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. [9, 13, 14]
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. [13] 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. [15] 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.
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.
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. [15, 16, 17, 18, 19] 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. [16, 20]
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. [9] As a result, there were significantly decreased maximal peak pressures and pressure time intervals during exercise that correlated with better pain and function outcomes.
Return to Play
The timetable for a patient's return to normal athletic function depends upon the nature of the injury and the specific demands of the particular sport. Resolution of the pathologic deficits that are associated with the injury includes restoration of flexibility, strength, aerobic fitness, good nutrition, and proprioception, which are required for each sport activity. Acceleration of physical activity should occur gradually and with stretching, both as a warm-up and warm-down.
Returning to play for most injured athletes exposes them to the same traumatic conditions that resulted in the original injury. Therefore, the individual must be completely healed, free of symptoms, and prepared for resuming the stress and trauma inherent to the sport. Track-and-field athletes should have normal orthokinetics, balance, and 90% of normal baseline strength before returning to play. Proper selection of running and training shoes is critically important to prevent reinjury.
Prevention
The preventive goal should focus on eliminating abnormal friction or pressure. Orthotics, metatarsal pads, and callus care can be used to prevent muscular and stress imbalances. Callus care includes razor debridement and buffing, which enhance tissue elasticity.
Some foot problems may not be caused by disease but by improper footwear. Proper positioning of the foot within the shoe depends upon appropriate fitting, as no 2 feet are the same. Athletes who perform on hard surfaces should make certain that new shoes have adequate cushioning. Rubber heels and soles that absorb shock better than other materials are helpful for athletes who perform repetitive running and jumping on hard surfaces.
