Treatment of Metatarsalgia (Ball of Foot Pain)
Start with metatarsal pads placed behind the metatarsal heads combined with appropriately fitting footwear that cushions and redistributes pressure—this conservative approach resolves symptoms in most patients and should be tried for at least 6 weeks before considering other interventions. 1
Initial Conservative Management (0-6 Weeks)
Footwear and Orthotic Interventions
- Use metatarsal pads positioned behind (not under) the metatarsal heads to transfer load proximally and relieve focal pressure 1
- Prescribe appropriately fitting footwear that cushions the feet and redistributes plantar pressure 1
- Consider prefabricated insoles or custom orthotic devices to redistribute plantar pressures 1
- For patients with bony deformities (hammertoes, prominent metatarsal heads, bunions), prescribe extra wide or deep shoes 1
Activity and Lifestyle Modifications
- Implement regular calf-muscle stretching exercises to reduce tension on the forefoot 1
- Recommend weight loss for overweight patients to decrease forefoot pressure 1
- Advise activity limitation and avoidance of barefoot walking 1
Pharmacologic Management
- Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation 1
Second-Line Treatment (After 6 Weeks Without Improvement)
- Continue metatarsal pads, orthotic devices, and calf-muscle stretching exercises 1
- Consider corticosteroid injections in appropriate cases for persistent pain 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 Neuropathic Plantar Metatarsal Head Ulcers (Diabetic Patients)
- Achilles tendon lengthening combined with an offloading device (Moderate evidence) 1
- Metatarsal head resection combined with an offloading device when osteomyelitis or metatarsophalangeal joint infection is present (Low evidence) 1, 2
- Metatarsal osteotomy combined with an offloading device for ulcers on metatarsal heads 2-5 1
For Neuropathic Hallux Ulcers
- Joint arthroplasty combined with an offloading device, particularly when limited range of motion of the first metatarsophalangeal joint exists 1, 2
For Toe Deformities
- Digital flexor tenotomy for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity (Strong recommendation, Moderate evidence) 1
For Mechanical Metatarsalgia
- Distal metatarsal osteotomy (Weil osteotomy) to decrease prominence of symptomatic metatarsal heads and provide axial decompression 3
Special Considerations for Diabetic Patients
- Ensure proper fitting of orthotic devices to prevent pressure sores and ulceration at the fracture site 2
- Focus on offloading and proper wound care to prevent complications 2
- Do not use conventional footwear or standard therapeutic footwear over an offloading device 4
Common Pitfalls to Avoid
- Avoid placing metatarsal pads directly under the metatarsal heads—they must be positioned behind the heads to effectively transfer load proximally 1
- Do not proceed to surgery prematurely—the 2-3 month conservative trial is essential as most patients respond to non-operative management 1
- In diabetic patients, never overlook proper offloading—inadequate offloading is a primary cause of treatment failure and ulceration 4, 2