The impact of body mass index on metatarsalgia surgical outcomes.

INTRODUCTION: Several studies have suggested that an increased body mass index (BMI) is a negative factor for forefoot plantar pain but its influence in the surgical correction of metatarsalgia is unknown. The purpose of the present study is to evaluate the influence of the BMI on the surgical outcomes of metatarsalgia. It has been hypothesized that the higher the BMI, the worse the functional outcomes after metatarsalgia surgical treatment at one year follow-up. MATERIAL AND METHODS: A prospective cohort study that included all patients operated on for third rocker metatarsalgia was conducted. Weil's osteotomy was performed on all the patients operated on. The patients' pre-operative height, weight, and BMI were recorded. The patients were subsequently divided into three groups based on their BMI. There was group 1 or the normal group (18.5 > BMI ≤ 25 kg/m2), group 2 or the overweight group (25 > BMI ≤ 30 kg/m2), and group 3 or the obese group (BMI > 30 kg/m2). Pre-operative, post-operative, and differential AOFAS were used to evaluate and compare the groups. The post-operative VAS was also measured to assess pain. The correlation between the BMI and those variables was also analyzed. RESULTS: After the exclusion criteria were applied, 107 patients were finally assessed. There were 22 patients (20.6%) in group 1, 52 patients (48.6%) in group 2, and 33 patients (30.8%) in group 3. No correlation was observed between the BMI and AOFAS (p > 0.05). Neither were any differences found when the three groups were compared (p > 0.05). Moreover, no correlation between the BMI and the VAS score was observed (p = 0.690). CONCLUSION: Obesity does not negatively influence functional outcomes after surgery for metatarsalgia in short to medium term. Regardless of their BMI, patients with propulsive metatarsalgia improve in functionality after surgical treatment.

Clinical and radiological outcomes after Weil osteotomy compared to distal metatarsal metaphyseal osteotomy in the treatment of metatarsalgia-A prospective study.

BACKGROUND: The distal metatarsal metaphyseal osteotomy (DMMO) may have lower complication rates than the Weil osteotomy (WO) due to its extraarticular location and its minimal invasive nature. This study compares the clinical and radiological outcomes and complications after DMMO and WO. METHODS: We compared 30 patients with WO (Group A) to 30 patients with DMMO (Group B). Ten males and 50 females with a mean age of 57.7 were included. 45 WOs and 73 DMMOs were evaluated in 60 patients. Allocation to Group A or B were random, indications comparable. The outcome was measured clinically using the Visual Analogue Scale Foot and Ankle and radiologically with an average follow up period of 13 months. RESULTS: Clinical examination six weeks postoperatively showed swelling of the forefoot in 66.7% for Group A and in 73.3% for Group B. Swelling subsided in the course of time, but postoperative stiffness, lack of toe purchase and range of motion deficits did not change in the course of time. All osteotomies healed. The VAS-FA improved for both groups. Tourniquet time and operating time were lower and radiation doses higher in Group B. CONCLUSIONS: The DMMO resulted in a comparable patient satisfaction and comparable radiological healing compared to WO and appears to be a valid alternative to the WO.

A comparison of two podiatric protocols for metatarsalgia in patients with rheumatoid arthritis and osteoarthritis.

OBJECTIVES: In rheumatoid arthritis (RA) and osteoarthritis (OA) forefoot involvement causes disability and metatarsalgia. Our objective was to evaluate, in RA and OA patients, the efficacy of two protocols combining insoles in polypropylene terephtalate (PPT) and custom silicone orthoses for toes on disability and metatarsalgia. METHODS: Twenty-four women (13 with OA, 11 with RA) with metatarsalgia were treated with two protocols: group A (protocol A) wore PPT insoles (T1) for 30 days and for another 30 days silicone orthosis for toes were added (T2). Group B (protocol B) wore PPT insoles and silicone orthosis (T1) for 30 days and in the following 30 days only insoles (T2). At T0, T1 and T2, pain, disability and function (Foot Function Index - FFI), pressure (KPA) and plantar contact areas (cm2) (baropodometer), and gait spatial-temporal parameters (GAITRite®) were assessed. RESULTS: At T0 versus T2, both protocols reduced FFI-pain, -disability and -functional limitation (p<0.05), with better results of protocol A than protocol B (p<0.05) for FFI-pain and -disability. Both protocols reduced baropodometer foot plantar pressures (p<0.001), with better results for protocol A for right foot pressures (p<0.05) and increased foot contact areas (p<0.05), with no difference between them (p=NS). Gait parameters were not significantly changed by both protocols (p=NS). CONCLUSIONS: In patients with RA and OA with metatarsalgia, the synergic action of silicone toe orthosis and PPT insoles improves FFI, reduces foot plantar pressures and increases foot plantar contact areas. Protocol A, using firstly insoles and then adding silicone toe orthoses, is the more efficacious.

