Metatarsalgia. Differential diagnosis and therapeutic algorithm

Metatarsalgia is explained as localized or more diffuse tenderness beneath the metatarsal heads. The pain may be attributed to various etiologies. Pathological changes affecting the positional relationship of the metatarsals in the sagittal plane can cause increased pressure and friction forces during weight bearing. Since the length of the metatarsals displays a wide range of disparity only a few pathological settings, i.e., brachymetatarsia, require surgical correction. Beside those disorders of positional relationship, metatarsalgia may be due to lesser toe deformities, osteonecrosis of a lesser metatarsal head (Koehler's disease), and neurological disorders (Morton's neuroma).Apart from the etiology increased load, which is transferred to the central metatarsals, can be treated successfully with orthotic devices. If conservative measures fail, surgical treatment can be indicated. Prior to any operative therapy it is mandatory to perform a detailed analysis of the underlying pathology to avoid persistent pain or recurrence of the deformity.