What are the treatment options for metatarsalgia?

Treatment of Metatarsalgia

Begin with conservative management using metatarsal pads placed behind the metatarsal heads combined with footwear modifications, as this approach significantly reduces pain (mean 3.2 points on NRS) and improves functional scores (mean 24.2 points on AOFAS) in the majority of patients. 1, 2

First-Line Conservative Treatment (0-6 weeks)

Mechanical Offloading

• Metatarsal pads positioned proximal to (behind) the metatarsal heads are the cornerstone of initial treatment, transferring load more proximally and relieving focal pressure 1
• Use appropriately fitting footwear with adequate cushioning and pressure redistribution—avoid high heels and narrow toe boxes 1
• Consider prefabricated insoles initially, progressing to custom orthotic devices if needed for better pressure redistribution 1
• For severe deformities, extra wide or deep shoes may be necessary 1

Exercise and Activity Modification

• Implement regular calf-muscle stretching exercises to reduce tension on the forefoot—this addresses biomechanical contributors to metatarsalgia 1
• Recommend activity limitation and avoidance of barefoot walking during the acute phase 1
• Address weight reduction in overweight patients to decrease forefoot loading 1

Pharmacological Management

• NSAIDs for pain and inflammation control during the initial treatment phase 1

Second-Line Treatment (6 weeks to 3 months)

If no improvement after 6 weeks of appropriate conservative care:

• Continue mechanical offloading with metatarsal pads and orthotics 1
• Consider corticosteroid injection for persistent focal pain in appropriate cases (avoid in patients with diabetes or those at risk for plantar plate injury) 1
• Reassess footwear compliance and pad positioning—improper placement is a common pitfall 1

Surgical Intervention (After 2-3 months of failed conservative treatment)

Surgery should only be considered after 2-3 months of appropriate conservative treatment has failed. 1

Surgical Options Based on Etiology

For Mechanical Metatarsalgia with Abnormal Metatarsal Length/Position

• Weil osteotomy (distal metatarsal oblique osteotomy) is the most reliable and well-evaluated procedure for decreasing metatarsal head prominence 3, 4
• This provides axial decompression and brings the metatarsal head proximal to the area of excessive pressure 4

For Soft Tissue Pathology

• Gastrocnemius recession for equinus contracture contributing to forefoot overload 3
• Plantar plate repair if MTP joint instability is present 3
• Tendon transfer procedures for specific deformities 3

Special Considerations for Diabetic Patients with Neuropathic Ulceration

If metatarsalgia has progressed to ulceration in diabetic patients with neuropathy:

• Achilles tendon lengthening combined with offloading device for plantar metatarsal head ulcers (moderate evidence) 1
• Metatarsal head resection combined with offloading device (low evidence) 1
• Digital flexor tenotomy for plantar or apex ulcers on digits 2-5 with flexible toe deformity 1

Important Clinical Considerations

Common Pitfalls to Avoid

• Do not confuse Morton's neuroma pain with true metatarsalgia—Morton's neuroma causes interdigital nerve pain rather than MTP joint pain and requires different management 4, 5
• Ensure metatarsal pads are positioned behind (proximal to) the metatarsal heads, not directly under them 1
• Do not rush to surgery—89.4% of patients respond to conservative treatment when properly implemented 6, 2

Predisposing Factors to Address

• High-heeled shoe use (present in 40% of cases) 2
• Prolonged standing work (68% of cases) 2
• First MTP joint osteoarthritis (47% of cases) 2
• Hallux valgus deformity (42% of cases) 2

Evidence Quality Note

The evidence strongly supports conservative management first, with metatarsal padding showing significant pain reduction (3.2 points on NRS, p<0.001) and functional improvement (24.2 points on AOFAS, p<0.001) in prospective studies 2. Surgical outcomes for Weil osteotomy are well-documented with good results, but should be reserved for true conservative treatment failures 3, 4.