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The response to the question below was authored by Marc Mitnick DPM

Post Bunion surgery and Metatarsalgia

by Shirley

metatarsalgia or neuroma?

metatarsalgia or neuroma?

Had bunion surgery on my left foot Nov 14, 2013. Not a lot of pain except on the top of my foot under the 4th and 5th toe. Since then I have developed Metatarsalgia. I have been to two different Kasier Podiatrist. The first one who did the surgery said I had a neuroma and gave me a cortisone shot. The second said that I had metatarsalgia. He told me to get rocker shoes, which I have done. That helped a little. I lost all of the fat pad on that foot after the surgery. Ok, I know you say that doesn't happen, but I had the day before the surgery and the very first time I put my foot flat 3 weeks later with the surgery boot on it felt like I was standing on rocks!!! If I flex my toes up towards my shin it sometimes clicks and it definitely pulls. It also hurts on the outside of my ankle.

So I have a couple of questions. First what do you think is going on?? Second, what kind of test to I ask for to see what might be going on in my foot. And last, what are things I can do to help my foot? Can you think of any questions I should be asking or test I should ask for. It has quite changed my life. Exercise or special shoes????

Thanks so much for taking the time to answer.


Hi Shirley,

This is difficult for me because I cannot actually examine you and I am going on the diagnosis of two different podiatrists who have given you two different opinions.

Having said that, let me make one assumption. What ever your problem, it appears to be the result of your post-operative care. What I mean by this is that you did not have this problem before your bunion surgery, your pain is far enough away from the surgical site, that the actual surgery did not adversely affect your fourth and fifth toes and metatarsals, so your pain has to be a result of what transpired after the surgery.

Now, I do not know what kind of bunion procedure you had performed, so I do not know if you wore a cast, or you were non-weightbearing for a period of time (although I would guess not), or were you in nothing more than a surgical shoe for a period of time.

I would assume you were wearing a surgical shoe because of all the options that would be the one that could cause pain on the outer portion of your foot.

What generally happens, in order to protect your surgical site, most people
tend to walk on the outside of their foot somewhat to keep pressure off the bunion area. That in essence could lead to pain where you are experiencing pain, but to aggravate the problem further, is the nature of the surgical shoe. All of them are rigid (for a reason) and depending on how hard the sole of the shoe is, could also aggravate the outside of the foot, if that portion of the foot is "leaning" into the shoe.

Given that assumption, I would lean more towards metatarsalgia then neuroma, but of course I am only guessing. If you look at the enclosed diagram, the red circles would represent pain from metatarsalgia, and the yellow arrows represent the course of pain for a neuroma.

So, lets talk about your symptoms. Simple metatarsalgia is pain by direct pressure on the heads of the metatarsal bones, whereas a neuroma would be painful in between the the fourth and fifth metatarsal bone.

Secondly, metatarsalgia pain would be limited to the area, while a neuroma may send pain (or tingling, or burning) into the fourth or fifth toes. Sometimes the pain may also travel backwards into the foot.

If the cortisone shot helped at all, even for a short period of time, I would lean more towards neuroma than metatarsalgia because the cortisone shot would not have helped metatarsalgia. The rocker bottom shoe could help either condition.

There is no reliable testing for these conditions. In theory, you could have an MRI or ultrasound for a neuroma, but anyone who has been treating neuromas for years will tell you that you can have a neuroma that does not show up on an MRI, so at the end of the day, you are no better off at knowing if there is a neuroma or not.

I guess what you really need is a tie breaker which would require going for a third opinion. Keep in mind conditions like capsulitis and submetatarsal bursitis would also have to be ruled out.

Without a definitive diagnosis, one option for you would be to consider going for physical therapy, since in my opinion, I think your pain is the result of post-operative care and not an ongoing problem, therapy may go a long way to rid you of your symptoms regardless of the diagnosis.

Lastly, one simple inexpensive option you could consider, would be to purchase a Spenco flat innersole, (not a Spenco arch support). This is nothing more than a cushioned innersole, primarily for sneakers. If you have metatarsalgia, the innersole should help; it will not help a neuroma, so it might be helpful in either reducing your symptoms or ruling out neuroma.

Marc Mitnick DPM

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