One of the most common forefoot pains that people complain about is known as metatarsalgia. As the name implies it is pain in the metatarsal bones, primarily the metatarsal heads. This is the portion of the metatarsal bones that bear the weight of the body when the heel lifts off during the gait cycle. As the heel rises, body weight is transferred to the metatarsal heads and remain there until the foot "pushes" off the ground to move forward.
There can be any number of reasons why a person experiences pain in the metatarsal heads. In many instances it is from nothing more than a certain pair of shoes. Obviously, high heels create more pressure on the ball of the foot. Compound that with a woman who does a lot of walking on hard surfaces and this combination certainly can create pain on the metatarsal heads.
Very thin soled shoes will also have the potential to create metatarsalgia, for two reasons. First, the thinness of the sole offers no cushioning for the foot and secondly, thin soled shoes have a lot of bend to them which will further create the stress on the head of the metatarsal bones. That is why many people who suffer from metatarsalgia will tell me that they feel much better in cushioned sneakers than dress shoes and their feet hurt less when they walk barefoot on a carpeted floor as opposed to walking on a tiled floor.
Foot structure also plays a role in the formation of metatarsalgia. Perhaps the biggest structural deficiency is lack of fat on the bottom of the bone. Some people just have naturally more fat padding on the bottom of the forefoot and this will cushion the metatarsal heads in gait. However, as we age, we tend to lose the fat on the bottom of the feet and this leaves the metatarsal heads susceptible to excess pressure, thus causing metatarsalgia.
Aside from lack of fat, other anatomical variations may cause metatarsalgia. The bottom portion of the metatarsal head has two prominences known as condyles. These are rounded portions of enlarged bone which actually bears the brunt of the surface that the foot hits. One or more metatarsal heads may have a naturally enlarged condyle which means it will probably have more pressure placed against it during gait and for that reason, could begin to hurt.
The length of the metatarsal heads, relative to each other, may also cause one or more of the metatarsal heads to begin to hurt. In most individuals, the second metatarsal head is the longest, followed by the third metatarsal head, then the first metatarsal, then fourth and fifth. Looking at the diagram above you can see that is the case. This is an ideal alignment for allowing the foot to bear weight and propel further forwared. However, many people have a variation in that alignment.
Variations to this normal parabola include a metatarsal bone which may be relatively short, thus creating excessive pressure on the adjacent metatarsal, or a metatarsal that is too long (usually the second metatarsal) which will create excessive pressure on that particular metatarsal bone.
There is also the issue of motion of the metatarsal bone. The first metatarsal bone has the ability in most individuals to move up and down during the gait cycle as it is the first metatarsal bone that helps propel the foot forward in what is known as the "push off" portion of the gait cycle. If the first metatarsal bone moves too much upward it creates more pressure on the second metatarsal bone and can lead to metatarsalgia.
Foot structure can also contribute to metatarsalgia. People with very high arches tend to put more pressure, when walking, on the heel and in particular the ball of the foot, meaning the metatarsal heads.
Metatarsalgia is one of the foot conditions that may respond quite well to a store bought arch support as I find most store offered arch supports certainly offer a lot of cushioning in their devices. The problem is usually one of inadequate arch support. Two potential reasons for this. The first is someone with a very high arch; most store bought arch supports are built for the "average" size arch so they will not even come close to supporting a person with a high arch. The second problem with many of these arch supports is that there is no rigidity to their structure; they are all about cushioning and therefore are made completely out of cushioning material, so not only do they not support the foot, they end up being so thick with cushioning material that they only fit in the most conservative, boxy shoes out there.
Orthotic therapy for metatarsalgia goes beyond simple support and cushioning. When the condition is the result of a sturctural (bone) mal-alignment, additions can be built into the orthotic to make up for the structural deficiency of a particular foot structure.
Possibly the most common additon to an orthotic is a metatarsal pad. This is a type of pad that can be incorporated into an orthotic. It ends up being placed just behind the metatarsal heads. Look at the photograph to the left of a metatarsal pad placed directly on the foot. In that location, as the foot comes forward after hitting the ground, the metatarsal pad adds support to the metatarsal shaft just behind the head and thus reduces pressure on the metatarsal head itself.
This type of pad can be very helpful for one or more metatarsals that may be painful.
Sometimes there may be only one metatarsal head that is painful. Once again padding may be built into an orthotic which will work to take pressure off the offending metatarsal head. This type of padding is known as accommodative padding. In this situation a pad is built into the orthotic with cutouts over the metatarsal heads that are painful. By doing so, this allows the affected metatarsal heads to "float" or not pick up their fair share of body weight and so the pressure on these individual metatarsal heads is reduced and so is the pain. The picture to the right demonstrates an accommodation of the first and fifth metatarsal heads. As a side note, typically pain under the first and fifth metatarsal heads is seen in individuals with very high arched feet.
When discussing prescription orthotics and metatarsalgia we need to talk about functional orthotics and their use changing the biomechaniics of the foot. As previously mentioned in this article, there are situations where the "normal" foot motion for a given patient is causing metatarsalgia. Through the use of functional orthotics where we control the motion of the foot in the gait cycle, in many instances we are able to control metatarsalgia.
In summary, for cases of simple metatarsalgia, you can try a store bought arch support and if that solves your problem, great, if not you should consider an off the shelf medical grade orthotic which although it is a pre-made device, they are made out of prescription grade material so you stand a better chance of the orthotic actually supporting your foot and reducing pressure on the forefoot. Most off the shelf medical grade orthotics can have simple metatarsal pads added to them.
If these devices do not afford you the relief you seek, then a visit to a local podiatrist for consultation on a custom orthotic might be in order.
store bought arch support if the device cushions the forefoot and has some degree of arch support could be helpful
medical grade off the shelf orthotic would be indicated for this problem in most foot structures except perhaps people with very high arches
prescription orthotic very effective in all foot types but the average person will probably do fine in one of the other two options unless accommodative padding is needed.