What is the recommended treatment for a patient with intermetatarsal bursitis, effusion at the metatarsophalangeal joints, partial-thickness plantar plate tear, and subcutaneous adventitial bursitis?

Management of Intermetatarsal Bursitis and Associated Foot Conditions

The recommended treatment for intermetatarsal bursitis and associated foot conditions should focus on offloading mechanical tissue stress, using appropriate footwear, orthotic devices, and anti-inflammatory medications, with surgical intervention reserved for cases that fail conservative management. 1

Initial Conservative Management

Offloading and Footwear Modifications

• Offloading mechanical tissue stress is indicated to allow healing of the affected areas, particularly for the intermetatarsal bursitis and plantar plate tear 1
• Appropriate footwear selection with proper fit, width, and cushioning is essential to reduce pressure on the affected areas 2
• Consider open-backed shoes to reduce pressure on the affected areas, particularly for the subcutaneous adventitial bursitis at the metatarsophalangeal joints 2

Orthotic Devices

• Custom or over-the-counter arch supports should be considered to redistribute weight and reduce pressure on the metatarsal heads 2
• Toe spacers may be beneficial for the intermetatarsal bursitis at the 3rd web space to reduce compression between metatarsal heads 1
• Orthoses should be considered for symptom relief, particularly for the partial-thickness plantar plate tear at the 2nd metatarsophalangeal joint 1

Pharmacological Management

• Topical NSAIDs (such as naproxen) should be considered as first-line pharmacological treatment due to safety reasons 1, 3
• If topical treatment is insufficient, oral NSAIDs can be used for a limited duration for pain relief and inflammation reduction 1, 3
• The recommended starting dose of naproxen for acute bursitis is 500 mg initially, followed by 250 mg every 6-8 hours as required, not exceeding 1250 mg on the first day and 1000 mg on subsequent days 3
• Caution should be exercised with NSAIDs in patients with cardiovascular, renal, or gastrointestinal risk factors 3

Physical Therapy

• Exercise therapy should be considered to improve function and muscle strength, as well as to reduce pain 1
• Cryotherapy (ice application) for 10-minute periods through a wet towel can help reduce pain and swelling 2

Advanced Management for Persistent Symptoms

Injection Therapy

• Intra-articular injections of glucocorticoids may be considered for the effusion at the 1st and 2nd metatarsophalangeal joints if other treatments fail, though this should not be a first-line approach 1
• Corticosteroid injections should be used judiciously and are contraindicated near the Achilles tendon due to risk of rupture 2

Surgical Intervention

• If conservative treatment fails after 6-8 weeks, referral to a foot and ankle specialist should be considered 2
• Surgical intervention may be necessary for the partial-thickness plantar plate tear if conservative measures fail 1
• For intermetatarsal bursitis that is refractory to conservative treatment, surgical excision of the bursa may be considered 4, 5
• The specific surgical approach should be adapted to the anatomical lesion location, lesion morphology, and general patient condition 1

Special Considerations

Differential Diagnosis

• Intermetatarsal bursitis can mimic Morton's neuroma, and proper radiological evaluation (MRI or ultrasound) is essential for accurate diagnosis 5
• MRI findings may show a heterogeneous mass with intermediate to high signal intensity on T2-weighted images in cases of adventitious bursitis 6

Monitoring and Follow-up

• Regular follow-up is recommended to assess clinical and functional status, medication adherence, and symptoms 1
• If symptoms persist despite appropriate conservative management, advanced imaging studies (MRI, ultrasound) may be necessary to confirm diagnosis and rule out other conditions 2

Common Pitfalls to Avoid

• Avoid complete immobilization to prevent muscular atrophy and deconditioning 2
• Do not overlook the possibility of infection in cases of bursitis, which would require antibiotic treatment 1
• Avoid overdebridement of hyperkeratotic tissue as it can make underlying skin susceptible to increased tenderness 2
• Do not delay referral to a specialist if symptoms persist despite appropriate conservative management 2