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Forefoot Disorders

Below are the most common causes of forefoot disorders we see and successfully treat.

Metatarsalgia is a medical term for pain in the ball of your foot. The metatarsals are the long bones in the forefoot that connect to the toes. The pain can have many causes and so show itself in many ways. The foot is a complex mix of muscles, tendons, nerves, blood vessels and bones, and metatarsalgia could be the result of damage to any of these. The location and description of the pain can greatly inform the podiatrist of its possible cause. 

Nerve entrapment, called Morton’s Neuroma, occurs when the space around the nerve narrows, trapping it and causing either a sharp burning pain, pins and needles, or even numbness, all of which can travel along the foot. The pain is between the third and fourth metatarsals. In addition to the pain there may be swelling in the area. The pain worsens when standing or engaged in weightbearing activities and is relieved when the foot is rested. Treatment will involve breaking the pain cycle either through oral medication or a corticosteroid injection. Conservative treatment may include modifying footwear, perhaps with orthoses to redistribute the pressure on the affected area. If conservative treatment is unsuccessful surgery may be indicated to resolve the entrapment.

Capsulitis occurs when the capsule around the joint becomes inflamed, causing pain and swelling. There may also be redness at the affected area. It generally affects the second metatarsal, although it can affect any of them. The pain has a gradual onset. It is worsened by long periods of standing or weightbearing activity and it feels like you are walking on a pebble. Capsulitis is caused by an overload to the joint. However, there are many causes for that overload. It can be functional, for example a long second or short fourth metatarsal, or a bunion on the first metatarsal which forces more pressure onto the second. Or it can also be caused by systemic diseases such as rheumatoid arthritis, diabetes, or lupus. In addition, it can have a synovial cause, when tight calf muscles overload the tendons and ligaments. It can also be caused by footwear. Therefore, the resolution of the condition will depend on its cause. Conservative treatment will involve breaking the pain cycle with oral medication and resting the affected joint. In addition, strapping the foot may help to relieve the symptoms, and orthoses and exercises could also be appropriate. In certain cases, surgery may be the most suitable treatment. 

Frieberg’s infraction is a disease that causes the degeneration of the head of the second metatarsal. This is generally an inherited condition which more frequently affects young women, and one that almost always leads to osteoarthritis. Therefore, it is important to seek treatment as soon as possible. Symptoms include pain, especially when engaged in weightbearing activities, and swelling and stiffness of the joint causing a limp. There is usually a lump of the top of the foot just below the second toe. Treatment depends on the severity of the condition but will involve breaking the pain cycle. It is also important to rest the joint, which for sporting enthusiasts, means a modification to non-weightbearing training. It might be necessary to wear an airboot or include the use of crutches to offload the joint. In addition, orthoses may be indicated to accommodate the joint by redistributing the pressure. In some cases, surgery might be indicated. 

Sesamoiditis is inflammation of the one or both sesamoid bones at the first metatarsal of the big toe which results in pain in the ball of the foot. The onset of the pain will be gradual, the toe may have a throbbing ache and the ball of the foot will hurt when walking, trying to bend the toe and when wearing certain footwear. There is usually tenderness and swelling around the joint and the range of motion of the joint will be limited. Treatment involves breaking the pain cycle and reducing the inflammation, initially with oral medication, however in severe cases corticosteroid injections may be indicated. Resting the joint is also crucial in this process, while orthoses may be indicated to resolve the cause of the sesamoiditis

Stress fractures can occur in sesamoid bones or any of the metatarsals (called a March fracture if affecting the second to fourth metatarsals). Stress fractures are caused by high-level trauma, such as an impact or a fall, or by low-level trauma resulting from intense exercise. Symptoms will include instant pain, swelling and tenderness and a temperature increase at the affect part of the ball of the foot. There may also be swelling and bruising on the top of the foot. A stress fracture will not show up on an x-ray for at least the first 3 weeks after it occurs. Treatment will include off-loading the joint, which may involve the use of an air-boot, cast or crutches and rest. Anti-inflammatory medication in the early stages will also help to break the pain cycle and reduce the swelling.

Plantar plate rupture generally affects the second metatarsal. It is caused by inflammation of the plantar plate, leading it to tear. It produces a persistent throbbing pain and may feel almost like walking on a bruise. There may also be swelling in the area. In some cases, the toe may have become misaligned. Treatment will initially involve breaking the pain cycle and relieving the pressure of the joint either through rest, taping or an airboot. Then when the inflammation has receded, customised orthoses may be required to redistribute the pressure on the affected area. 

Fatty pad atrophy is often caused by certain diseases, for example osteoarthritis, rheumatoid arthritis, or diabetes mellitus. It can affect any or all of the metatarsals. Over time the fatty pads which protect the metatarsals are displaced or dispersed. As a result, it may feel like walking on pebbles and callus or corns might form. Treatment may involve the removal of the callus and corns and orthoses to redistribute the pressure on the affected areas.

Several skin conditions may also cause metatarsalgia, for example, verrucae, callus and corns. Verrucae are viruses. They have different appearances and cause varying degrees of pain. They can affect any part of the foot but can be most problematic when they arise on the metatarsals. There are many treatments and the podiatrist will discuss the most appropriate. Callus and corns have many biomechanical causes which result in increased pressure and friction at the metatarsals where the pain will arise gradually and increase in intensity. There are several conservative treatments, such as modifying footwear or using customed orthoses, but generally the callus and corns need to be removed to allow for pain-free walking.