You have been directed to this section of the website because you have pain in the ball of your foot caused by inflammation of one or more joints.
The word metatarsalgia refers to pain in the ball of the foot. It is a non-specific term but is often used to describe inflammation in one or more of the joints where the toes join the foot. This is known as capsulitis/synovitis of the metatarso
-phalangeal joints.
The most commonly affected joint is at the base of the 2nd toe called the 2nd metatarso-phalangeal joint. Symptoms include throbbing, swelling and the feeling of walking on a stone or pebble. Occasionally, there may be hard skin or a corn under the painful joint(s).
The problem is often worse in thin soled or high-heeled shoes and is aggravated by standing or walking for prolonged periods of time. If the problem has been present for long enough, the toes may begin to splay and may start to claw up or lift off the ground. This occurs because the joint is taking more stress than it is designed to take and the ligaments supporting the toes weaken.
Factors that can contribute to the problem include poor foot function, a long or prominent metatarsal bone and tightness in the calf muscles.. Occasionally, previous surgery for a different problem can result in increased pressure beneath the forefoot joints. At times, it can be very difficult to determine the exact cause.
Conservative Treatments
The vast majority of patient find that they can control their symptoms through non-surgical means. Footwear is a key factor in the non-surgical management of the condition and Mr McCallum will give you specific advice on the most suitable type of shoe for you. Flexible shoes are to be avoided. If inadequate footwear is worn, then the rest of the non-surgical treatments are unlikely to be effective in the long term.
• Footwear
• Insoles (orthoses)
• Ice packs
• Anti-inflammatory and pain killing medication
• Cortisone injections into the painful joints. There is a risk with injections that they may cause the toe to become deformed or worsen a pre-existing deformity
Surgery is generally only considered if the conservative options have been tried and have failed to reduce the pain sufficiently. Unfortunately the surgical options do not always have a predictable outcome and there are risks of failure. As such, they are normally reserved as a last resort.
The surgery normally involves an osteotomy (cutting of the bone) of one or more metatarsal bones. The metatarsal is shortened by a few millimeters and if necessary, it can also be elevated (if it is prominent on the ball of the foot). This is performed through an incision on the top of your foot. The metatarsal is cut, repositioned and then the bone is repaired using a small screw.
Recovery:
After your operation, you will be placed into an Aircast walking boot and you will remain in this for a period of approximately 6-weeks. The Aircast is removable and you should take it off when resting so that you can mobilise your foot and ankle. It must be worn at all times when moving around.
Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast. It is advisable to use your crutches until Mr McCallum reviews you with a post-operative x-ray.
You should travel home by car and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist but if washing, you must exercise caution when putting the foot to the floor in a shower.
You will be reviewed within one week of your operation for a change of dressing and at the 2-week mark, the dressings will be removed and the suture tags will be cut. You will be shown how to perform range of motion exercises and from this point forward it is safe to get the foot wet. You will be reviewed again at the 6-week mark to ensure that the bone(s) are healing in a satisfactory manner and it is normally safe to transfer into your own comfortable footwear at this stage and gradually increase your activity levels. After 3-months, the bones should have healed sufficiently for you to resume full activity levels.
On average, it takes approximately 6-9 months for the foot to have fully recovered and it is not unusual to experience swelling, discomfort and stiffness during this time.
Possible Complications following surgery:
Outlined below are the possible problems or the rare complications following foot surgery with serious outcomes. In cases where there are no accurate audit results, published results from podiatric literature have been used.
- Prolonged swelling taking more than 6-months to resolve can occur in 1 in 500 operations.
- Haematoma- a painful collection of blood under the skin. This can increase the risk of developing an infection and may require further surgery to resolve.
- Thick or sensitive scar.
- Irritation from internal fixation. Screws and plates are only required whilst the bone is healing (during the first 3-months) after which they provide no further benefit. However, fixation is not generally removed unless it causes a problem. This may occur in up to 10% of cases.
- Adverse reaction to the post operative painkillers. 1 in 50 patents report that codeine preparations make them feel sick.
- Infection of the soft tissue. 1 in every 83 operations.
- Infection of bone- osteomyelitis. This is a serious complication and in severe cases, can lead to amputation.
- Delayed healing of soft tissue or bone.
- Circulatory impairment with loss of tissue.
- Loss of sensation can occur although this is not normally permanent and can continue to improve over 18-months.
- Deep vein thrombosis (blood clot) can result in the clot travelling to the lung and this can be a life threatening condition. Deep vein thrombosis incidence is 3 in 1000 cases.
- Complex pain syndrome- a condition where the nervous system dealing with pain over reacts. This is a very painful condition that can result with even with minor trauma. It normally requires management by specialists in this condition and does not always resolve. This is a rare condition that occurs in 3 in 2500 cases.
- Recurrence of deformity or failure of the surgery.
- Development of secondary problems such as overloading of adjacent joints- transfer metatarsalgia.
Specific complications Associated with lesser metatarsal surgery:
- Transfer pain or skin lesion to an adjacent metatarsal head.
- Floating toe (25-30%).
- Joint stiffness, which can result in difficulty with wearing shoes with a heel.
- Scar contracture.
- Fracture.
- Continued pain.
The risk of developing a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the post-operative regime.
The pre-operative screening helps us determine whether you are fit for surgery or if any extra measures need to be considered to minimise your risk of developing a complication. It is important that you disclose your full medical history. If there is a query regarding your health then further investigations may be required and Mr McCallum will liaise with the appropriate medical specialists. Mr McCallum and the there team will ensure that your operation is carried out safely and effectively.
You can improve your healing process and reduce the risks by:
- Adhering to the post-operative instructions, which include resting and elevating the operated foot. Keeping the wound dry and clean until advised otherwise. Please ask Mr McCallum if you are not sure what to do.
- Having a healthy diet is important; this provides the nutrition required for healing.
- Smoking is associated with a 20% increased risk of delayed or non-healing of bone.
- Alcohol can interact with the drugs that are prescribed and can impair wound healing.
- Post-operative mobilisation will be advised; this helps improve flexibility, strength and stability of your foot.