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Forefoot Pain – Part I

This article is going to look at pain in the forefoot or the so called “ball” of the
foot. As with the last couple articles, we’ll look at some of the causes for the problem,
how it may manifest itself in regard to symptoms, how you can try to treat it yourself and
some treatments your sports medicine physician may recommend if necessary.
Family doctors frequently send patients to my office with a diagnosis of
“metatarsalgia”. Well the foot guys, like myself, don’t tend to like that diagnosis. Not
because it’s bad, but it doesn’t really describe what the true problem is. The metatarsals
are the long bones in the foot that connect the thicker middle section of the arch to the
toes. The joints where the metatarsal bones connect to the toes is the “ball” of the foot or
the metatarsal-phalangeal joints (MPJ’s). The “algia” part of the word means pain. So
“metatarsalgia” just means pain in the area of the metatarsals. It doesn’t say if the pain
due to any of a number of problems.
We’ll look at some of the more common causes for “metatarsalgia” such as
Morton’s neuromas, stress fractures of the metatarsals and capsulitis/bursitis.
We all have nerves running between our metatarsal bones and then separating out
into branches to give sensation to the adjacent sides of the toes. These nerves can become
irritated and then with time become thickened and enlarged due to either chronic
irritation or trauma. The enlarged portion of nerve is called a neuroma. This can occur
between any two metatarsals, but most commonly occurs between the third and fourth. A
neuroma in this area is called a “Morton’s” neuroma. Why Dr. Morton wanted it named
after him is subject for debate.
Symptoms associated with a neuroma may include sharp or shooting pain,
numbness, pins and needle sensation or, at times, a “popping” or “clicking” sensation.
Many runners describe it as feeling like a sock is wadded up under the toes or ball even
though it isn’t. It is frequently temporarily relieved by removing the shoes and massaging
the area.
Neuromas can be caused, as mentioned earlier, by trauma or chronic irritation.
Chronic irritation can be in the form of wearing shoes that are not wide enough in the
forefoot area causing compression of nerve. The irritation may also occur from abnormal
mechanics of the foot causing excess motion of the metatarsal bones such as in a
overpronated foot.
Self – Treatment
First, be sure all your shoes, not just your running shoes, have adequate
forefoot width. When fitting shoes, be sure to have them fitted at the end of the
day and/or after running. Since the foot naturally swells with activity, if you try it
first thing it may actually become too small after running. Ladies, stay away from
the heels and narrow toed shoes.
Second, try this trick. Go to pharmacy and purchase a “metatarsal pad”.
With the use of the pad, as they say in realty, everything is “location, location, location.” To ensure it is in the correct location, make a mark with lipstick (guys
ask the ladies first before you borrow it) or some other marker just behind the ball
area on the bottom of the foot. Pull out an insole from a running shoe on the
affected side and place it on the floor. Now stand on the insole and the mark
should be transferred from your foot to the insole. Place the wide end of the
metatarsal pad along this line and put the narrow part toward your heel. The pad
should be just behind the ball of the foot and not directly beneath the nerve. The
concept is to spread the metatarsal bones apart and take the pressure off the nerve.
If placed directly under the inflammed portion of the nerve it will only increase
the pain rather than relieve it. You may wish to try metatarsal pads in your other
shoes as well. You can also try to put a piece of cotton between the toes to reduce
the pressure on the neuroma and spread the metatarsal bones as well.
Finally, after your runs or if inflamed by activity, ice the area 15 minutes.
Physician Treatment
Your sports medicine physician may try custom molded orthotics if you
have mild but not complete relief with your home-made insert or if they feel you
have a biomechanical problem.
In addition, two types of injections may be considered. Cortisone
injections attempt to shrink the swelling around the nerve. Meanwhile alcohol
schlerosing injections, that attempt to kill the nerve altogether, may also be
Finally, if conservative treatment options have been exhausted, surgical
excision and removal of the enlarged portion of the nerve may be required.