Comparison of plantar-pressure distribution and clinical impact of anatomically shaped sandals, off-the-shelf sandals and normal walking shoes in patients with central metatarsalgia.

PURPOSE: Metatarsalgia is one of the most frequent pathological conditions of the foot and ankle. Numerous studies exist on plantar-pressure characteristics in various types of shoes. However, to the best of our knowledge, plantar-pressure distribution and clinical effects in sandals has not as yet been the the focus of any study. METHODS: Twenty-two patients (42 feet) with central metatarsalgia were assessed. Time and distance until symptom occurrence in terms of metatarsalgia were evaluated for normal walking shoes (WS), standard sandals (SS) and anatomically shaped, custom-made sandals with a metatarsal pad (AS). Pain intensity was measured with the visual analogue (VAS), and clinical assessment was performed with the American Orthopaedic Foot and Ankle Society (AOFAS) score for the respective shoes. Additionally, plantar-pressure distribution was assessed with the emed-at platform (Novel GmbH) and the F-scan insole system (Tekscan Inc.), respectively. RESULTS: The average walking distance until symptoms occurred was 1,894 m [standard deviation (SD) 1,196 m) for WS, 1,812 m (SD 1,079 m) for SS and 3,407 m (SD 1,817 m) for AS (p < 0.01). Mean duration until occurrence of symptoms was 22.3 min (SD 14.9 min) for the WS, 21.8 min (SD 13.4 min) for the SS and 42.0 min (SD 23.0 min) for the AS (p < 0.01). Plantar-pressure parameters were significantly reduced in the forefoot region for the AS compared with the other walking devices. CONCLUSIONS: The results of this study reveal that a modified standard sandal can significantly influence the onset of metatarsalgia, as increased walking time and distance in these patients was observed.

The role of Weil and triple Weil osteotomies in the treatment of propulsive metatarsalgia.

BACKGROUND: The Weil and triple Weil osteotomy are widely used to treat third rocker metatarsalgia. The aim of this study was to analyze the results and complications of Weil and triple Weil osteotomy used for the treatment of third rocker metatarsalgia. METHODS: This is a report of 82 patients who were operated due to third rocker metatarsalgia from March 2004 to May 2007. A total of 76 completed the study, 68 women and eight men, with a total of 93 operated feet, 52 right and 41 left ( 17 bilateral). The clinical results were evaluated using the AOFAS score for the assessment of lesser metatarsals and interphalangeal joints, and weightbearing lateral and AP foot X-ray for radiological evaluation. RESULTS: The median AOFAS score was 90 (range, 34 to 100). We had good results in 80% and unsatisfactory in 20%. Prior to surgery 75 feet were index minus, but after all 81 feet were plus-minus. With regard to complications, we had serious recurrence of metatarsalgia in 4.3%, moderate stiffness in 60.2% (severe in one case), floating toes in 4.3% and delays in bone healing in 7.5%. CONCLUSION: We believe that Weil and triple Weil osteotomies are effective procedures in the treatment of third rocker metatarsalgia. We feel preoperative planning with tracing on the weightbearing AP radiographs is an essential step.

Metatarsal length does not correlate with maximal peak pressure and maximal force.

