What is the treatment for metatarsalgia?

Treatment for Metatarsalgia

The first-line treatment for metatarsalgia includes footwear modifications with appropriately fitting shoes that cushion the feet and redistribute pressure, combined with orthotic devices such as metatarsal pads to offload pressure from the affected metatarsal heads. 1

Conservative Management Options

Footwear and Orthotic Interventions

• Extra-depth or wide shoes should be used for patients with bony deformities to reduce pressure on the metatarsal heads 1
• Custom-molded shoes may be necessary for severe bony deformities that cannot be accommodated with commercial therapeutic footwear 1
• Metatarsal pads placed behind the metatarsal heads can relieve focal pressure and transfer load more proximally 2
• Felted foam in combination with appropriately fitting footwear can be considered when specialized offloading devices are not available 1
• Prefabricated insoles or custom orthotic devices can help redistribute plantar pressures 2

Activity Modifications and Physical Therapy

• Regular calf-muscle stretching exercises help reduce tension on the forefoot 2
• Weight loss should be recommended for overweight patients to decrease forefoot pressure 2
• Activity limitation and avoidance of barefoot walking can reduce symptoms 2

Pharmacological Interventions

• Nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation 2
• In appropriate cases, corticosteroid injections may be considered for persistent pain 2

Surgical Management

Surgical intervention should be considered only when conservative measures fail after 2-3 months of appropriate treatment 2.

Surgical Options Based on Specific Conditions

• For neuropathic plantar metatarsal head ulcers where non-surgical offloading fails:
  • Achilles tendon lengthening in combination with an offloading device is conditionally recommended (Moderate evidence) 1
  • Metatarsal head resection in combination with an offloading device is conditionally recommended (Low evidence) 1
• For neuropathic hallux ulcers resistant to conservative treatment, joint arthroplasty combined with an offloading device may be beneficial 1
• For neuropathic plantar ulcers on metatarsal heads 2-5 resistant to conservative treatment, metatarsal osteotomy with an offloading device can be considered 1
• Distal metatarsal oblique osteotomy (Weil osteotomy) is effective for managing metatarsalgia due to subluxed or dislocated metatarsophalangeal joints 3
• Gastrocnemius recession may be considered for patients with metatarsalgia associated with gastrocnemius contracture and ankle equinus 4

Special Considerations for Diabetic Patients

• Non-removable knee-high offloading devices are recommended as first-line treatment for patients with diabetes and neuropathic plantar forefoot ulcers 1
• When non-removable devices are contraindicated or not tolerated, removable knee-high or ankle-high offloading devices should be considered 1
• Proper fitting of orthotic devices is essential to prevent pressure sores and complications such as ulceration 5, 6
• Digital flexor tenotomy is strongly recommended for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity 1

Treatment Algorithm

1. Initial Treatment (0-6 weeks):

   • Appropriate footwear modifications with cushioning and pressure redistribution 1
   • Metatarsal pads or orthotic devices 2
   • Calf-muscle stretching exercises 2
   • NSAIDs for pain management 2
   • Activity modification and weight loss if indicated 2

2. If No Improvement After 6 Weeks:

   • Continue initial treatments
   • Consider customized orthotic devices 1
   • Consider corticosteroid injections in appropriate cases 2
   • Consider night splinting 2

3. If No Improvement After 2-3 Months:

   • Consider surgical intervention based on specific diagnosis 2
   • For diabetic patients with ulceration, implement appropriate offloading strategies 1
   • Consider specific surgical procedures based on the underlying pathology 1, 3

Common Pitfalls and Caveats

• Failure to identify and address the underlying cause of metatarsalgia can lead to persistent symptoms 7
• Inadequate indication for surgery can result in treatment failures and persistent post-surgical complaints 7
• For diabetic patients, conventional footwear should not be used over an offloading device 1
• Corticosteroid injections should be limited in number to avoid complications 2
• Surgical intervention without proper diagnostic workup may lead to suboptimal outcomes 8