​Kembara Xtra - Medicine - Metatarsalgia

​Kembara Xtra - Medicine - Metatarsalgia 
Pain under one or more of the metatarsal heads in the forefoot is known as metatarsalgia.
There are three categories:
- Secondary: as a result of disorders that increase metatarsal loading through indirect processes, such as chronic synovitis, fractures, or damage to the MTP joint. - Primary: as a result of anatomical problems between the MT and other areas of the foot - Iatrogenic, typically following a prior forefoot operation

Incidence
The prevalence ranges from 5 to 36% in the general population; it is more prevalent in rock climbers (12.5%), older active adults, and athletes who participate in high-impact activities (such as running, leaping, and dancing).
occurrence Common

Pathophysiology and Etiology 

When walking or running, the first metatarsal head carries a sizable amount of weight. This balance is guaranteed by a proper metatarsal arch. Normally, the first metatarsal head has enough cushioning to withstand increasing stresses.
The pain may be made worse by a callus formed by reactive tissue around the metatarsal head.
- Prolonged or excessive stress. During various phases of walking and running (midstance and push off), forces are transferred to the forefoot. Nearly three times as much weight as the body is used to transfer these stresses over the metatarsal heads.
- This equilibrium is upset by a pronated splayfoot, which causes equal weight bearing on each metatarsal head.
- Any foot deformity alters the weight distribution, putting pressure on parts of the foot that don't have enough padding.
- Soft tissue dysfunction: laxity in the Lisfranc ligament and intrinsic muscle weakness - Improper footwear, abnormal foot posture, loss of the metatarsal arch, splayfoot, pronated foot, forefoot varus or valgus, cavus or equinus abnormalities - Dermatologic: calluses and warts
Hallux valgus (bunion), either rigidus or varus, in the great toe.
Lesser metatarsals: Freiberg infraction (aseptic necrosis of the metatarsal head frequently brought on by trauma in young people who jump or run) - Claw or hammer toes - Morton syndrome (long second metatarsal)


Obesity, forefoot surgery, or trauma, high heels, narrow shoes, or shoes that fit excessively tightly (rock climbers frequently wear small shoes) are risk factors.  Competitors in weight-bearing sports, such as baseball, football, soccer, basketball, ballet, and jogging Foot abnormalities or variations in range of motion, such as hallux valgus, prominent metatarsal heads, excessive pronation, hammer toe deformity, or tight toe extensors.


Aspects of Geriatrics
In senior athletes, metatarsalgia and concurrent arthritis are prevalent.
The metatarsal fat pad's age-related atrophy may make people more susceptible to metatarsalgia.
Child Safety Considerations
 Muscle imbalance conditions that lead to infant foot abnormalities (such Duchenne muscular dystrophy).
Salter I injuries may have an impact on the epiphysis's subsequent growth and healing in adolescent girls.
pregnant women's issues
Pregnancy-related forefoot pain is typically brought on by changes to the gait, the center of mass, and joint laxity.
Wear low-heeled footwear that is correctly fitting.

Prevention 
Put on appropriately padded, well-fitting shoes.
• Gradually introduce weight-bearing workout regimens.
 Proper stretching, with emphasis on calf muscles Losing weight if overweight


Arthritis, Morton neuroma, sesamoiditis, and plantar keratosis—the development of calluses—are associated conditions.

History Pain across the heads of one or more metatarsals progressively develops and continues. Typically, plantar surface pain gets worse during the midstance gait phase.
Pain is frequently ongoing.
 Pes cavus and hyperpronation predisposition  Pain that is increased during the midstance or propulsion stages of walking or running, and is sometimes compared to walking with a stone in your shoe.

clinical assessment 

Morton neuroma is indicated by point discomfort over the plantar metatarsal heads, pain between the fingers, or a positive metatarsal squeeze test.
 Plantar keratosis Tenderness to pressure from the examiner's finger and thumb on the metatarsal head(s) Occasional erythema and edema