BACKGROUND: Primary metatarsalgia of the lesser metatarsals is common and caused by mechanical overload of the affected metatarsal heads. Increased metatarsal length generally is believed to be a factor in the development of primary metatarsalgia. However, there is no clear biomechanical evidence supporting this theory. QUESTIONS/PURPOSES: We asked whether metatarsal length correlated with plantar-loading parameters under the corresponding metatarsal heads. PATIENTS AND METHODS: We prospectively followed two groups of patients 46 (51 feet) with and 45 (51 feet) without metatarsalgia. Each foot was physically examined and underwent standardized full-weightbearing radiography and dynamic pedobarography to assess maximal peak pressure and maximal force under the first, second, and third metatarsal heads. We correlated the relative length of the first and third metatarsals with the corresponding two plantar-loading parameters. We compared maximal peak pressure and maximal force in patients with metatarsalgia with those of symptom-free patients. RESULTS: The relative length of the first and third metatarsals did not correlate (r < 0.13) with the maximal peak pressure or maximal force under the corresponding metatarsal heads. Maximal force under the first metatarsal head was decreased in the metatarsalgia group. There was no difference in maximal peak pressure between the metatarsalgia and nonmetatarsalgia groups. CONCLUSIONS: Relative metatarsal length had no influence on plantar-loading parameters. Shortening of a symptomatic ray to decrease plantar-loading parameters cannot be supported from a biomechanical rationale.

Metatarsalgia.

Metatarsalgia (ie, metatarsal pain) is one of the most common reports in patients with foot problems. This pain is confined to the area across the plantar forefoot, including the second through fourth metatarsal heads. However, it is frequently accompanied by deformity of the first and fifth rays as well as of the toes. There is great variability in possible causative factors, but all of them seem to be related to gait mechanics, foot anatomy, and foot and ankle deformity. An individualized treatment protocol is required. Nonsurgical management is usually sufficient to achieve satisfactory results. Surgical correction must be precise, and all pain-producing deformities must be corrected. Most patients present with abnormalities of the distal metatarsals. Metatarsal osteotomy, long a staple of treatment, always fails in the long term. Improved equipment and internal fixation methods may lead to better long-term outcomes.

First ray mobility increase in patients with metatarsalgia.

BACKGROUND: The significance and measurement of first metatarsal hypermobility has been difficult to quantify in relation to transfer metatarsalgia. We evaluated the hypothesis that dynamic elevation of the first metatarsal relative to the second metatarsal could be measured with a simple device and would be associated with transfer metatarsalgia. We also assessed intraobserver and interobserver reliability of the simple device. MATERIALS AND METHODS: A series of 352 patients were prospectively measured for dynamic metatarsal elevation: 64 patients with transfer metatarsalgia and 288 patients without symptoms. RESULTS: Those with metatarsalgia symptoms had significantly greater first ray mobility (9 mm versus 7 mm; p < 0.0002) and metatarsal elevation (5 mm versus 3 mm; p < 0.0002) than patients without symptoms. CONCLUSION: In this prospective series, the device was reliable for measuring dynamic first metatarsal elevation at different time points with different examiners. Patients with metatarsalgia had higher dynamic metatarsal elevation compared to patients without metatarsalgia, suggesting a mechanism by which load can be transferred from the first to lesser metatarsals.

The use of collagen injections in the treatment of metatarsalgia: a case report.

Metatarsalgia is an increasingly common condition seen in the outpatient setting. A number of conservative and surgical management options are available for this condition. We present an interesting case that was unsuccessfully treated with'dermal filler.' To our knowledge, we have not found any published material in peer-reviewed journals documenting the use of collagen injections in the treatment of metatarsalgia. The authors feel that the lesson learned from this case should be highlighted for other foot and ankle surgeons.

Effect of toe exercises and toe grip strength on the treatment of primary metatarsalgia.

