What is the treatment for chronic fifth toe metatarsal issues?

Treatment of Chronic Fifth Metatarsal Issues

For chronic fifth metatarsal problems, initiate conservative management with a CAM-walker boot or hard-soled shoe combined with metatarsal padding and custom orthotics, reserving surgical intervention only after 2-3 months of failed conservative treatment. 1, 2

Initial Conservative Management (First 6-12 Weeks)

Footwear and Offloading

• Use a CAM-walker boot as the preferred immobilization method, which demonstrates significantly faster bone healing (7.2 weeks) compared to hard-soled shoes (8.6 weeks), though both achieve similar functional outcomes 2
• If a CAM-walker boot is unavailable or not tolerated, a hard-soled shoe is an acceptable alternative with comparable clinical results 2, 3
• Apply metatarsal pads positioned behind the metatarsal heads to redistribute plantar pressure proximally 1
• Prescribe custom orthotic devices or prefabricated insoles to redistribute forefoot loading 1

Additional Conservative Measures

• Implement regular calf-muscle stretching exercises to reduce forefoot tension 1
• Recommend weight loss for overweight patients to decrease forefoot pressure 1
• Advise activity limitation and avoidance of barefoot walking 1
• Consider NSAIDs for pain management and inflammation control 1

Important caveat: Splints (boot or bandage support) produce superior foot function scores compared to short-leg casts and lower nonunion rates, so avoid rigid casting when possible 3

Treatment Escalation (6 Weeks to 3 Months)

If no improvement after 6 weeks of initial conservative treatment:

• Continue metatarsal padding and orthotic devices 1
• Continue calf-muscle stretching exercises 1
• Consider corticosteroid injections for persistent pain in appropriate cases 1

Surgical Intervention (After 2-3 Months of Failed Conservative Treatment)

Surgery should only be considered when conservative measures fail after 2-3 months of appropriate treatment 1

Surgical Options Based on Specific Pathology

For tuberosity avulsion fractures with painful nonunion:

• Internal fixation with or without bone graft is the treatment of choice 4
• Consider endoscopic bone grafting to minimize soft tissue dissection while allowing thorough debridement and assessment of the fifth metatarsal-cuboid articulation 4

For displaced fractures (>2mm displacement or >30% cubometatarsal joint involvement):

• Surgical fixation is indicated using percutaneous K-wires, plate, or screw fixation 5

For chronic metatarsalgia in diabetic patients with failed conservative treatment:

• Metatarsal head resection combined with an offloading device (low evidence quality) 1
• Metatarsal osteotomy combined with an offloading device for metatarsal heads 2-5 1
• Digital flexor tenotomy for flexible toe deformities causing plantar or apex ulcers 1

Surgical Complications to Monitor

Potential complications include post-operative infection (9.5% in diabetic neuropathy patients), transfer ulcers (up to 41% after single metatarsal head resection), gait problems, and acute Charcot neuro-osteoarthropathy 6

Special Considerations for Diabetic Patients

• Use non-removable knee-high offloading devices as first-line treatment for neuropathic plantar forefoot ulcers 1
• When non-removable devices are contraindicated, use removable knee-high or ankle-high offloading devices 1
• Never use conventional footwear or standard therapeutic footwear over an offloading device 1
• For severe bony deformities including Charcot foot, custom-molded shoes may be necessary 1

Monitoring and Follow-up

• Assess radiographic healing, pain scores (VAS), and functional outcomes (AOFAS midfoot score) at 4,8,10,12, and 24 weeks 2
• Continue follow-up until the patient is asymptomatic and able to return to prior activity levels 2
• For surgical cases, monitor for a minimum of 6 months post-treatment to define remission 6