- Stress fracture
- Morton’s neuroma
- Plantar fasciitis at the metatarsal insert (less common than at the calcaneal insert)
- Rheumatoid arthritis
- Peripheral neuropathy
Stress fracture: may be relatively minor trauma which has been forgotten. A tender callus may be palpable after 4 – 6 weeks.
Morton’s neuroma: can give the sensation of walking on a pebble. Pain can come in flashes similar to that in trigeminal neuralgia. May be associated numbness of toes. Rubbing one metatarsal head against another can produce a click (Mulder’s click) and a sensation of release between the bones. Note that metatarsal squeeze test can be positive for neuroma as well as RA.
RA: remember the metatarsal squeeze test.
OA: look for hammer toes and Heberden’s nodes – don’t rule out in the young though much less common.
Differential diagnosis may be difficult in the early stages, but fortunately is not hugely important at this point as pain is likely to respond to conservative Rx regardless of diagnosis.
- Padding of soles
- Shoes with plenty of toe space
- Weight loss if appropriate
- If a new exercise programme has just been started, advise that increase in intensity/duration should be gradual – aim for no more than 10% per week.
- Metatarsal pads – available OTC (unfortunately didn’t say which counters) and should be used just proximal to tender area for relief.
- Podiatry referral – they can help with advice and insoles.
If a couple of months of this treatment doesn’t help, move to investigations:
- X-ray (note may be negative for stress fracture in early stages)
- Bone profile – look for raised ALP in bony damage/fracture
- Inflammatory markers
- Neuropathy investigations as needed.
and to referral.