BACKGROUND: The relationship of metatarsalgia and toe function is poorly understood. We investigated the efficacy of toe exercises for the treatment of metatarsalgia. METHODS: Forty-one (56 feet) metatarsalgia patients (mean age ± SD: 63.4 ± 10.6) underwent toe strength measurement. We recorded pre- and post-treatment VAS score, AOFAS score, marble pickup, single-leg standing time (SLST), and compared in two subgroups to evaluate impact of disease duration on treatment outcome. RESULTS: Post treatment, toe plantarflexion strength improved (all p < 0.01); VAS scores decreased (p < 0.01); AOFAS scores, marble pickup, and SLST improved (all p < 0.01). Patients symptomatic for > 1 year had significantly lower changes in VAS scores (p < 0.01). Multivariate analysis showed patients with longer disease duration, and larger body mass index had significantly lower improvement in VAS scores (p = 0.029 and p = 0.036, respectively). Device consistency assessed by ICC was excellent (0.89-0.97). CONCLUSION: Toe function and metatarsalgia are improved by toe exercises, suggesting that they are closely related.

Relationship between plantar pressure and soft tissue strain under metatarsal heads with different heel heights.

BACKGROUND: Metatarsalgia due to increased plantar pressure under the metatarsal head (MTH) is often seen with wearing high-heeled shoes. However, the concomitant soft tissue strain has not been well discussed. The objective of our study was to explore the standing plantar pressure and corresponding soft tissue strain under the metatarsal heads (MTHs) with different heel heights. MATERIALS AND METHODS: Twenty-one healthy subjects (10 male and 11 female) participated. The plantar pressure and soft-tissue thicknesses were measured simultaneously with a load cell and a 10-MHz linear-array ultrasound (US) transducer respectively. The changes in plantar pressure and soft tissue strain under the MTHs were analyzed for different heel heights. RESULTS: As hypothesized, plantar metatarsal pressure significantly increased and shifted to the first and second MTHs with increasing heel height from 2 cm to 4 cm (p < 0.05). However, the change in soft tissue strain under the medial forefoot became insignificant when the heel height was greater than 2 cm (p = 0.473 and 0.517). CONCLUSIONS: Increased heel height resulted in increasing medial forefoot loading pressure; however, the soft tissue exhibited stationary compressibility when the heel height was greater than 2 cm. CLINICAL RELEVANCE: Our finding provides an understanding of the biomechanical changes with wearing high-heeled shoes and suggests possible strategies to reducing discomfort and risk of injury, such as limiting heel height to no greater than 2 cm and using medial padding under MTHs.

Magnetic resonance imaging in adolescent painful flexible flatfoot.

BACKGROUND: The cause of navicular tuberosity pain in adolescents with flexible flatfeet is not well understood. We hypothesized that some of the navicular tuberosity pain may be related to insertional enthesopathy of the posterior tibial tendon at the navicular. Magnetic resonance imaging was performed to look for abnormal signal changes in a series of patients. MATERIAL AND METHOD: Consecutive adolescent patients presenting with flexible flatfeet and navicular tuberosity pain were prospectively recruited. A detailed foot examination and body fat analysis was performed. Standing radiographs and Tekscan pedobarograph of both feet were obtained. Magnetic resonance examinations were performed on a 1.5-T whole-body magnetic resonance imaging system utilizing a standard extremity coil. RESULTS: MRI abnormality was detected in 15 of the 36 feet in 18 adolescents examined. Abnormalities detected included thickening of the posterior tibial tendon insertion, marrow edema in the accessory navicular, marrow edema in the navicular tuberosity, and contrast enhancement at the posterior tibial tendon insertion site. Patients with MRI abnormalities were significantly taller, had a lower body mass index and a lower body fat percentage than those without MRI abnormality. Forward stepwise logistic regression analysis identified low body fat percentage and presence of an accessory navicular as independent predictors for abnormality on MRI. CONCLUSION: MRI abnormality was frequently detected in adolescents with painful flexible flatfeet. The MRI signal changes indicated an enthesopathy like process occurring at the posterior tibial tendon insertion to the navicular which could explain the origin of pain in flexible flatfeet patients without an accessory navicular. Early identification and appropriate treatment to prevent progression may be helpful.

Biomechanical analysis of functional adaptation of metatarsal bones in statically deformed feet.

