Diagnosis of Common Causes of Forefoot Pain
Forefoot pain can be debilitating and there are many condition which can be the cause of forefoot pain, these include, but are not limited to;
Mortons neuroma, Hammer toes, plantar plate tearing, capsulitis, sesamoiditis, stress fracture, intermetatarsal bursitis and metatarsalgia. Each of these conditions will present differently in a clinical situation. Usually there are many contributing factors to each condition. Your podiatrist will be able to identify which of these conditions may be causing your forefoot pain and guide you on a treatment plan to decrease your pain and get you back to activity.
A morton’s neuroma is a common cause of forefoot pain. A morton’s neuroma is irritation or inflammation of the plantar nerves that run down to the toes. Usually the neuroma will present between the 2nd and 3rd or 4th and 5th toes.
A forefoot neuroma is usually caused by compression of the metatarsal heads, this can be due to wearing narrow or heeled shoes or there may be a biomechanical cause.
The common symptoms for this condition include; burning, numbness and tingling sensations that can travel into the toes, pain when the toes are compressed (usually in footwear) and sometimes the feeling that there is a pebble under the foot when walking.
Your Podiatrist will do a number of assessments on your foot to determine whether you have a neuroma, usually there is no radiology required to diagnose this condition.
Once your podiatrist has a diagnosis, they will likely issue you with a metatarsal dome which is strategically placed on your innersole to spread out your metatarsal bones and relieve the compressed nerve.
A hammer toe or claw toe is a deformity of the digits, usually caused by tension in the tendons of the toes. The tight tendon causes the digit to retract and therefore creates areas of pressure that can become quite painful. Hammer toes or claw toes are highly prevalent and can be managed.
Hammer toes are usually caused by; poorly fitting footwear, trauma to the toes or an imbalance of the muscles in the toes.
Although this deformity usually occurs in the 2nd and 3rd toes, it can affect all the lesser toes.
Symptoms associated with hammer toes may include; rigidity of the toes, pain in the joints and callus and corns on the prominent areas of the toes.
How can Hammer toes be treated? Usually conservative treatments will be trialed first, these include; strengthening exercises, wider footwear and possibly orthotics. If the conservative treatments are unsuccessful your podiatrist may refer you for surgery.
Plantar plate disruption or tear
What is a plantar plate? The plantar plate is a ligament that attaches to the metatarsal heads and keeps them aligned. If too much load is placed on the plantar plate, it may tear.The tear usually occurs to the second digit. A plantar plate tear is usually caused by; over pronation, increase in activity or activities that place a lot of load through the forefoot, having bunions and having a long second digit.
The symptoms of a plantar plate tear may include; pain in the second digit on the bottom of the foot, possible swelling in the painful area, numbness in the webbed space and the second toe may stick up.
Diagnosis of a plantar plate tear will include assessments to reproduce the pain, as well as a thorough history to determine the cause of the tear.
Treatment may include strapping of the toe and offloading of the metatarsal head with felt padding. Your Podiatrist may also encourage you to rest from physical activity and take anti-inflammatory medications to address the pain. Usually, if the treatment plan is followed closely the plantar plate will heal in 6 to 8 weeks.
Capsulitis is a condition in which the ligaments of the toe joints become inflamed and sore. Often, like plantar plate tears, the second digit is affected. Usually capsulitis is caused by overload of the second toe joint.
Symptoms of capsulitis include; pain and swelling specific to the second toe joint, difficulty wearing shoes, pain when walking barefoot and the second toe may sit up higher than the other toes.
Diagnosis of capsulitis will include a thorough examination and history of the pain. Often capsulitis is caused by biomechanical factors, which place a higher load on the second metatarsal joint.
Treatment of the condition will require; a reduction in physical activity, medication to relieve pain and inflammation, icing of the painful area, strapping and padding of the toe, orthotic therapy to offload the toe and alter mechanics and a change in footwear.
Do I need surgery? Sometimes if the second toe begins moving toward the big toe surgery may be needed to correct the digit.
