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Lois: We’ll be talking about metatarsalgia, disorders of the forefoot, with Dr. Brett Fink. Dr. Brett Fink is an orthopedic surgeon at the Indian Orthopedic Center and author of the book, The Whole Foot Book, a general reference on foot care which will be published in December of this year. I am Lois Wingerson. Welcome, Dr. Fink.
Dr. Fink: Thank you, Lois.
Lois: Dr. Fink, what are the biggest challenges in diagnosing and treating metatarsalgia?
Dr. Fink: Well, let’s start by defining what metatarsalgia is. Metatarsalgia simply means forefoot pain. And so metatarsalgia by itself is a description rather than a diagnosis. And so the biggest challenge in diagnosing and managing this problem is really to make the correct diagnosis. Traditional medical training, the type of training that a medical student generally has, is not very complete in describing musculoskeletal problems. It’s more something that people generally pick up as they go along during training. It’s even more weak in foot and ankle problems, because for the most part these problems have been relegated to the podiatric community. A significant portion of the people saying a primary care doctor will have foot problems even though this may not be the primary complaint. The forefoot is not a very big structure, but it’s packed with a lot of stuff, ligaments, tendons, arteries, bones, and nerves. And all of these things can be a part of the problem. Being familiar with the anatomy is very important in understanding what can go wrong with it. That is probably the biggest thing that a physician needs to know. You need to be aware of the diagnoses metatarsalgia is commonly caused by, because you can diagnose what you don’t know. After this, many effective nonoperative treatments can be instituted even by the primary care physician. This is one of the reasons that I wrote The Whole Foot, to help patients and their physicians learn about nonoperative care, because often it is passed over. People often go straight to an operation, which is really a unnecessary shame in my opinion.
Lois: What are the keys to determining the cause of metatarsalgia pain?
Dr. Fink: I think the key is a careful physical exam. And that involves really meticulously going over issues such as skin, nerves, and circulation as a part of the general exam and then being very careful to define exactly where it hurts. One diagnosis, Morton’s neuroma, is really very over-diagnosed. The reason is because Morton’s neuroma may be the only diagnosis that the physician may be familiar with that causes forefoot pain. If someone has pain which is really across the entire forefoot or is where Morton’s neuroma pain is usually not present, then this is probably not the cause of the problem. Also, I think it’s important to understand how deformities may interact with the causes of forefoot pain.
Lois: Please explain how other structures may be involved in the development of forefoot pain.
Dr. Fink: It is very important to understand that the foot does not exist in isolation. The simple act of walking is really a function of the back, the hip, knee, and the entire leg. And all the joints, ligaments, and muscles of each one of these areas are involved in the act of walking. Any dysfunction of any one of them will affect the way that the foot experiences pressure, and this pressure is what overloads the foot and causes many common foot problems including metatarsalgia. One of the results of this dysfunction is to shift the pressure in the foot from the entire foot and concentrated on the forefoot itself. This will eventually wear out a structure in the foot. If the weak part of the foot chain is the forefoot, then you will get metatarsalgia. One common illustration that I can think of off the top of my head is that all of someone that has a restriction of knee motion because of osteoarthritis or hamstring contractures, this will subtly change the way that they walk. It will shift the weight to the forefoot. This is something that we can look at on a forefoot pressure scan, a computerized device that measures the pressure on different parts of the foot as we step. Hamstring contractures, according to one article, were the factor most associated with common foot complaints.
Lois: Thank you very much, Dr. Fink.
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