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INTRODUCTION
Norman Espinosa, MD
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Systemic conditions that can lead to secondary metatarsalgia include trauma,28 inflammatory arthropathy, gout,6,20
arthritides and instability of the MTP joints,13,50 Mortons
neuroma,11,36 tarsal tunnel syndrome48 and Freibergs infraction.13 Not all of these conditions directly affect the
metatarsal, and instead indirectly overload the forefoot.
Trauma may shorten, elevate or plantarflex a metatarsal fracture and cause pain, but an associated dislocation of the
MTP joint or periarticular soft tissue injury may contribute
to pain. The effect of metabolic disorders such as gout or
rheumatoid arthritis may cause the MTP joint to hyperextend, resulting in a shift of plantar pressure to the metatarsal
heads. This shift of plantar pressure combined with distal
migration of the plantar fat pad may lead to pain. Atrophy
of the fat pad secondary to a systemic condition may also
cause central metatarsalgia. The same forces that overload the
metatarsal head and surrounding soft-tissues can also injure
the plantar digital nerve and result in pain similar to mechanical metatarsalgia.
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Iatrogenic metatarsalgia
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ESPINOSA ET AL.
TREATMENT
Not much scientific literature exists to confirm the effectiveness of conservative treatment for the treatment of
central metatarsalgia. Nevertheless, such measures often
meet with success and have the additional benefit of not
compromising future treatment. Conservative treatment may
include stretching exercises, shoe modification, shaving of
the callosity, rest, use of metatarsal pads and molded insoles,
corticosteroid injections, and anti-inflammatory medications.
Stretching exercises
Stretching exercises in patients suffering from gastrocnemius or gastrocnemius-soleus tightness are intended to
lengthen the triceps surae muscles and thereby decrease
the pressure at the forefoot. These exercises are best
performed by the patient after education by a physical
therapist.12 Gajdosic and coworkers demonstrated that a 6week stretching program increased the maximal ankle dorsiflexion angle and length extensibility, as well as the passive
resistive properties throughout the full stretch range of
motion. They further demonstrated that stretching enhances
the dynamic passive length and passive resistive properties (Level I study).16 However, this study did not examine
patients with central metatarsalgia. Thus insufficient data
exists to render a proper recommendation for its use in central
metatarsalgia (Grade I recommendation).
Shoe modifications and padding
This padding serves to distribute force away from a prominent metatarsal head. Experimental studies support their
effect in decreasing pressure underneath the metatarsal
heads.7,23 Conservative treatment may be successful if
capsulitis and instability are diagnosed early. In a prospective study performed by Kang et al., 13 patients (18 feet)
with secondary metatarsalgia were investigated regarding the
use of metatarsal pads. The group found that the successful
decline in the pressure time integral and maximum peak pressures under the second metatarsal head after metatarsal pad
application was correlated to subjective pain improvement
(Level II evidence). Based on the evidence provided from
these Level III and IV studies, a Grade B recommendation applies to the use of shoe modification and padding for
central metatarsalgia.
Shaving of callosities
If non-operative treatment is unsuccessful, surgical treatment may be warranted. The primary goal of surgery is to
restore a normal distribution of pressure within the forefoot.
As a rule, it is important to restore a harmonic Maestro
curve,37 to restore the correct metatarsal slope, and to provide
adequate ground contact for the metatarsal heads. It is also
important to understand the effect of metatarsal osteotomies
on forefoot biomechanics to avoid possible complications.
A variety of surgical treatments for metatarsalgia have been
described. They include plantar condylectomy, distal oblique
metatarsal osteotomy, diaphysieal metatarsal osteotomy,
flexor to extensor transfer for the management of lesser MTP
joint instability, and metatarsal head resection.
Plantar condylectomy
Plantar condylectomy of the metatarsal is rarely indicated for central metatarsalgia. It may be considered for
the treatment of well-localized IPKs. A major disadvantage of a plantar condylectomy is the possibility of destabilizing the plantar plate. The loss of capsuloligamentous
restraint may lead to iatrogenic instability and arthritis of
the MTP joint. Condylectomy is not indicated for larger
IPKs: a distal metatarsal osteotomy may be the more logical
approach.9,51 Conklin performed a retrospective review of
86 basal hemiphalangectomies in 52 patients (Level IV
evidence).41 In his series 60% of the patients had total relief
of pain; however, 29% were classified as dissatisfied. An
extensor tenotomy increased the satisfaction rate and was
found to decrease the radiographic sagittal angulation of the
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Hofstatter et al.22 performed a prospective study and evaluated the short- to long-term results of the Weil osteotomy for
the treatment of metatarsalgia with subluxated or dislocated
lesser MTP joints in 25 feet (Level II evidence). Good to
excellent results were achieved in 88% of cases at a followup
of 7 years. The AOFAS score significantly improved from
48 to 83. The authors found that the procedure significantly
reduced pain, diminished isolated plantar callus formation
and increased walking capacity. Recurrent dislocation of the
metatarsophalangeal joint was seen in 12% of cases. The
authors concluded that although floating toes and restricted
movement of the metatarsophalangeal joint may occur, the
Weil osteotomy was safe and effective. Retrospective reviews
by Beech et al.,3 Vandeputte,66 and Trnka et al. (Level IV
evidence)59 also identified good to excellent results in most
patients undergoing a Weil osteotomy.
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The optimal treatment of metatarsalgia remains controversial. Principles that underlie the diagnosis and management
of metatarsalgia appear to include:
1. Concentrated repetitive loading over a prominent
metatarsal head during the second and third-rocker
stages of gait leads to chronic irritation to skin, softtissues, MTP synovium, and/or digital nerves producing
localized forefoot pain characteristic of metatarsalgia.
2. Metatarsalgia can be considered primary or secondary.
Primary metatarsalgia results from metatarsal head
overload due to intrinsic causes such as a long
metatarsal, a plantarflexed metatarsal, or a dorsiflexed first ray leading to second metatarsal overload.
Secondary metatarsalgia results from extrinsic causes
such as a metatarsal fracture, malunion, Freibergs
infraction, and the sequelae of metabolic diseases such
as rheumatoid arthritis and gout.
3. Metatarsalgia is often associated with subluxed and
dislocated lesser MTP joints. These deformities lead to
distal migration of the plantar fat pad and predispose to
increased loading over the prominent metatarsal head.
4. Many patients with metatarsalgia can be treated nonoperatively with good success. Non-operative treatment
may include: comfortable shoes with a wide toe box,
a comfortable insert with a metatarsal pad or bar to
disperse the force more widely over the forefoot, corticosteroid injections, anti-inflammatory and/or regular
shaving of a prominent callus.
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