How to manage chronic metatarsal pain in the greater toe?

Management of Chronic Metatarsal Pain in the Greater Toe

For 8 months of metatarsal pain in the great toe, begin with conservative management including proper footwear modifications, NSAIDs, and custom orthotic devices for at least 3-6 months before considering surgical intervention. 1

Initial Diagnostic Approach

Obtain plain radiographs of the foot first to exclude structural abnormalities, arthritis, stress fractures, or bipartite sesamoids. 2, 3 This is the appropriate initial imaging for chronic foot pain of unknown etiology. 2

If radiographs are negative or equivocal and pain persists, proceed to MRI of the foot without IV contrast as the next imaging study. 2, 1 MRI is superior for evaluating:

• Sesamoiditis (bone marrow edema in the hallucal sesamoid bones under the first metatarsophalangeal joint) 3
• Stress fractures and occult fractures 2
• Cartilage loss and subchondral bone changes in the first metatarsophalangeal or tarsometatarsal joints 1
• Plantar plate injuries 2

Ultrasound is an acceptable alternative that allows dynamic examination and direct clinical correlation, with 90% sensitivity for detecting pathology. 4, 2

Conservative Treatment Protocol (First-Line for 3-6 Months)

Footwear Modifications

• Use well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure away from the metatarsal heads. 2
• For bony deformities (hammertoes, prominent metatarsal heads, bunions), prescribe extra-wide or depth shoes. 2
• For extreme deformities, custom-molded shoes may be necessary. 2

Orthotic Devices

• Custom orthotic devices with metatarsal supports to redistribute excessive loading under the metatarsal heads. 2, 5
• Dynamic impression insoles can reduce peak pressure by 46% and pressure-time integral by 49% compared to flat insoles, with significant pain reduction in metatarsalgia. 5

Pharmacologic Management

• NSAIDs (such as naproxen 375-500 mg twice daily) for pain and inflammation control. 2, 1, 6
• Naproxen has been shown to be effective for musculoskeletal pain with onset of relief within 1 hour and duration up to 12 hours. 6

Additional Conservative Measures

• Callus debridement by a foot care specialist if present. 2
• Padding and strapping of the foot. 2
• Activity modification to reduce excessive loading. 2
• Physical therapy and stretching exercises. 1

When Conservative Treatment Fails

If no improvement occurs after 6 months of conservative treatment, consider surgical options. 1

Surgical Interventions

For sesamoiditis or first metatarsophalangeal joint pathology:

• Metatarsal head resection in combination with an offloading device when non-surgical interventions fail. 2
• Metatarsal-phalangeal joint arthroplasty for hallux ulcers with limited range of motion of the first metatarsophalangeal joint, which may increase healing by 7% and decrease amputations by 52%. 2

For general metatarsalgia:

• Distal metatarsal osteotomy (Weil osteotomy) is the best-evaluated procedure to decrease prominence of the symptomatic metatarsal head. 7
• Proximal metatarsal osteotomies are more powerful but technically demanding, used when shortening or elevation is needed. 8
• Fixation improves union rates and symptom relief compared to non-fixated osteotomies. 8

Critical Clinical Pearls

• Weight-bearing radiographs are essential, as non-weight-bearing films may underestimate joint instability and malalignment. 1
• Distinguish sesamoiditis from Morton's neuroma, intermetatarsal bursitis, and plantar plate injuries, as these require different management approaches. 3, 4
• CT can help differentiate sesamoiditis from stress fractures and bipartite sesamoids when MRI findings are equivocal. 3
• Avoid local corticosteroid injections in Achilles tendon-related pathology due to rupture risk, though they may be considered for other conditions. 2
• Metatarsal osteotomy without addressing all pain-producing deformities leads to long-term failure. 9