Forefoot Pain

Forefoot pain can be known as a generic term of metatarsalgia and is often used as a diagnosis which is incorrect. The forefoot is the front of the foot. There are many types of fore foot pain ranging from a Morton’s Neuroma to a stress fracture.

Morton’s Neuroma
Will typically present with a sharp and stabbing pain between the 3rd and 4th metatarsophalangeal joint which can be sporadic in nature and have particular activity that starts the pain off, narrow ill-fitting footwear tends to increase the pain. Numbness can travel to the 3rd and 4th toes. It is possible to get a Neuroma between any of the metatarsophalangeal joints, however it is called a Neuroma only.

Plantar Plate Injury
Is an injury that is under diagnosed in the UK and is often the cause of lesser digit (2nd to 5th toe) deformities such as a hammer toe and aggravation of the joint which could result in synovitis and capsulitis. A plantar plate injury will typically present as a chronic pain, with no history of trauma. Pain is typically located at the metatarsophalangeal joint and can be described as an ache, however there may well be a burning, stabbing or sharp pain. There may be some swelling, however this is not always present. Walking bare foot and excessive dorsi-flexion of the toes will increase pain, as will activities such as walking up and down stairs, jumping and running. Wearing a stiff soled shoe will reduce the pain along with rest. The 2nd toe is most commonly affected, however it is possible for any toe to be affected.

Stress Fractures
Is a stress/overuse injury to a bone and is common in long distance runners, it is also more common in females. A stress fracture has no particular history of trauma. It will present with it a dull ache and pain can be present at night, there will be tenderness on palpation at the stress fracture site. There may be some swelling. There will be pain on running and possibly walking, which will continue for days after sport.

Is irritation and inflammation of the synovial membrane, which helps with lubrication of the metatarsophalangeal joint. The pain is usually due to overloading of the joint and can be described as an ache or sharp pain. It is aggravated by barefoot walking and any activity that puts excessive pressure and stress through the joint.

Hallux Abducto Valgus (Bunion)
Is a very common problem and is often pain free and requires no treatment, this affects the 1st metatarsophalangeal joint and is where the Hallux moves medially and rotates and can sometimes ride over the 2nd toe. It can be a congenital condition, however can be related to wearing high heeled, narrow toe shoes.

It can be treated conservatively to help reduce pain, however it will not slow down or stop the progression of the deformity. Unfortunately there is no evidence to back up the use of night splints to straighten the toe. The only way to correct the deformity is surgery however this is not for everyone and should be your last treatment option.

Muscle / Tendon Strain
There are multiple muscles within the forefoot, of which some are intrinsic (so start and end within the foot) and the others are extrinsic (come from the leg and end in the foot), which can be overused resulting in an overuse strain. This tends to present with a burning pain and will follow the path of the muscle affected and will be aggravated by activation of the muscle.

Initial treatment is the same as all new tendon injuries:

Protection – protect the injured tendon by not putting weight through it
Load – old thinking was to rest, however latest research suggests off loading the affected area is more effective than complete rest
Ice -10 minute on and 10 minute off cycles (never put bare ice on your skin)
Compression – compression on the injured area, something like a tube grip can help
Elevation – this will help to reduce the swelling

Then seek medical advice as soon as possible

Turf Toe
Is an injury of the 1st metatarsophalangeal joint capsule and the surrounding ligaments. This can range from a small tear of the joint capsule to a full tear and even dislocation of the 1st metatarsophalangeal joint and is graded 1-3. The injury is usually from excessive dorsi-flexion of the 1st metatarsophalangeal joint and will be painful on dorsi-flexion of the joint. Palpation of the sesamoids which are 2 small bones located under the 1st metatarsophalangeal joint will usually not be painful. Dorsi-flexing the 1st metatarsophalangeal joint to the end range of motion tends to be painful. So any sports where excessive dorsi-flexion of the 1st metatarsophalangeal joint occurs leaves you prone to this, including dancing, football, sprinting and the list could go on.

Is aggravation and possible swelling of the 1st metatarsophalangeal joint capsule and 1 or both of the sesamoid bones. Unlike a turf toe injury dorsi-flexion of the 1st metatarsophalangeal joint is generally pain free although direct palpation of the sesamoids is painful. The pain can be described as burning. There are many factors that can result in sesamoiditis ranging from biomechanical abnormalities to poor footwear and particular sports where excessive force is applied to the 1st metatarsophalangeal joint such as running, racquet and jumping sports.

To sum up, there are many causes of forefoot pain with a few listed above. It is important to remember that if there is pain it is the body’s way of saying there is something wrong, so stop and get it checked out.