In some patients the cause of metatarsalgia may be obvious and may even be presented as the problem: e.g. the rheumatoid forefoot. Generally the cause is less apparent and a full history and examination are essential.
Remember that there may be more than one factor in the development of metatarsalgia, and that the presence of a possible cause does not necessarily prove causation: there are a lot of people with hammertoes in the population but not all have metatarsalgia.
Ask about exactly where the pain is felt:
- under metatarsal heads
- localised or generalised
- is there a corresponding callus?
- between the metatarsals - if so does the adjacent toe hurt, tingle, go numb or change colour (suggesting interdigital neuralgia)
- in the area of the MTPJs - suggesting Freiburg’s disease, arthritis or instability; pain felt directly under the MTP joint rather than the MT head suggests instability
- over the top of the metatarsus - often referred from proximal problems such as TMTJ OA
- diffusely under the toes with tingling - suggesting tarsal tunnel syndrome
All patients with foot and ankle problems should be asked about:
- inflammatory arthropathy
- neurological disease
- vascular disease
- markers of spondyloarthropathy such as iritis, psoriasis, colitis and urethritis
- is there marked callus formation requiring chiropody, or is there even skin breakdown?
- has the patient recently taken up or increased athletic activities or walking - suggesting a stress fracture
- is the pain better on removing shoes - suggesting interdigital neuralgia or bursitis - or worse - suggesting pressure problems
- a long history of rather vague but severe symptoms localised to one or two toes suggests interdigital neuralgia
- if the patient has had 1st ray surgery, was the pain present before and has there been an obvious change in symptom level afterwards?