Stress fractures, as the name infers, are cracks or breaks in the bone due to excess
cumulative stress to bone due to repetitive microtrauma (as in absorbing trauma due to
running many miles on hard surfaces). Over training or wearing inappropriate or worn
out shoes due to inadequate cushioning and support can cause this to occur.
The metatarsal bones are particularly susceptible to stress fractures due to their
size (relatively thin) and the amount of weight and force they receive. The second, third
and fourth metatarsals are particularly in danger of fracture, although it can occur in any
Symptoms associated with a stress fracture include pain and swelling in the area
just behind the ball of the foot. Usually both top and bottom. Usually the pain is localized
to a small area but with compensation can cause pain in other areas as well in later stages.
Standard x-rays may not initially pick up the fracture and may take two weeks or
more to be seen. At this time the body produces extra calcium around the area to bridge
and stabilize the fracture called a bone callus. Sometimes a bone scan or MRI are
required to confirm the fracture, but many times if the doctor feels that is the correct
diagnosis they’ll treat it like a stress fracture for couple weeks, then take follow-up x-rays
to confirm the diagnosis.
A stress fracture is a real fracture and can displace and create other long
term problems if not treated appropriately. The first thing to do is to stop
running. This is typically six to eight weeks to allow healing of the bone. A cast is
not usually required but a surgical shoe may be recommended to further
immobilize the area. The symptoms of a stress fracture, a neuroma and the next to
be discussed capsulitis are similar in nature. So if you are not improving despite
the outlined self-treatment protocols, I suggest seeing your local sports medicine
specialist for an evaluation. In the mean time, swimming, pool running and
cycling can help to maintain sanity and aerobic fitness.
Surrounding the joint connecting the metatarsal bone and the toe bone (metatarsal
phalangeal joint or MPJ), is a fibrous tissue which holds the fluid that lubricates the joint.
This fibrous tissue is called the capsule. If there is too much pressure beneath the MPJ’s,
the capsule becomes inflamed and thus we give it the name of capsulitis. Some
physicians feel that a fluid filled sac or “bursa” develops as well, while others argue this
is not true. Either way, if your doctor says capsulitis or metatarsal bursitis, he’s talking
about the same thing.
This can be caused by the chronic repetitive stress of running. It can also be
related to a bone that is too long or sits too low (plantarflexed). It may also result if you
have a contracted toe or “hammertoe”. This also causes a downward pressure at the MPJ.
Once again, be careful of worn out or inappropriate shoes and big increases in
mileage or speedwork.
Symptoms may include swelling and pain, this time directly beneath the end of
the metatarsal bone at the MPJ rather than behind it as is usually the case in a stress
fracture. You may also have a callous or thickening of the skin in the area. It is usually
painful when you go to push off or “propel” yourself during running and walking.
Self – Treatment
Look back earlier in the article where I discuss the self-treatment of
neuromas. Now make the same modifications to your running shoe insole as
previously with the lipstick and metatarsal pad.
Now that you have the metatarsal pad in the correct location make one
more modification. Take the lipstick or marker back out and feel the tender spot
on the bottom of the foot and make a circle around it. Now step back down on the
insole and you should have a circle on it. Take a pair scissors and cut out a hole
right through the insole. This will allow the pressure to be taken off the inflamed
capsule and allow it to heal. You may need to enlarge or change the location of
the hole if you still feel significant pressure in the area. I would use an insole from
an old pair or running shoes so if you need to try again it won’t be a big deal. You
can also use a U-shaped pad around the area of tenderness and tape or use
adhesive to keep it in place directly to the bottom of the foot. This needs to be replaced daily so it is not a good “long term” solution. Also, be sure to ice the
area for 15-20 minutes two-three times per day and especially after running.
At times over-the-counter anti-inflammatories can be beneficial, such as
ibuprofen or Aleve, but be careful not to use these just before a run as they also
serve as an analgesic and eliminate the pain. You may think this would be good
but pain is our body’s mechanism of letting us know something is wrong and we
can do damage and not know it. Also, if you any history of stomach, liver or heart
dysfunction, it is important to contact a physician before trying these medications.

Physician Treatment
Treatment may include orthotics devices with special accommodations,
similar to your homemade insole to take the pressure off the area. With a custom
orthotic, the correction and accommodation can be much more exact.
The physician may attempt ways to decrease the inflammation in the area
with oral medications or cortisone injections.
Rarely is surgery indicated unless, as mentioned earlier, a hammertoe is
present and causing continuous pressure. I would definitely exhaust conservative
treatment before “going under the knife” for this particular problem.
Forefoot pain can come in a variety of causes and it is important to determine this
to achieve proper treatment. Because you may be dealing with a stress fracture or
creating further aggravation of the neuroma or capsulitis, if you continue to have
symptoms despite conservative treatment, it is important to seek out the advice of your
sports medicine physician.
See you on the roads!

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