From the Guidelines
Metatarsalgia is a condition that can be effectively managed with conservative measures, including proper footwear, rest, and pain management, to reduce morbidity, mortality, and improve quality of life. The diagnosis of metatarsalgia is primarily clinical, based on symptoms of pain and tenderness in the forefoot that worsens with walking or standing and improves with rest 1.
Causes and Risk Factors
The causes of metatarsalgia include biomechanical imbalances, high-impact activities, or foot deformities that create abnormal pressure distribution across the metatarsal heads, causing inflammation and pain in the surrounding tissues. According to the most recent guidelines, people with bony deformities (e.g., hammertoes, prominent metatarsal heads, bunions) may need extra wide or deep shoes to accommodate their foot shape and reduce pressure on the metatarsal heads 1.
Treatment
Treatment begins with conservative measures including rest, ice application for 15-20 minutes several times daily, and activity modification to reduce impact on the forefoot. Footwear changes are essential, with recommendations for a broad and square toe box, laces with three or four eyes per side, padded tongue, quality lightweight materials, and sufficient size to accommodate a cushioned insole 1. Over-the-counter metatarsal pads or cushioned insoles can redistribute pressure away from painful areas. For pain management, NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) can be used for 1-2 weeks. Weight loss is recommended for overweight patients to reduce pressure on the forefoot. Proper foot exercises, including toe stretches and marble pickups, can strengthen foot muscles.
Management and Prevention
Most cases resolve with these conservative measures within 2-3 months. If pain persists, custom orthotic devices may be prescribed, and in rare cases, corticosteroid injections or surgery might be considered. The routine prescription of therapeutic footwear is not generally recommended, but patients should be provided with adequate information to aid in the selection of appropriate footwear 1. Use of custom therapeutic footwear can help reduce the risk of future foot ulcers in high-risk patients. Early diagnosis and treatment of underlying conditions, such as Charcot neuroarthropathy, is crucial to prevent deformities that increase the risk of ulceration and amputation 1.
From the Research
Diagnosis of Metatarsalgia
- Metatarsalgia is a common report in patients with foot problems, characterized by pain in the area across the plantar forefoot, including the second through fourth metatarsal heads 2
- The diagnosis of metatarsalgia involves a thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs 3
- Metatarsalgia can be viewed as more of a symptom rather than a distinct diagnosis, and the timing of forefoot pain during the gait cycle and evaluation of whether the pain is from anatomic abnormalities, indirect overloading, or iatrogenic causes can suggest a specific metatarsalgia etiology 3
Treatment of Metatarsalgia
- Nonsurgical management is usually sufficient to achieve satisfactory results, and an individualized treatment protocol is required 2
- Nonoperative treatment consists of physical therapy, orthotics, shoe wear modification, and injections 3
- Surgical correction must be precise, and all pain-producing deformities must be corrected, but metatarsal osteotomy, long a staple of treatment, always fails in the long term 2
- Improved equipment and internal fixation methods may lead to better long-term outcomes 2
- NSAID injections may be safe and effective alternatives to steroid injections, especially in certain orthopedic conditions, but the effectiveness of NSAID injections in metatarsalgia is not directly addressed in the provided studies 4
Causes of Metatarsalgia
- The causes of metatarsalgia are related to gait mechanics, foot anatomy, and foot and ankle deformity, with great variability in possible causative factors 2
- Deformity of the first and fifth rays as well as of the toes can accompany metatarsalgia 2
- Abnormalities of the distal metatarsals are common in patients with metatarsalgia 2