I thought the topic of forefoot pain would be a nice one, as I have seen a few tweets with runners complaining of pain in the ball of the foot. I shall split the blog into 2 parts as it is a lengthy topic. As always if you are in pain, seek medical advice in person with your Local GP, Podiatrist or Physio, so a formal diagnosis can be made and you can formulate a treatment plan together.
Lets get started, I often hear people say ‘I have been diagnosed with metatarsalgia’, unfortunately this is not a diagnosis, it’s just a term to describe pain in the ball of the foot, it gives no indication of what is causing the pain and what is the treatment. There are many types of forefoot pain ranging from a Morton’s Neuroma to a stress fracture to even the rarity of cancer. I will go through the most common types of forefoot pain I see in clinic. I shall break down each diagnosis into presentation and treatments.
A Morton’s Neuroma is irritated/thickened nerve between the 3rd and 4th metatarsals, just behind the metatarsal phalangeal joint (MTPJ). It is worth noting that you can get other inter-metatarsal Neuromas, however being technical it is not called Morton’s neuroma. It is possible to have a Neuroma which is a symptomatic.
This will typically present with a sharp and stabbing pain between the 3rd and 4th MTPJS, (toes joints) the pain may track into the 3rd and 4th toes with associated numbness. The pain can be sporadic and nature, offered described as like a light bulb, on or off, as the pain can come and go quickly. Trauma is not necessary. Narrow footwear and trainers can increase the pain, along with anything that increases the load through the lesser MTPJs, this can include running or it could be mechanical natured, for example an hallux adducto-valgus (bunion) can increase loading through the lesser MTPJs and thus aggravate any neuroma pain.
Treatments can in as simple as change in footwear, or making sure that footwear fits, I often see runners, who use footwear that is too small. See my other blog on the myths around footwear, for some advice, click here to read.
Other treatments include the use of orthoses, these may include the use of a metatarsal dome to help off load the forefoot.
Steroid injections can be useful and are commonly used, however the effects of the injection is not always long term. It would be advisable to have the neuroma confirmed with imaging in the form of an Ultrasound scan or MRI. X-ray is not sensitive to a neuroma, however can help rule out some bony pathologies.
Other treatments include cryo- ablation (freezing the nerve) or the nerve can be surgically removed, this tends to be quite successful, however is always a last resort.
Hallux Abducto Valgus (Bunion)
Is a very common problem and is often pain free and requires no treatment. It is a misconception that the bunion is the lump you see on the inside of the 1st MTPJ, this is normally the result of the bunion formation with a possible associated bursar (fluid-filled sac) a bunion actually affects the first metatarsal and the hallux big toe where the first metatarsal deviates medially and the hallux deviates laterally.
As we already know, many bunions are pain free, and just because you have a bunion doesn’t mean it will always become painful. Sometimes bunions are painful due to your footwear; a narrow fitting shoe may cause irritation by rubbing on the bunion itself, though sometimes they can be painful regardless of footwear for activity, it is normally described as an ache. Bunions can be hereditary or they can be aggravated by external factors like footwear choice, for example narrow high heeled shoes.
Unfortunately there is no way of saying at what point the bunion will become painful and there is no correlation between the size of the bunion and pain. Bunions do tend to be progressive, however the rate of progression is different everyone.
There are conserved treatment options for bunions, however these will only be looking at pain management, there will not reduce the size of the bunion itself.
Conservative treatment includes footwear advice, wider fitting shoes, the use of orthoses to help with foot function and off load the force through the bunion. Anecdotally some people find taping the bunion in a straighter position can be beneficial especially when running, though this is very much horses for courses, as I have found just as many people who tolerate it and find it beneficial, to those who find it not helpful. I shall imagine a lot of you would have heard the use of night splints, however there is no evidence to back the use of night splints up to help straighten the toe.
As mentioned earlier the only way to correct the deformity is via surgery, and again this is a last resort and you will need to have a discussion with your local Orthopaedic Surgeon or Podiatric Surgeon to discuss if surgery is correct for you.
Is irritation and inflammation of the joint capsule and the synovial membrane, commonly seen within the MTPJs. When the MTPJs are exposed to excessive force we can sometimes get an increased production of synovial fluid, resulting in swelling of the MTPJ. Synovial fluid occurs naturally within the joints and helps in lubricating the joints.
The presentation is normally an ache, however they can be some sharp tendencies if the joint is now compressing on the nerve. Like with the Morton’s neuroma activities that increase the load through the lesser MTPJs can aggravate the joint capsule, along with activities that constantly dorsi flexed (bent upwards) the toes. It is also important to keep in mind any possible mechanically natured factors within the foot, such as, bunions or long metatarsals etc. there may well be some swelling around the affected MTPJ and mild redness.
Treatments are very similar to those of a Morton’s neuroma, making sure that the footwear fits well and is suitable, you may look at orthoses to help off load the affected area with the use of a metatarsal dome. Taping the toe to help reduce the amount of dorsi flexion and thus offloading the joint can be used.
The use of a steroid injection is commonly used. Surgery is not common for this problem, unless there is an overriding mechanical reason as to why the pain is present which needs to be corrected surgically. It is worth noting that if there is a mechanical cause for the pain whilst they steroid injection may help relieve the pain unless you look at the dressing the initial cause the problem is likely to return.
In part 2 Ishall go through some more of the common forefoot injuries I see in clinic.
As always if you are experiencing pain, my advice is seek professional medical advice. Happy running!
You can see the article here: http://www.ukrunchat.co.uk/metatarsalgia-part-1/