Time to discuss a clinical topic Section

Does a Ferrari have something to do with metatarsalgia?

I thought we would dip into a clinic today as some interesting points emerged. Is this you?


Clinic was busy as usual but the common denomenator came from patients having metatarsalgia. This condition is akin to rheumatism as I tell patients – meaningless unless defined! Pain under the ball of the foot is not only common but complicated to diagnose. In a recent audit covering 6 years, metatarsalgia accounted for 1.9% of a podiatric surgeons workload. If this is specified to say one type, it jumps to 5.4%. This is not the only cause. Ben (53 years) was an ironman challenger and Mary (72 years) a part time fitness dance instructor. Both had metatarsalgia and seemed surprised that their foot problems had suddenly started to incapacitate them.  Both were medically fit. It was time to have a philosophical discussion at the consultation.

So, consider a car in the garage, one that is taken out to the shops to make the weekly purchases and perhaps undertake a few other journeys. The car, no doubt well made, will go on for a long time, although doubtless will need a service and the odd part replacing. The metaphor for a car plays well to the analogy of the human body; the power house of people movement.

Jean, a third patient aged 42 said that she was told she had arthritis!

As medical disease had been ruled out arthritis was not the case. Her big toe joint was stiff and clearly suffered  wear and tear. Back to the car. So is the car broken? No, it might be dented or scratched, but it can be fixed and go on for a few more years. I pointed out I do not like labelling people with arthritis for a single joint; one that is inevitably exposed to wear and tear over many years. The car as indeed the foot will go on but might not work as efficiently if pushed hard.

One day we might ask the car to do more than it usually does. At this point there is always a risk it may resent being pushed harder up the motorway than usual, or around a tight bend, or carry one too many sacs of cement. Ben was lean, Mary was just sensibly active. Tears in the fine lining of tendons and joint covering (capsules) leak out and cause swelling and pain. Ben was the Ferrari; highly tuned and but perhaps as an older model performed less well. Mary wanted a Ferrari for its extra performance. Her usually highly reliable car regaled at the continuous treatment.

Forgive the analogies but brand new cars age as much as we do. We have high expectations and for those of us 40-70 we believe we can pick up where we left off. I am not critical as I am the same. At 45 I pushed myself, became lean and dropped off pounds. My blood pressure was impressively low and my pulse a fantastic 60 beats per minute. Then – I popped my knee! At 57 I was on my third surgery (same knee) and  can no longer run. My Ferrari is truly knackered ( a non medical term) and so when James came to clinic, on the same day as Ben and Mary, his tendo-achilles had popped up as a swelling. At 52 he was mortified as he wanted to keep up with his young daughter. As a professional comedian he had the right attitude and we went about fixing his problem, but I talked about the car again. Keep it there for high days and holidays and just cruise. Make sure you go out on safe roads and potter along letting the 25 year olds speed past. Tomorrow those same youngsters will be in clinic as weight gain arises and they seek youth once again. Sure we can fix things but do not have expectations that we clinicians can save you from age. Our connective tissue, that is the stuff that holds us together, is genetically programmed. Some parts will wear out sooner than others. So do please come to clinic and let us talk and be optimistic. Much can be done, but DO have realistic expectations.


All names used are anonymised.




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