We analysed the functional adaptation of the first and second metatarsal bones to altered strain in flexible flatfoot. Fifty consecutive women (20-40 years of age) were enrolled: 31 patients with a flexible flatfoot and metatarsalgia (59 feet) and 19 controls with asymptomatic feet (37 feet). They were compared for cortical thickness (medial, lateral, dorsal and plantar) of the two bones. The null hypothesis of no overall difference between the deformed and healthy feet with regard to cortical thicknesses of the two bones was rejected in a multivariate test (p = 0.046). The groups differed significantly only regarding dorsal cortical thickness of the second metatarsal, which was around 18.1% greater in the deformed feet (95% confidence interval: 7.7-28.4%, p < 0.001). Hypertrophy of the dorsal corticalis of the second metatarsal bone appears to be the main metatarsal adaptive reaction to altered strain in the flexible flatfoot.

Scientific Evidence in the Treatment of Metatarsalgia.

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

Evolution of the Weil Osteotomy: The Triple Osteotomy.

Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot disorders.

Metatarsalgia: Assessment Algorithm and Decision Making.

Historically, metatarsalgia was approached as a forefoot condition, most often associated with hallux valgus. Consequently, surgical treatments were limited to that anatomic zone, disregarding more proximal structures. In order to assess this entity properly, it is necessary to consider anatomic and biomechanical factors, as well as general and local conditions of the affected patients. A thorough understanding of the multiple potential causal factors is essential to ensure selection of the optimal treatment.

An assessment of the information lost when applying data reduction techniques to dynamic plantar pressure measurements.

Data reduction techniques are commonly applied to dynamic plantar pressure measurements, often prior to the measurement's analysis. In performing these data reductions, information is discarded from the measurement before it can be evaluated, leading to unkonwn consequences. In this study, we aim to provide the first assessment of what impact data reduction techniques have on plantar pressure measurements. Specifically, we quantify the extent to which information of any kind is discarded when performing common data reductions. Plantar pressure measurements were collected from 33 healthy controls, 8 Hallux Valgus patients, and 10 Metatarsalgia patients. Eleven common data reductions were then applied to the measurements, and the resulting datasets were compared to the original measurement in three ways. First, information theory was used to estimate the information content present in the original and reduced datasets. Second, principal component analysis was used to estimate the number of intrinsic dimensions present. Finally, a permutational multivariate ANOVA was performed to evaluate the significance of group differences between the healthy controls, Hallux Valgus, and Metatarsalgia groups. The evaluated data reductions showed a minimum of 99.1% loss in information content and losses of dimensionality between 20.8% and 83.3%. Significant group differences were also lost after each of the 11 data reductions (α=0.05), but these results may differ for other patient groups (especially those with highly-deformed footprints) or other region of interest definitions. Nevertheless, the existence of these results suggest that the diagnostic content of dynamic plantar pressure measurements is yet to be fully exploited.

Mechanical Basis of Metatarsalgia.

The 3-rocker mechanism of gait provides a framework to understand why patients have mechanical metatarsal pain and to differentiate between the various types of metatarsalgia. Clinical examination of the patient together with radiological findings allows identification of the type of metatarsalgia and the pathomechanics involved, and the planning of surgical treatment. Second-rocker/nonpropulsive metatarsalgia is related with an abnormal inclination of a metatarsal in the sagittal plane, either anatomic or functional (equinism). Third-rocker/propulsive metatarsalgia is related to an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the transverse plane.

Metatarsalgia in Metatarsus Adductus Patients: A Rational Approach.

Metatarsus adductus (MA) is a congenital condition resulting in adduction of the forefoot at the tarsometatarsal joint, medial metatarsal deviation, supination of the hindfoot through the subtalar joint, and plantarflexed first ray. The exact underlying pathophysiology remains elusive. There is increasing evidence highlighting the importance of recognizing MA as an associated deformity that complicates management of hallux valgus (HV). Unfortunately, metatarsalgia and lesser toe pathology is also common in this population. We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia.

Gastrocnemius Recession in the Setting of Metatarsalgia: The Baumann Procedure.

A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.