From the Guidelines
For persistent metatarsalgia that hasn't responded to orthotics after 10 months, I strongly recommend a multi-faceted approach prioritizing rest, activity modification, and proper footwear to reduce pressure on the forefoot and alleviate symptoms. This approach is supported by the most recent guidelines on offloading foot ulcers in persons with diabetes, which emphasize the importance of reducing mechanical stress on the foot 1.
Key Components of the Approach
- Rest and activity modification to reduce pressure on the forefoot
- Apply ice for 15-20 minutes several times daily to reduce inflammation
- Take over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily) for pain and inflammation for up to two weeks
- Consider metatarsal pads placed just behind the painful area to redistribute pressure
- Proper footwear is crucial—choose shoes with a wide toe box, good cushioning, and low heels
- Physical therapy focusing on foot strengthening and stretching exercises can help address biomechanical issues
- For severe cases, a corticosteroid injection administered by a podiatrist or orthopedist may provide relief
Importance of Footwear
The selection of appropriate footwear is critical in managing metatarsalgia, as emphasized in the guidelines on offloading foot ulcers 1. Shoes should have a broad and square toe box, laces with three or four eyes per side, a padded tongue, quality lightweight materials, and sufficient size to accommodate a cushioned insole. Custom-made or extra-depth shoes may be necessary for individuals with bony deformities or those who cannot be accommodated by conventional therapeutic footwear.
Additional Considerations
Metatarsalgia often results from excessive pressure on the metatarsal heads, causing inflammation of the joints and surrounding tissues. If conservative measures fail, it is essential to consult a foot specialist to rule out other conditions like Morton's neuroma, stress fractures, or arthritis that may require different treatment approaches. The use of offloading devices, such as total contact casts or removable walkers, may be considered in severe cases or when other treatments have failed, as recommended by the guidelines 1.
Prioritizing Morbidity, Mortality, and Quality of Life
In making treatment decisions for metatarsalgia, it is crucial to prioritize morbidity, mortality, and quality of life outcomes. The recommended approach aims to reduce pain and inflammation, promote healing, and improve functional ability, thereby enhancing the patient's overall quality of life. By following the most recent and highest-quality guidelines, healthcare providers can ensure that patients receive evidence-based care that addresses their unique needs and promotes optimal outcomes 1.
From the Research
Treatment Options for Metatarsalgia
- Nonsurgical management is usually sufficient to achieve satisfactory results, and may include:
- Soft-tissue surgical procedures may also be considered, such as:
- Gastrocnemius muscle recession
- Tendon transfer
- Plantar plate repair 2
- Metatarsal osteotomy, including the Weil procedure, may be a reliable option for some patients 2
- Percutaneous methods are being developed, but require further evaluation 2
Considerations for Treatment
- A thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs are critical for diagnosis and treatment 4
- An individualized treatment protocol is required, taking into account the underlying causes of metatarsalgia and the patient's specific needs 5, 6
- Treatment should aim to increase weightbearing tolerance by balancing the metatarsal load, assisting proper foot biomechanics, and cushioning or protecting the metatarsal heads 3
Limitations of Current Evidence
- Only limited scientific evidence is available in the literature to support the effectiveness of various treatments for metatarsalgia 6
- Most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results, but further research is needed to fully understand their effectiveness 6