Question
When someone has metatarsalgia, what do you address first in a bike fit? Shoe cleat fit or knee angle?
Answer
The common origin of metatarsalgia in bike injuries is the cleat being too far forward on the shoe. Take a look at that first metatarsal head and evaluate where it is. Secondarily, irregular width of stance is a causal factor. For example, yesterday in clinic I had a gentleman whom I have seen before for bike fit and he changed out his cleats, shoes, and pedals. Now all of sudden, he has metatarsal pain, specifically fifth metatarsal pain. When we evaluated him, we found that he had a width of stance that was really far too narrow in correlation to his pelvic width. When we altered his width of stance and brought it out to a more normal width of stance, that pressure or compression of the fifth metatarsal was minimized and allowed him to pedal quite comfortably. Typically it is cleat fore and aft, but often secondarily it will be a width of stance issue. Thirdly, there is another issue with regards to carbon shoes. There are more and more carbon shoes and they are obviously sold as being attenuative in nature, but there is one nice study that looked at carbon shoes versus polycarbonate plastic shoes. It demonstrated that these carbon shoes, even though they were said to absorb shock, had much greater peak plantar compressive forces to the foot when compared to the polycarbonate shoe. Sometimes if a person has a really stiff shoe, really stiff carbon light shoe, that can be a source of metatarsal pain or vibratory type pain to the foot, or there can be sesamoid type pain with this type of shoe. I would say those are the most common sources of metatarsalgia.
