Forefoot pain, also referred to as metatarsalgia, is a type of pain that occurs in the ball of the foot (around the tip of the metatarsal bones). Generally, forefoot pain is associated with aging. Individuals with metatarsalgia experience pain of varied intensity and discomfort and find difficulty in activities like walking, running, playing, and several others.
The forefoot is the anterior portion of the foot formed by five metatarsals, fourteen phalange bones, and soft tissues. This complicated structure makes pain in this region more complex to diagnose.
Patients with metatarsalgia usually experience a sharp, aching or burning pain in the ball of their feet. The pain usually worsens during standing, walking, running or when the affected foot is flexed. Some may have numbness or tingling sensation in their toes. In most cases, the skin overlying the affected area becomes thick and hard, rough-textured, along with either complete/partial loss of sensation. This is often referred to as hyperkeratosis or callosity. Some people may notice changes in the shape of the feet or toes depending upon the cause of pain.
There are many causes of forefoot pain which requires careful judgment to conclude the diagnosis and the treatment plan. Some common causes include:
- Overweight: Excess body weight tends to put more pressure on the metatarsal bones and cause pain.
- Overuse: Pain from overuse is seen in sports people (athletes and runners). This condition exhibits from inflammation to fracture of metatarsal bones.
- Shape of the foot: People with hammer toes (toe is bent at the middle joint) and bunion (a painful bump at the base of big toe) are also more prone to metatarsalgia.
- Big toe arthritis: Arthritis is an inflammation of the cartilage and lining of the bone joints. Osteoarthritis is the most common type which causes excessive trauma and wearing away of the cartilage in the joints of the foot.
- Gout: It is a very common, painful form of arthritis which causes swelling, redness and stiffness of the joints. It usually affects the big toe and leads to severe pain.
- Stress fractures: Stress fractures of the foot which may occur in athletes or walkers can result in pain.
- Morton’s neuroma: Morton's neuroma is a painful condition affecting one of the nerves between the toes (interdigital nerve). Morton’s neuroma refers to the thickening of the nerve tissue between your third and fourth toes due to scar tissue formation.
- Sesamoiditis: This condition is an inflammation of the sesamoid bones. These are the small, round bones embedded within the tendons leading to the big toe. The main source for sesamoiditis is consistent pressure and tension applied over the foot. It is common in people who participate in potentially high intensity sports (runners) or jarring (jogging or boxing) activities.
- Pes cavus: This is a condition of highly-arched foot shape. The gap between the sole of a foot and the floor is higher than normal in case of Pes cavus. This place excessive pressure on the balls of the feet.
- Loss of fat pad under the ball of the foot: With aging, the protective fat pad under the ball of the foot tends to thin out with overuse and may increase the susceptibility to pain in the ball of the foot.
- Poorly-fitting shoes: Wearing tight, narrowed or high-heeled shoes can put constant strain on the metatarsal bones causing forefoot pain.
- Achilles Contracture: Tight calf muscles cause significant force to transmit to the forefoot with each stride when walking. This is worse walking up inclines such as incline treadmills. Improving calf flexibility, shortening stride length and activity modification are beneficial.
A diagnosis must be cautiously made using a comprehensive history of the condition and direct questioning. A skilled knowledge of the forefoot anatomy allows a detailed examination and identification of an injured structure. Your surgeon may order X-rays or MRI of affected foot or ankle to confirm the diagnosis.
Early treatment is critical to relieve pain. Mild to moderate cases of forefoot pain can be managed by conservative treatment. Severe cases of neuroma and bunions may require surgery. The following conservative measures help to ease the pain of metatarsalgia:
- Medications: Your doctor may prescribe pain medications to reduce pain and inflammation.
- Resting your feet and applying ice packs wrapped in a towel over the sole of the affected foot can reduce pain and swelling
- Adaptation to a weight loss dietary regimen, if you are overweight
- Activity modification: Avoid vigorous activities that exert excessive stress on bones and tendons of the feet (avoid incline treadmill). Begin specific exercises to help strengthen the foot muscles. Calf stretching 1 minute 10 times per day will help decrease the forefoot load with walking.
- Use customized orthotics or insoles to support and protect the foot. It also helps cut back the pressure placed on the metatarsal bones.
- Extra-fit toe pads, softening or gel pads can be placed inside your shoes to help cushion the shock while walking. Simple footwear modifications include using low-heeled shoes and broad toe box shoes with silicone gel pads to minimize discomfort at the tip of the toes. Stiffer soled closed back shoes or stiff sandals with a strap on the back transmit less loading through the forefoot.
- Immobilization using a cast, splint, brace, walking boot, or other device to prevent movement of the feet and assist in faster healing of the ruptured tendon.
Surgery is considered as the last option if in case the symptoms fail to resolve with the conservative treatments and depends on the age and activity level of the individual, extent of damage to the tendon or bone or nerve, and other factors.
Surgical treatment involves realigning or reshaping the metatarsal bones.