, 31 Finestone A, Giladi M, Elad H, et al: 10: 23-26, 2000. NYCPM.

96 PODIATRY MANAGEMENT • MARCH 2002 www.podiatrym.com EXAMINATION

See instructions and answer sheet on pages 136-138. Continuing Medical Education

1) What is the most common cause of forefoot pain? A) Morton’s neuroma EARN CME CREDITS B) Rheumatoid arthritis C) Osteoarthritis FROM D) Callus PODIATRY MANAGEMENT 2) The nature of the pain in intractable plantar keratosis can be characterized as: Now you can earn CME credits by care- A) Vascular fully reading articles and answering B) Psychological questions. C) Neuritic D) Endocrinological You have two methods to enroll: 1) on a per issue basis (at $15 per topic) or 2) per year for 3) What is the most common cause of intractable the special introductory rate of $99 (you save plantar keratosis? $51). You may submit the answer sheet, along A) Enlargement of the plantar medial condyle of with your check (payable to Podiatry Manage- the metatarsal head B) Enlargement of the plantar lateral condyle of ment) and your state license number(s). the metatarsal head If you correctly answer seventy percent (70%) C) Clawtoe deformity of the corresponding digit of the questions correctly, you will receive a cer- D) Plantar flexion of the metatarsal head tificate attesting to your earned credits. This program is approved by the Council on Podia- 4) What is the most common etiology of a callus tric Medical Education (CPME). PM’s CME pro- under the first metatarsal head? gram is valid in all states except Kentucky, A) Enlargement of the tibial sesamoid B) Enlargement of the fibular sesamoid Pennsylvania, and Texas. Podiatry Management C) Cavus foot cannot guarantee that these CME credits will be D) Forefoot valgus deformity acceptable by any state licensing agency, hospital, managed care organization, or other entity. 5) Which of the following results in first ray over- PM will, however, use its best efforts to ensure load syndrome? the widest acceptance of this program possible. A) Relaxation of the capsuloligamentous structures of the first metatarsal This instructional CME program is designed B) Hallux valgus C) Sesamoiditis to supplement, NOT replace, existing CME D) Flatfoot seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We 6) What is the torque of the metatarsals? will endeavor to publish high-quality manuscripts A) Neutral torque by noted authors and researchers. If you have any B) Valgus torque of the first metatarsal and questions or comments about this program, you varus torque of the lesser metatarsals. C) Varus torque of all five metatarsals can write us at: Podiatry Management, P.O. D) Valgus torque of the lesser metatarsals and Box 490, E. Islip, NY 11730, or e-mail us at neutral torque of the first metatarsal [email protected] or call us at 1-631-563-1604.

7) The findings of recent research on metatarsal Simply go to page 77, read the article by Drs. pads and foot orthoses show that: Sobel and Levitz, and/or go to page 123 and A) They have been found to reduce pressure, read the article by Dr. Rehm, then answer the but only in asymptomatic subjects. 20 multiple choice questions that correspond to B) They have been shown to reduce pressure in asymptomatic subjects and patients with each article. You then have the choice to mail, metatarsalgia. fax, or call in your answers. C) They have been shown to reduce pressure in Continued on page 100 Circle #25 www.podiatrym.com MARCH 2002 • PODIATRY MANAGEMENT 99 Continuing EXAMINATION

Medical Education (cont’d)

asymptomatic subjects and B) Sesamoiditis and trauma callus formation EXCEPT: symptomatic patients as well C) Metatarsophalangeal sub- A) Short leg with equinus con- as re duce pain in symp- luxation tractures tomatic patients D) Structural and postoperative B) Removal of metatarsal head D) While they are effective C) Calcaneus foot type clinically, they have not been 12) Which is NOT TRUE pertain- D) Fracture of a metatarsal demonstrated to reduce ing to metatarsal pads? pressure in asymptomatic A) Metatarsal pads can be 17) Plantar metatarsal callus is a individuals or patients with placed directly in the shoe. thickening of the skin caused by metatarsalgia B) Metatarsal pads increase hyperplasia of the keratin layer, pressure under the metatarsal histologically similar to a dorsal 8) Recent research on patients necks. digital heloma durum. with plantar metatarsal calluses C) Metatarsal pads are placed A) True have shown that when calluses directly under the metatarsal B) False are debrided: heads. A) Plantar pressure is reduced D) Metatarsal pads can be 18) Why must fractures of the 4th B) Plantar pressure is not made out of wool felt. metatarsal be observed very care- reduced fully? C) Plantar pressure may or 13) Summarizing the literature A) Because they are difficult to may not be reduced on insoles/foot orthoses used to heal. D) Pain is not reduced treat metatarsalgia, which of the B) Because they are easily following insoles would have the missed and more common 9) What has recent research best pain and pressure-reducing than once thought. found pertaining to the relation- features? C) Because they are associated ship between plantar fat pad at- A) Prefabricated, soft and lam- with osteoporosis in rophy and metatarsalgia? inated menopausal females. A) Atrophy of the plantar fat B) Prefabricated, soft, laminat- D) Because they are associated pad has been found to be one ed and containing metatarsal with LisFranc fracture disloca- etiology of metatarsalgia pad tion. B) Atrophy of the plantar fat C) Custom molded, semirigid pad has been found to be asso- foot orthosis 19) The best use of prefabricated ciated with metatarsalgia, but D) Custom molded, soft, with wool felt metatarsal pads avail- does not in a causal manner metatarsal pad able from Hapad, Inc. (Bethel C) Plantar fat pad atrophy is Park, PA) is to: associated with increased 14) Which shoe feature or modifi- A) Place them directly on the pressure under the plantar fat cation would be LEAST helpful for skin pad, but does not cause pain a patient with metatarsalgia? B) Place them on an insole D) There is no relationship be- A) Rocker bar C) Place them directly in the tween atrophy of the plantar B) High toe box shoe fat pad and metatarsalgia C) Rubber sole D) Place them on a custom D) SACH heel foot orthosis 10) What is the main stabilizing structure of the MTP joint? 15) Which type of insert/foot or- 20) What type of rocker sole is A) Plantar plate thosis has been most effective in most frequently found on run- B) Flexor digitorum longus preventing stress fractures? ning shoes? C) The metatarsal lateral col- A) Semi-rigid custom foot or- A) There usually is no rocker lateral ligament thoses sole on running shoes. D) The metatarsal phalangeal B) Soft accommodative foot B) Double rocker plantar ligament orthoses C) Sharp angle rocker C) Prefabricated laminated in- D) Mild rocker 11) In Scranton’s study of soles metatarsalgia, what were the D) None of these most common diagnoses? SEE INSTRUCTIONS A) Rheumatoid arthritis and 16) All of the following may re- AND ANSWER SHEET Morton’s neuroma sult in excess plantar metatarsal ON PAGES 136-138.

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