Plantar forefoot pain or metatarsalgia is a common ailment that typically develops secondary to high-impact loading under the metatarsal heads, poor gait biomechanics, and/or abnormal foot anatomy (1). Patients typically complain of plantar pain at the second, third, and/or fourth metatarsal heads during weight-bearing activities. Dorsal foot pain is typically absent or mild. Numbness and paresthesias into the toes also may be present and are typically secondary to concomitant intermetatarsal plantar nerve irritation or neuroma.
PEARL: Patients will often demonstrate a low distal transverse plantar arch along with an abnormal plantar callus pattern. Callus should be present at the plantar aspect of the first and fifth metatarsal heads, but is instead often preferentially formed at the second through fourth metatarsal heads in patients with metatarsalgia (Figure A).
A simple, low-cost, and often rapidly effective treatment is the use of metatarsal pads (also referred to as “bars” of “cookies”) which are thought to reduce pain by redistributing plantar forces across the forefoot (2). In our clinical experience, this treatment is highly effective provided appropriate pad placement and size, and placement and adjustments should be made based on the patient’s response when weight-bearing. The provider is encouraged to consider other diagnoses in recalcitrant cases, such as lumbar radiculopathy, stress fracture, or Freiberg's infraction.
PEARL: Improper placement of the pads can result in lack of efficacy or exacerbation of the pain. Proper placement is just behind the metatarsal heads (3) (Figure B). In our clinical experience, patients who complain of worsening pain typically place the pad under the heads themselves or need to decrease the height of the pad they are using. Patients who complain of ineffective pain relief but not exacerbation of pain are typically inappropriately placing the pad under the midfoot or instead need to increase the height of the pad.
1. Espinosa N, Brodsky JW, Maceira E. Metatarsalgia. J. Am. Acad. Orthop. Surg.
2. Holmes GB Jr, Timmerman L. A quantitative assessment of the effect of metatarsal pads on plantar pressures. Foot Ankle
. 1990; 11:141–5.
3. Hsi WL, Kang JH, Lee XX. Optimum position of metatarsal pad in metatarsalgia for pressure relief. Am. J. Phys. Med. Rehabil.