Metatarsalgia Treatment & Management

  • Author: Britt A Durham, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Feb 28, 2010
 

Acute Phase

Rehabilitation Program

Physical Therapy

The initial treatment includes regular icing and application of a pressure bandage (or RICE: rest, icing, compression, and elevation). Recommend non–weight-bearing ambulation for the first 24 hours, after which passive range-of-motion (ROM) and ultrasound treatments can be initiated. The use of metatarsal pads and other orthotic devices may provide relief, even in the early phases of treatment.[6, 11]

Rehabilitation begins on the first day of injury, with the goal of restoring normal ROM, strength, and function. Long-axis distraction and dorsal/plantar glides of the metatarsophalangeal joint are self-mobilization techniques that can be used throughout the treatment process.

Occupational Therapy

Semi-rigid orthoses worn in supportive shoes have been shown to be effective treatment for metatarsalgia.[11] Supportive shoes worn alone, with or without soft orthoses, have not been shown to provide adequate pain relief.

Medical Issues/Complications

The patient should avoid disrupting the healing process; rather, the patient should perform stretching and strengthening exercises carefully. Likewise, the patient’s return to higher-level activity should be pursued gradually and with caution to prevent reinjury. However, this obvious decreased level of activity may not be acceptable to some athletes. The practitioner may need to reinforce the relationship between the pain and the activity and discourage the athlete from trying to run in spite of the pain.

Surgical Intervention

Successful metatarsal pain outcomes have been reported with oblique osteotomy.[12] The better outcomes are attributed to improved techniques to facilitate precise metatarsal positioning in different planes.

Other Treatment

  • Removing the callus (plantar keratosis) is not advised because the callus is a response to pressure and is not the primary disease. Temporary relief can be achieved by shaving down the callus; however, the clinician should avoid causing bleeding from excessive debridement and from the use of acids and other chemicals.
  • If the patient's symptoms are acute with a short duration, abnormal pronation of the subtalar joint can be the primary etiology. Use orthotic devices in these cases. Chronic symptoms respond better to a metatarsal bar that can be added to the running or athletic shoe.
  • Individuals with a pes cavus foot type who experience pain from metatarsalgia respond well to an orthotic device that provides total contact to the medial longitudinal arch because preventing collapse of the arch reduces the stress on the metatarsal heads. Patients with a Morton toe respond well to a rigid orthotic with an extension underneath the first metatarsal bone.
Next

Recovery Phase

Rehabilitation Program

Physical Therapy

The primary focus of treatment is restoration of normal foot biomechanics and relief of pressure in the symptomatic area. Therapy must allow the inflammation to subside or resolve by relieving the repeated excessive pressure.

Once the individual is pain free, initiate isometric, isotonic, and isokinetic strengthening exercises. Passive ROM exercises can progress to active exercises as the inflammation resolves. Therapy to increase dorsiflexion ROM allows improved forward progression of the tibia over the foot, with reduced stress on the forefoot. Strengthening the toe flexor muscles may allow for greater weight-bearing capacity on the toes.

Recreational Therapy

Swimming is an excellent exercise for maintaining physical conditioning while the patient is in a restricted weight-bearing phase of healing.

Other Treatment (Injection, manipulation, etc.)

Patients with an interdigital neuroma component of injury can benefit from a nerve block in combination with administration of long-acting steroids. Individuals with primary metatarsalgia receive little benefit from such injections.

Previous
Next

Maintenance Phase

Rehabilitation Program

Physical Therapy

As the inflammation subsides, an orthotic device is often the only intervention that is required to maintain normal mechanical function. These orthoses are necessary to distribute force away from the site of injury. Patients should continue self-mobilization exercises, including long-axis distraction and dorsal/plantar glides.

Surgical Intervention

Shoe modification with an orthosis may be the only treatment required for metatarsalgia. In severe cases, surgical realignment of the metatarsal bones may be required to balance weight bearing among the metatarsal heads.

In cases where conservative treatment has failed to provide relief of symptoms, surgical intervention may be required, including operative synovectomy, arthroplasty, wedge osteotomies of the metatarsal bases, ligamentous release, and tendon transfer.

Many types of osteotomies have been described as possible surgical interventions for metatarsalgia.[12, 13] Success and complications rates vary. The Weil osteotomy of the second and third metatarsals has been shown to be an effective and safe procedure for the treatment of central metatarsalgia.[13]

Consultations

Consider referral to an orthopedic specialist if no improvement has been achieved after 3 months of treatment.

Other Treatment

The high pressure under the metatarsal heads can be reduced by applying metatarsal pads. In a double-blind study, tear-drop shaped, polyurethane metatarsal pads were applied by experienced physiatrists to a total of 18 feet.[6] As a result, there were significantly decreased maximal peak pressures and pressure time intervals during exercise that correlated with better pain and function outcomes.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Britt A Durham, MD  Director of Risk Management, Department of Emergency Medicine, Martin Luther King Medical and Trauma Center, King-Drew Medical Center; Assistant Professor of Emergency Medicine, Drew College of Medicine; Assistant Clinical Professor of Emergency Medicine, UCLA School of Medicine; Partner and Chief Financial Officer, Durcress Medical Group, California Medical Board District Medical Consultant, Lakewood Atheletic Sports Medicine Team Physician

Britt A Durham, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Anthony J Saglimbeni, MD  President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD, is a member of the following medical societies: California Medical Association and Santa Clara County Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Russell D White, MD  Professor of Medicine, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding

References
  1. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. Jul 1999;31(7 suppl):S448-58. [Medline].

  2. Safran MR, McKeag DB, Van Camp SP, eds. The foot: endurance events, marathon. Manual of Sports Medicine. Philadelphia, Pa: Lippincott-Raven; 1998:485, 558-9.

  3. McPoil TG, McGarvey T. The foot in athletics. In: Hunt GC, McPoil TG, eds. Clinics in Physical Therapy: Physical Therapy for the Foot and Ankle. 2nd ed. New York, NY: Churchill Livingstone; 1995:207-35.

  4. Quirk R. Metatarsalgia. Aust Fam Physician. Jun 1996;25(6):863-5; 867-9. [Medline].

  5. Steinberg GG, Akins CM, Baran DT, eds. Metatarsalgia. Orthopedics in Primary Care. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:284-7.

  6. Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskelet Disord. 2006;7:95. [Medline]. [Full Text].

  7. Tóth K, Huszanyik I, Kellermann P, Boda K, Róde L. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int. Jan 2007;28(1):61-3. [Medline].

  8. Endres S, Quante M. Oedema of the metatarsal heads II-IV and forefoot pain as an unusual manifestation of Lyme disease: a case report. J Med Case Reports. 2007;1:44. [Medline]. [Full Text].

  9. Iagnocco A, Coari G, Palombi G, Valesini G. Sonography in the study of metatarsalgia. J Rheumatol. Jun 2001;28(6):1338-40. [Medline].

  10. Yu JS, Tanner JR. Considerations in metatarsalgia and midfoot pain: an MR imaging perspective. Semin Musculoskelet Radiol. Jun 2002;6(2):91-104. [Medline].

  11. Chalmers AC, Busby C, Goyert J, Porter B, Schulzer M. Metatarsalgia and rheumatoid arthritis--a randomized, single blind, sequential trial comparing 2 types of foot orthoses and supportive shoes. J Rheumatol. Jul 2000;27(7):1643-7. [Medline].

  12. Kennedy JG, Deland JT. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. Dec 2006;453:309-13. [Medline].

  13. O'Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int. May 2002;23(5):415-9. [Medline].

Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.