The sesamoids are tiny bones which sit underneath the first toe joint. When the tendons which attach to them become inflamed, you are said to have the condition sesamoiditis. Usually sesamoiditis is caused by overuse.
The symptoms are usually a dull ache underneath the big toe joint. The pain usually comes and goes and can be exacerbated by different footwear and activity.
Diagnosis of sesamoiditis usually involves a thorough examination of the joint and toe, as well as the foot posture and gait. Sometimes your Podiatrist may recommend imaging such as ultrasound and X-ray to determine your diagnosis.
How can we treat sesamoiditis? Once your Podiatrist has diagnosed the condition it may be treated with the following conservative methods;
Padding, strapping or taping to offload the first toe joint, An immobilization boot to reduce the amount of load going through the big toe joint and therefore give it time to heal, Non-steroidal anti-inflammatory drugs to reduce inflammation and pain, Orthotics to change the plantar pressures going through the foot and sometimes steroid injections are utilized to reduce pain levels. If all of these conservative treatments fail, your Podiatrist may refer you to a surgeon for surgical treatment.
Stress fractures are a common cause of forefoot pain. Stress fractures are caused by repetitive force going through the bones over time, they usually affect the bones in the feet that take the highest load. Stress fractures can be really difficult to heal if the foot is not properly rested.
What are the symptoms of a stress fracture? Sometimes you may experience bruising and swelling. You will experience pain that improves with rest and worsens with activity. Usually this pain gets worse over time.
Who is most at risk of acquiring a stress fracture?
- Women are more at risk than men
- People who play sports such as basketball, netball, tennis, dance or gymnastics.
- People who suddenly increase the intensity, duration or frequency of exercise.
- People who are undernourished or have vitamin and mineral deficiencies are at a greater risk of developing stress fractures
- Anyone wearing footwear than is too worn out
Stress fractures can be diagnosed in the clinic with a thorough history and examination of the foot, but often they are identified through radiology such as ultrasound and X-ray.
Treatment usually involves conservative measures first, these include;
- RICE – Rest, Ice, compression and elevation. Each of these methods encourage a reduction in pain and inflammation.
- Footwear modifications to offload the painful area – This may include; A stiff soled shoe or specific modifications made by your Podiatrist.
- An immobilization boot to offload the fractured bone and encourage healing
- Surgery may be recommended by your Podiatrist if conservative treatments do not resolve the pain.
An intermetatarsal bursitis is inflammation of the small fluid sac that lies beneath the metatarsal bones. The sac can become inflamed when extra load is placed on the metatarsal heads, this can occur due to tight fitting footwear, digital deformities, increase in physical activity and pressure due to foot posture.
What are the symptoms of intermetatarsal bursitis? If you have an intermetatarsal bursitis, you will likely experience pain, swelling and tenderness when pushing off during gait.
Diagnosis of intermetatarsal bursitis will include a thorough biomechanical examination. Sometimes imaging may be used – Ultrasound is the preferred method. Treatment of intermetatarsal bursitis is similar to that of a morton’s neuroma, being the application of a metatarsal dome to your innersole to splay the joints and provide relief from the inflammation.
Metatarsalgia is described as inflammation in the ball of the foot – it can present clinically very similar to some of the other conditions already mentioned.
Metatarsalgia is usually caused by a multitude of contributing factors, these include; foot posture, walking/running gait, hypermobile joints, shoes that are worn out or don’t fit well, sudden weight gain or being overweight, bunions and torn ligaments.
The symptoms of metatarsalgia include pain, usually a dull ache or a burning sensation, Numbness and tingling in the foot and increased pain when walking or running, especially barefoot.
How is metatarsalgia diagnosed? Usually your podiatrist will conduct a thorough examination or your foot posture and gait as well as a thorough history of your pain. As with all other forefoot conditions, radiology is often used to diagnose metatarsalgia. Metatarsalgia can be treated with rest, change in footwear, met domes and sometimes surgery if all else fails.
Need to see a Podiatrist for forefoot pain?
If you are experiencing forefoot pain, it is recommended that you seek advice from your Podiatrist as soon as possible. Call us on 03 9553 0044 to book your appointment.