When foot pain and tenderness
occurs under the second metatarsal head in the ball of the foot
with walking or running, usually either a metatarsal stress fracture
is present, a nerve is being entrapped or a painful callous is
present. A callous is usually the cause of the ball of the foot
pain if the bone does not hurt with compression from top and
bottom but the skin is tender. A nerve problem is present if
the pain is between the metatarsal bones in he ball of the foot
and the skin and metatarsal heads do not hurt with squeezing
the bones. Review the Corn and Callous Page or the Neuroma Page
if you think your problem is a painful callus or a neuroma and
not a stress fracture.
Many metatarsal stress
fractures are associated with a callous formation under the metatarsal
head that is being heavily pressured. A metatarsal stress fracture
is a condition that occurs from repetitive pressure to the second
metatarsal head. The second metatarsal head is the most common
of the lesser metatarsal heads to become injured. The second
metatarsal will take up most of the weight of the body if the
foot is flattening or pronating during gait or standing. The
big toe joint is pushed out of the way from the rotation that
occurs as the foot pronates during standing and gait and exposes
the second metatarsal to excessive pressure. The pain is typically
a deep aching type pain that increases with more weight bearing
and decreases with rest. One of the examination findings that
is helpful is that the foot hurts with squeezing the bones directed
from top to bottom. Besides the foot flattening out, the other
cause is poor short absorption in the shoes that are used for
long walks or athletics. Rarely poor bone density is the cause
of stress fractures as well as the first metatarsal becoming
too short from a bunion procedure. If the first metatarsal becomes
too short, the second metatarsal will take on too much weight
and many times a stress fracture will result.
Treatment is first aimed
at making the diagnosis and then moving forward with a plan of
treatment based on the severity of the stress fracture. Initial
intervention for a mild to moderate stress fracture is to off
load the second metatarsal head by changing the padding in the
shoe or by wearing a padded post-operative shoe. Custom molded
foot orthotics are also routinely prescribed along with motion
control athletic shoes. Anti-inflammatory medication such as
Celebrex will help with the pain but until the pressure is off
the foot, the pain will continue. The key is that the body is
trying to stop further injury to the bone from further ground
pressure. As soon as the bone has no pressure on it from standing
and walking, the pain and related disability will diminish quickly.
A cast is required for moderate to severe stress fractures and
the decision is on a case-by-case basis. Beside x-ray, sometimes
a bone scan is performed to make the diagnosis because the stress
fracture only is seen on the x-ray after bone healing has occurred.
Most of the time, the clinical examination and the history of
the patient are the primary factors for making the diagnosis.
In certain sports injury situations, a bone growth stimulator
is used to speed the time it takes for the body to lay down bone
at the stress fracture site. Typically, a stress fracture healed
in six weeks before all of the pain is resolved. In using a bone
growth stimulator, the stress fracture can be healed in about
two to three weeks to allow the athlete to return to full activities.
The use of a bone growth stimulator is a decision between you
and your doctor and usually the cost prohibits the use of the
bone growth stimulator.
If there is a rigid hammertoe
deformity, the hammertoe may need to be surgically treated to
resolve the callous formation and excessive pressure being placed
on the metatarsal head. In some patients, a pad going around
the base of the hammertoe helps and is called a buttress pad.
However, if there is a hammertoe and the patient developed stress
fractures from the hammertoe, usually surgery to straighten out
the hammertoe is warranted.
In summary, if you are having pain in the second metatarsal head
that is a deep ache, hurts with direct pressure to the bone in
the ball of the foot and increases with more weighty bearing,
a stress fracture is likely the diagnosis. Mild to moderate stress
fractures are treated with padding, foot orthotics, anti-inflammatory
medications and if indicated a bone growth stimulator. Moderate
to Severe stress fractures require a cast to insure that the
pressure is taken off the metatarsal and to insure the bone heals
fully. A Podiatrist should be consulted whenever the amount of
pain becomes debilitating.