What are the treatment options for metatarsalgia that has not improved with orthotics (orthotic devices) after 10 months?

From the Guidelines

For persistent metatarsalgia that hasn't improved with 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 foot care and offloading interventions, such as those outlined in the 2023 update by the International Working Group on the Diabetic Foot (IWGDF) 1.

Key Components of Treatment

• 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 or naproxen 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; try toe stretches, towel scrunches, and calf stretches daily

Additional Considerations

• For severe cases, a corticosteroid injection administered by a podiatrist or orthopedist may provide relief
• If conservative measures fail, consult a foot specialist to rule out other conditions like Morton's neuroma or stress fractures, which may require different treatments
• Metatarsalgia often results from excessive pressure on the metatarsal heads, so treatments aim to reduce this pressure and inflammation while supporting proper foot mechanics, as discussed in guidelines for offloading foot ulcers in persons with diabetes 1.

Given the emphasis on reducing pressure and inflammation, and considering the patient's condition has not improved with orthotics, a thorough reassessment of footwear and the potential need for custom-made insoles or shoes to accommodate any deformities and redistribute pressure is essential, as highlighted by recent studies on footwear and offloading interventions 1.

From the Research

Treatment Options for Metatarsalgia

• Nonsurgical management is usually sufficient to achieve satisfactory results, and may include:
  • Stretching exercises
  • Footwear modification
  • Insoles or orthotics 2, 3
  • Lesion debridement 2
• 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