Last evidence check April 2010

The management of interdigital neuralgia and MTP instability are described elsewhere in the Hyperbook.

Where sub-metatarsal pain is felt to be a significant component of the problem simple measures can be tried:

High-heeled shoes increase forefoot peak pressures by about 50% (Hong 2005). That study also showed that much of the increased pressure could be alleviated by a total contact insole - although just wearing a lower-heeled shoe would seem more sensible and appropriate in clinical practice.

There are a wide variety of metatarsal insoles and pads on the market. Some basic science studies, but not all, have shown reductions in sub-metatarsal head pressure with pads and insoles. Mant of these studies were conducted on asymptomatic volunteers ratehr than patients with forefoot pain. Hayda (1994) and Hsu (2005) found that precise positioning of the pad was mportant, although, they did not agree where it should be - Hsu found "just proxmal to the metatarsal head" reduced peak pressure by 28%, while Hayda found that 5mm distal to the head was marginally better. Chang (1994) found that a pad transferred pressure to the metatarsal shafts, although it is not clear where the pad was positioned in that study.

There are not very many clinical studies using symptom improvement as an end-point. Kelly (1998) compared the Viscoped and Langer Blue Line insoles in a randomised trial in 35 patients. Subjetively, 6/18 patients with the Viscoped and 12/15 with the Langer insoles considered themselves improved. The Langer insole group also had twice the improvement in a visual analogue smptom score and three time more plantar pressure reduction (though this was measures through the insole). However, the difference in VAS pain scores was not large. Kang (2006) measured clinical and pressure outcomes in 13 patients with sub-2nd metatarsal pain - not very typical metatarsalgia patients as mean symptom duration was only 18 weeks and mean BMI 23. VAS pain score improved only from 4.9 to 3.9. Improvements in pain score were most closely corelated with pressure-time integral rather than peak pressure. Kang suggested metatarsal pads might be improving symptoms by factors other than simple pressure relief, which opens interesting avenues for research.

In our experience, about 2/3 of patients will be improved by this regime. If non-surgical treatment appears ineffective, it is worth re-evaluating the patient fully before considering surgery, as simple things may have been missed: