Treatment of Pain Between 1st and 2nd Metatarsals
For pain localized between the 1st and 2nd metatarsals, initiate conservative management with proper footwear modifications, metatarsal padding, and NSAIDs, reserving surgical intervention for cases that fail 6-8 weeks of conservative therapy.
Initial Conservative Management
Footwear and Offloading
- Immediately discontinue walking barefoot, in socks only, or in thin-soled slippers to protect the affected area 1
- Prescribe properly fitting therapeutic footwear with adequate toe box width to reduce compression between metatarsal heads 1
- Apply metatarsal pads positioned proximal to the metatarsal heads to redistribute plantar pressure away from the painful area 2, 3
- Consider custom-made orthoses to correct weight distribution and reduce abnormal pressure concentration 3
Pharmacologic Management
- Start ibuprofen 400 mg every 4-6 hours as needed for pain relief, using the lowest effective dose for the shortest duration 4
- Maximum daily dose should not exceed 3200 mg, and medication should be taken with meals or milk if gastrointestinal complaints occur 4
Activity Modification
- Reduce high-impact activities and prolonged standing that exacerbate forefoot loading 2
- Implement structured exercise programs focusing on gastrocnemius stretching if ankle equinus is present 5
Diagnostic Considerations
Key Clinical Findings to Assess
- Perform compression test of the affected web space - highly specific for Morton's neuroma, which commonly affects the 3rd web space but can occur between 1st and 2nd metatarsals 6, 7
- Evaluate for gastrocnemius contracture using Silfverskiold test, as ankle equinus increases forefoot pressure 5
- Assess for callus formation under metatarsal heads, indicating abnormal pressure distribution 2, 3
- Examine for toe deformities (hammertoes, claw toes) that contribute to metatarsalgia 2
Imaging When Indicated
- Ultrasonography can determine exact size of neuromas in atypical presentations 6, 7
- Radiographs help identify structural abnormalities, metatarsal length discrepancies, or arthritic changes 2
Surgical Intervention (If Conservative Treatment Fails After 6-8 Weeks)
Indications for Surgery
- Persistent pain despite adequate conservative management for 6-8 weeks 1, 3
- Progressive functional limitation affecting activities of daily living 2
- Confirmed structural abnormality requiring correction 3
Surgical Options
- Distal metatarsal osteotomy (Weil osteotomy) is the best-evaluated procedure for mechanical metatarsalgia, providing axial decompression and reducing metatarsal head prominence 3
- Neurectomy or neurolysis for confirmed Morton's neuroma produces dramatic pain relief when conservative measures fail 6, 7
- Gastrocnemius recession for patients with concomitant gastrocnemius contracture and positive Silfverskiold test 5
Special Populations
Patients with Diabetes
- Exercise extreme caution with any offloading devices to prevent pressure sores and ulceration 8
- Ensure meticulous wound care if any skin breakdown occurs 1
- Avoid aggressive debridement that could create new wounds 1
- Consider earlier surgical consultation if conservative measures risk prolonged pressure and ulcer formation 1
Common Pitfalls to Avoid
- Do not inject corticosteroids near the Achilles tendon insertion if posterior heel involvement is present 1
- Avoid overdebridement of calluses, which can increase pain and create vulnerable areas 1
- Do not delay surgical referral beyond 6-8 weeks if conservative treatment shows no improvement 1, 3
- Ensure all contributing deformities are addressed surgically - isolated metatarsal osteotomy without correcting associated toe deformities leads to long-term failure 2