What is it?
Forefoot pain or metatarsalgia is pain in the region from the ball of the foot forward to the toes. This can involve the bones, joints, skin and nerves of the foot. The most common forefoot problems are metatarso-phalangeal joint pain, metatarsal stress fracture, neuroma and ligament tears.
How did I get it?
The causes of forefoot pain are multifactorial and can be due to trauma, poor footwear, excessive pronation, long 2nd metatarsal length and poor training techniques. The nerves, bones and ligaments if placed under excessive pressure for a long period may become irritated or fail, leaving pain and swelling. Poor footwear for example can squash the foot compressing the nerves that run between the bones or in the case of high heels place the joint at an extended position thereby stretching the ligaments under the foot.
What does it feel like?
Pain is felt when weight is transferred onto the ball of the foot. You may feel pain in the top or bottom of the foot depending on the diagnosis. Neuroma pain is often felt when wearing tight shoes upon forefoot loading and can frequently be described as burning or shooting pain sometimes into the toes. Stretching of the ligaments under the foot or arthritic conditions often feel as if there is a stone under the ball of the foot and will be aggravated by walking alone. Stress fractures of the metatarsals will provoke pain on forefoot weight bearing and commonly swelling will be present on the top of the foot.
How is it diagnosed?
Clinical signs and a history of the condition generally lead to a provisional diagnosis. Palpation of the most pain provoking area is helpful in distinguishing between neuroma, metatarsal head pain or stress fracture for example. Radiological investigations are useful to support a diagnosis. X-rays may give an indication of Freiberg’s disease or arthritis of the metatarso-phalangeal joints. Ultrasound is good for diagnosing neuroma. CT, MRI and Bone scan detect stress fracture. MRI is generally the best radiological investigation to determine ligament and plantar plate tears.
How do I fix it?
It depends on the diagnosis, Neuroma can be relieved from massage of the foot or a small dome under the metatarsals to relieve pressure on the nerve. Metatarso-phalangeal joint pain and Freiberg’s disease can be relieved by deflective padding in the shoes. Conditions related to excessive pronation will benefit from a supportive orthotic device. Rest and a stiff shoe or boot protects the metatarsal if fractured and provides sufficient support for healing.
Will I need surgery?
On occasion, damage to the nerve or the ligaments will be beyond conservative measures and will need to be either resected or repaired. Severe arthritis of the joint may require arthrodesis (fusion) to relieve pain. Metatarsal stress fractures may require stabilisation if non union occurs.
How do I stop it coming back?
Improving the strength of the foot can in some cases provide protection for the joints and nerves if the symptoms are mild and action is taken relatively early in the disease process. Modification of activity and sound graduated training techniques assist in keeping stress fracture form reoccurring. Deflective domes or padding will provide relief from the condition for as long as the device is worn and for a short time after but usually permanent modification of either footwear or orthotic support is required to maintain pain free function in the longer term.