Foot pain can interfere significantly with normal activities, and severely limit participation in sports.  Metatarsalgia is foot pain involving the metatarsal bones in the forefoot—the complaint of pain on the bottom of the ball of the foot.

Metatarsalgia may be due to overuse of the foot during sports, improper footwear,¹ excessive weight, foot subluxations, or other factors.  The underlying cause is often faulty foot mechanics; the most common problem is excessive pronation.  Blake and Ferguson found that joint pain and capsulitis of the metatarsals were common foot problems reported by recreational walkers and hikers.²  The second and third metatarsophalangeal joints were the most frequently involved joints.  Since the vast majority of foot problems in recreational walkers and hikers were unilateral, rather than bilateral, these researchers concluded that, “Structural anomalies and faulty biomechanics, i.e., limb length discrepancy or abnormal pronation, may be the cause or additional cause in many injuries.”

Arch Problems

The anterior transverse arch is located immediately behind the metatarsal heads.³  When non-weightbearing, the first and fifth metatarsal heads are most prominent, and initially bear the weight of the body during gait.  As weightbearing progresses, pressure is distributed across the arch to the other three heads.  As with all arches, the ligaments and connective tissues support the anterior transverse arch,⁴ not muscular strength.⁵  Arch problems will develop when supportive tissues are put under excessive stress—either from high loads for sudden, brief periods, or from more moderate, but repetitive stresses over longer periods.  In most cases, it appears that chronic overstretching of the transverse ligaments is the underlying cause of metatarsal problems.⁶

Callus Formation

One sign of abnormal transverse arch biomechanics is callus build-up.  Since plantar callosities form in response to sustained pressure patterns, they provide helpful clues regarding altered foot function.  These are commonly seen in either the forefoot (under the metatarsal heads), or under the anterior aspect of the heel.⁷  This pattern (under the transverse arch and at each end of the medial longitudinal arch) has always been taken to indicate that most calluses are caused primarily by arch collapse and/or excessive pronation.  A 1999 study confirmed that callus formation is closely associated with several specific “abnormal foot weightbearing patterns.”  These are a lower medial arch with greater pronation, reduced dorsiflexion of the first metatarsal joint, and limited ankle dorsiflexion (due to calf muscle tightness).⁸  All three factors can contribute to abnormal biomechanics of the metatarsal arch.

Relief and Control

Helping a patient with pain at the metatarsal region requires a phased approach.  Immediate care can reduce the acute pain and inflammation.  Long-term control of the problem usually requires custom-made orthotics.

Acute relief.  Any aggravating activity must stop, and shoes should be evaluated and changed, if necessary.  A temporary metatarsal pad should be placed just proximal to the metatarsal heads to support the anterior transverse arch.9  This will relieve the weightbearing pressure on the sensitive metatarsophalangeal joints.  Anti-inflammatory and pain-relieving modalities can be considered.  Any subluxations, such as “dropped” or fixated metatarsal heads should be adjusted, as necessary.  Multiple foot subluxations, arch collapse, and excessive pronation are frequently found, so the navicular and the cuboid must be carefully evaluated.

Permanent control.  Patients should avoid shoes with a tight toe and forefoot region and reduce high heels to 1½ inches.  These instructions must be followed for best results.  Patients with tight Achilles tendons and diminished foot dorsiflexion should perform calf stretches.  In order to improve foot biomechanics and provide permanent support for the transverse arch, most patients will need custom-made orthotics.  Flexible orthotics are the most beneficial, especially for people who must be on their feet for many hours each day.  The orthotics need to support all three arches of the foot and provide cushioning and shock absorption.  Additional forefoot padding also appears to be very helpful. TAC

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program.  He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System.  He has been in private practice in Massachusetts for 27 years.  He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Jarboe NE, Quesada PM. The effects of cycling shoe stiffness on forefoot pressure. Foot Ankle Int 2003; 24(10):784-788.
2. Blake RL, Ferguson HJ. Walking and hiking injuries: a one year follow-up study. J Am Podiatr Med Assn 1993; 83:499-503.
3. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts, 1976:208.
4. Huang CK et al. Biomechanical evaluation of longitudinal arch stability. Foot & Ankle 1993; 14:353-357.
5. Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963; 45A:1184-1190.
6. Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchill Livingstone, 1992:129-184.
7. Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders, 1987:323.
8. Bevans JS, Bowker P. Foot structure and function: etiological risk factors for callus formation in diabetic and non-diabetic subjects. The Foot 1999; 9:120-127.
9. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Pubs, 1997:351.

The classic presentation of plantar fascitis is “a sharp heel pain that radiates along the bottom of the inside of the foot.  The pain is often worse when getting out of bed in the morning.”1  This can occur in runners or other athletes who repetitively land on the foot.  Another susceptible group is middle-aged persons who have spent much time on their feet.  More rarely, the fascia becomes inflamed after a single traumatic event, such as landing wrong after a jump, or running a long hill. 

The vast majority (95%) will respond to conservative care, and not require surgery.2  Proper treatment is necessary, however, to both ensure continued participation in sports and daily activities and avoid chronic damage.  The plantar fascia is the major structure that supports and maintains the arched alignment of the foot.3  This aponeurosis functions as a “bowstring” to hold up the longitudinal arch.

Pathology
Plantar fascitis develops when repetitive weight bearing stress irritates and inflames the tough connective tissues along the bottom of the foot.  High levels of strain stimulate the aponeurosis to try to heal and strengthen.  If the biomechanical strain continues, it overwhelms the body’s repair capacity, and the ligaments begin to fail.  It is this tear/repair process that causes the chronic, variable symptoms that can eventually become unbearable in some patients.

Since the plantar fascia inserts into the base of the calcaneus, the chronic pull and inflammation can stimulate the deposition of calcium, resulting in a classic heel spur seen on a lateral radiograph.  Unfortunately, there is no correlation between the presence of a heel spur and plantar fascitis; many heel spurs are clinically silent, and most cases of plantar fascitis do not demonstrate a calcaneal spur.4

Examination
Biomechanical evaluation may find either excessive pronation or supination.  The flatter, hyperpronating foot overstretches the bowstring function of the plantar fascia, while the high-arched, rigid foot places excessive tension on the plantar aponeurosis.  In either case, it is the combination of improper foot biomechanics and excessive strain that causes the connective tissue to become inflamed.  A careful assessment of the weight bearing alignment of the lower extremities is helpful, since many patients will have functional imbalances up the kinetic chain, into the pelvis and spine.

Direct palpation of the plantar fascia will demonstrate discrete painful areas, most commonly at the insertion on the antero-medial calcaneus.5  Fibrotic thickenings are frequently felt—these are remnants of the repetitive “tear and repair” process.  With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion.  Since this maneuver stretches the irritated plantar aponeurosis, it is frequently quite painful, and is an obviously positive objective sign.

Conclusion
Plantar fascitis usually responds well to focused, conservative treatment.  Steroid injections and surgical release are seldom necessary, and are best avoided.  One of the most important treatment methods is to reduce any tendency to pronate excessively.  In addition to custom-made orthotics, runners should wear well-designed shoes that provide good heel stability. 

The use of custom-made orthotics can prevent many overuse problems from developing in the lower extremities.  Investigation of foot biomechanics is a good idea in all patients, but especially for those who are recreationally active.

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program.  He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System.  He has been in private practice in Massachusetts for 27 years.  He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .