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Metatarsalgia Treatment & Management

  • Author: Britt A Durham, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Jan 22, 2015
 

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

See the list below:

  • 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.
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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.

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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, 14, 15, 16] 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, 17]

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.

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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

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, 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, American Medical Society for Sports Medicine

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 Division of the Biological Sciences, The Pritzker School of Medicine

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

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

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, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor Daniel Kaplan, MD, to the development and writing of this article.

References
  1. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999 Jul. 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. 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. 1996 Jun. 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. 2007 Jan. 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. 2001 Jun. 28(6):1338-40. [Medline].

  10. Yu JS, Tanner JR. Considerations in metatarsalgia and midfoot pain: an MR imaging perspective. Semin Musculoskelet Radiol. 2002 Jun. 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. 2000 Jul. 27(7):1643-7. [Medline].

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

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

  14. Pearce CJ, Calder JD. Metatarsalgia: proximal metatarsal osteotomies. Foot Ankle Clin. 2011 Dec. 16(4):597-608. [Medline].

  15. Schuh R, Trnka HJ. Metatarsalgia: distal metatarsal osteotomies. Foot Ankle Clin. 2011 Dec. 16(4):583-95. [Medline].

  16. Lui TH. Percutaneous dorsal closing wedge osteotomy of the metatarsal neck in management of metatarsalgia. Foot (Edinb). 2014 Dec. 24(4):180-5. [Medline].

  17. Pérez-Muñoz I, Escobar-Antón D, Sanz-Gómez TA. The role of Weil and triple Weil osteotomies in the treatment of propulsive metatarsalgia. Foot Ankle Int. 2012 Jun. 33(6):501-6. [Medline].

 
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