Treatment: Change shoes, consider NSAIDs. Treatment for metatarsalgia begins conservatively, with a change in footwear. High heels or pointy-toed shoes should be avoided, and metatarsal pads (FIGURE 1) can be placed inside the shoes to help off-load the metatarsal head.6 The pads come prefabricated or can be custom made, and are typically placed by physical therapists to ensure proper placement. Orthotics should also be considered, as they can help normalize abnormal foot mechanics that may contribute to metatarsalgia.7,8 (See “A word about runners’ footwear”.9,27-31)
Metatarsalgia is believed to be an inflammatory process, and NSAIDs may be helpful. Contrast baths—alternately submerging the affected foot in a basin of hot (but not scalding) water for 1 to 2 minutes, then immersing it in cold water for 30 to 60 seconds and repeating the process for about 20 minutes once or twice daily—may be helpful. Magnetic insoles are not recommended, as they have been found to be no better than sham insoles.32 Rarely, surgical repair of underlying mechanical abnormalities is indicated for treatment of refractory metatarsalgia.
CASE On examination, Jim F has no swelling, but some hyperkeratosis overlying the second and third metatarsal heads. He has tenderness to palpation at these heads as well as the corresponding metatarsophalangeal joints, and a negative tuning fork test.
You advise Jim that he has metatarsalgia, educate him about the pathophysiology of this condition, and give him a prescription for a nonsteroidal anti-inflammatory drug. You suggest he use contrast baths—and explain how this is done—once or twice a day and refer him to physical therapy for proper placement of metatarsal pads in his shoes, and schedule an appointment for a 6-week follow-up.
Return to running. There is no firm recommendation regarding abstaining from running with metatarsalgia. Advise patients to use pain as a guide in determining the intensity and duration of activity.
FIGURE 1
Treatment for metatarsalgia is conservative
In addition to changing to more comfortable footwear, patients with metatarsalgia can place metatarsal pads like the one shown here in their shoes to ease the metatarsal load.
A word about runners’ footwear
The proper footwear for runners is subject to considerable debate, with arguments supported by contradictory evidence. What is known, however, is that running shoes should:
- be a comfortable fit with cushioning chosen to accommodate arch type
- be replaced after running 300 to 500 miles or every 12 months, whichever comes first27,28
- be purchased from a sporting goods or running store, rather than at a discount retailer. That’s because the shoes sold at discount stores are often older, and breakdown of the protective cushioning is more likely to have occurred prior to purchase.28
The most expensive shoe is not automatically the best choice for the runner, however. Some studies have found no benefit in foot strike pressures with expensive cushioned running shoes compared with low- or medium-cost brands.29 Shoes should be selected based on comfort, although the patient’s arch type should also be considered when selecting running footwear.30
Barefoot running shoes, designed to simulate barefoot running, are also an option. As with cushioned running shoes, evidence regarding barefoot running is contradictory. Some studies suggest that running mechanics are improved with barefoot running or barefoot running shoes; others have had unfavorable or inconsistent results, indicating a need for further research.9,31
Stress fracture: Tenderness and pain of insidious onset
Stress fractures of the foot (SFF)—overuse injuries also known as fatigue fractures—are common in recreational runners. They are thought to result from microtraumas, which alone are not sufficient to break bone but together overwhelm the bone’s natural ability to remodel and recover over time. SFF are characterized by tenderness and pain of insidious onset, and typically occur when more than one training variable (eg, frequency, duration, and intensity) is changed simultaneously. SFF can also result from a change in exercise mechanics, such as foot strike.
Stress fractures can occur in any bone in the foot, but are most common in the metatarsal bones, specifically the mid or distal portion of the second or third metatarsal, or the tarsal navicular.2,33 On examination, the patient will have tenderness to palpation, often well localized. A positive tuning fork test (see page 647) is highly suggestive of a stress fracture.
FAST TRACK
Some studies suggest that barefoot running or barefoot running shoes improve running mechanics; other studies have had unfavorable or inconsistent results.
In female runners, stress fractures may be associated with the female athlete triad—osteoporosis or osteopenia, disordered eating (specifically caloric deficiency and low BMI), and amenorrhea. In addition to the major long-term health problems that may result from even one component of the triad, SFF may be a short-term consequence.34