What are the treatment options for intermittent swelling between the first and second metatarsal?

Treatment Options for Intermittent Swelling Between First and Second Metatarsal

For intermittent swelling between the first and second metatarsal, the primary treatment options include conservative measures such as offloading devices, footwear modifications, and orthotics, with surgical interventions reserved for cases that fail to respond to non-surgical management. 1, 2

Initial Conservative Management

Offloading Approaches

• Removable offloading devices - These should be the first-line treatment to reduce pressure on the affected area 1
• Custom orthotic devices with metatarsal pads to redistribute pressure away from the painful area 1, 2
• Footwear modifications:
  • Wide toe box to reduce compression between metatarsals
  • Rocker-bottom soles to reduce forefoot pressure during walking
  • Low heels to minimize forefoot loading 2

Additional Conservative Measures

• Debridement of hyperkeratosis (if present) - Should be performed conservatively by a podiatrist experienced with foot conditions to avoid overdebridement which can lead to increased pain and blistering 1
• Emollients and non-adherent dressings after debridement to protect the skin 1
• Anti-inflammatory medications - NSAIDs and topical analgesics to reduce pain and inflammation 2
• Physical therapy - Toe and foot strengthening exercises, range of motion exercises, and gait training 2, 3
• Mechanical Diagnosis and Therapy (MDT) - Utilizing direction-specific exercises based on the patient's response to repeated end-range movements 3

Advanced Non-Surgical Options

• Corticosteroid injections - Can provide temporary relief for inflammation between metatarsals 4
• Capsaicin injections - May be effective for pain if a Morton's neuroma is present (a common cause of intermetatarsal swelling) 4
• Felted foam padding in combination with appropriate footwear when offloading devices are unavailable 1

Surgical Interventions

When non-surgical treatments fail after 3-6 months of consistent application, surgical options may be considered:

• Metatarsal head (MTH) resection - Indicated when there is persistent pain, limited joint mobility, or evidence of infection/osteomyelitis 1, 2

  • Provides moderate increases in healing (RR 1.33) and sustained healing (RR 1.21) compared to offloading devices alone 1
  • May cause temporary decrease in quality of life during healing but moderate increases after healing 1

• Metatarsal osteotomy - For realignment of the metatarsal to reduce pressure between the first and second metatarsals 1, 2, 5

  • Particularly useful for plantar ulcers on metatarsal heads 2-5 that don't respond to non-surgical treatment 1

• Coalition resection - If imaging reveals a coalition (abnormal connection) between the first and second metatarsals 6

Treatment Algorithm

1. First-line: Conservative management for 3-6 months

   • Removable offloading devices
   • Custom orthotics with metatarsal pads
   • Appropriate footwear modifications
   • Physical therapy and exercise

2. Second-line: If no improvement after 3 months

   • Consider corticosteroid or capsaicin injections
   • Assess for Morton's neuroma or other specific diagnoses with ultrasound or MRI

3. Third-line: If persistent symptoms after 6 months of conservative care

   • Surgical consultation
   • Consider metatarsal osteotomy or MTH resection based on:
     • Presence of infection/osteomyelitis (favors MTH resection)
     • Structural deformity (favors osteotomy)
     • Location and nature of the swelling

Important Considerations

• Pre-surgical vascular assessment is essential, particularly in diabetic patients 2
• Post-surgical care should include continued use of offloading devices and appropriate footwear 1, 2
• Avoid common pitfalls:
  • Failing to address underlying biomechanical issues
  • Overdebridement of hyperkeratosis by inexperienced providers 1
  • Neglecting vascular status assessment before surgical intervention 2