Differential diagnosis: Morton neuroma (also known as an interdigital neuroma), stress fracture (most frequently affecting the second metatarsal), tarsal tunnel syndrome, sesamoiditis or sesamoid fracture, Salter I fracture in children, arthritis (including gouty, rheumatoid, inflammatory, osteoarthritis, septic, and calcium pyrophosphate dihydrate [CPPD] crystal deposition disease), Lisfran

Laboratory Results 

Initial examinations (lab, imaging)
Weight-bearing radiographs: lateral, oblique, and anteroposterior views: - When the metatarsophalangeal (MTP) joints are in dorsiflexion (to check alignment), it is occasionally possible to get metatarsal or sesamoid axial films (to rule out sesamoid fracture) or a skyline view of the metatarsal heads.  Ultrasound and MRI in difficult instances, especially if there is a possibility of a stress fracture
 Capsular tears, typically of the distal lateral edge of the plantar plate (a frequently overlooked cause of metatarsalgia), can be identified by MR arthrography of the MTP joint.
Only if the diagnosis is in doubt - C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, uric acid, glucose, and CBC with differential Diagnostic Procedures/Other
Analysis of the plantar pressure distribution may assist identify pressure distribution patterns brought on by misalignment.


Management 
The usual course of action for metatarsalgia is conservative.
Pain relief. Initially, ice.
Rest includes changing weight-bearing activities temporarily and using a cane or crutches. For patients who are more physically active, offer a different workout or cross-training: - Later moist heat - Taping or a gel cast
- Shoes with stiff soles will serve as a splint.
- Stretching drills for the gastrocnemius
 Use orthotics to rebalance the foot's pressure load in order to relieve pressure beneath the location of greatest pain.
Weight loss if you are overweight.

Medication 
if there are no contraindications, non-steroidal anti-inflammatory drugs for 7 to 14 days.

Referral 

Early podiatric or orthopedic examination may be advantageous for elite athletes.

Further Therapies 
Physical therapy to recover the typical biomechanics of the feet  Shoes with a big toe box and low (2 cm) heels  Supports for the metatarsal arch, pads, and bars. If hallux valgus is present, you may want to use a valgus splint instead of pads. Insoles with a rocker bar
(Prescriptive orthotics have been demonstrated to be an efficient form of treatment.)  Shoes with thick soles
The callus could be temporarily relieved by shaving. Excision of calluses is not suggested.
Interdigital neuritis may be helped by corticosteroid injection, however it should only be done sparingly because it may result in MTP instability and fat pad atrophy.
Improve the flexibility and strength of the intrinsic foot muscles by performing the following exercises:
- Physical therapy to preserve range of motion and return to standard biomechanics 

Surgical Techniques 
If after three months of conservative therapy there has been no progress, consult a podiatrist or foot/ankle orthopedic surgeon.
Surgery, such as a bunionectomy, partial osteotomy, or surgical fusion, may be used to rectify anatomic abnormalities.
Various procedures have different success rates.
Direct plantar plate repair (grade II tear) and Weil osteotomy can return the MTP joint to its proper position, reducing pain and raising functional test results.
Removal of calluses is typically not advised.
Morton neuroma treatment options include alcohol ablation with ultrasound guidance and Morton neurectomy.
If there is no anatomic anomaly, surgery should only be used as a last option.

Alternative Therapies 
Magnetic insoles are ineffective for treating persistent, generalized foot discomfort.

Patients are often only admitted for surgery during admission

Patient Follow-Up Monitoring
Consider surgical assessment or corticosteroid injection (depending on the condition) if stress fracture has been ruled out and the patient's condition has not improved after >3 months of conservative treatment.


Patient education includes instructions on wearing appropriate footwear, a gradual increase in activity, and cross-training till symptoms go away. The intention is to remove painful pressure on the plantar metatarsal heads and to return foot biomechanics to normal.

The severity of the issue and if surgery is necessary to fix it determine the prognosis.

Complications include: Transfer metatarsalgia following surgical surgery, which causes more stress to be placed on other places; back, knee, and hip pain brought on by a change in gait.

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