Common Conditions of the Forefoot
Forefoot pain is common amongst adults and a frequent consultation for GPs and Specialists. The objective of this article is to review the common causes of forefoot pain in the adult, a description of important conditions, how to reach a diagnosis and possible treatments.
The forefoot is the most common location for foot pain in adults. It contains a complex network of bones, ligaments, tendons, muscles, nerves and blood vessels. Common problems in the forefoot include bunions, hammer toes, Morton’s neuromas and bunionettes. Forefoot pain causes disabling symptoms in one third of individuals older than 70 years of age.
Certain activities and occupations place significant stress on the feet. Those who spend a great deal of their time on their feet, have a greater chance of developing forefoot pain; particularly if they wear narrow pointy shoes. In addition, intense training and marching (soldiers, police officers) is associated with stress fractures of the forefoot. Also, the type of recreational activities and the surface on which these are performed may predispose these individuals to forefoot pain.
Let’s go through the most common forefoot pain aetiologies:
It is a condition in which the ball of the foot becomes painful and inflamed. This may develop during activities that involve running and jumping. People with tight Achilles tendon, long metatarsals, soft tissue laxity and overweight are predisposed to suffer from this condition. Patients usually complain of a sharp pain on the ball of the foot and they feel like they are walking on a pebble which is trapped inside the shoe. The pain worsens when walking on bare feet since the metatarsal head has direct contact to the hard floor. When examining the patient, they usually have callosities on the ball of the foot and direct manual pressure on the base of the metatarsal heads elicits the same pain they complain about.
Morton’s neuroma was initially described by Lewis Durlacher in 1845, but it was Dr Thomas Morton in 1876 who first documented this pathology. The Morton’s neuroma is a compressive neuropathy of the interdigital nerve caused more commonly by the intermetatarsal ligament (which connects the metatarsal necks). It is most frequently located between the 3rd and 4th metatarsal heads and it commonly affects middle-aged women. Patients complain of a burning pain that worsens when wearing narrow shoes, but it improves when walking barefoot as the intermetatarsal space widens relieving the pressure on the neuroma. They also complain of numbness in the interdigital space. The classic diagnostic manoeuvre is the compression test followed by a click (Mulder’s sign).
The term bunion, or hallux valgus, describes a variety of deformities involving a painful bump and swelling at the base of the big toe. People with a positive family history and women have an increased predisposition to suffer from this pathology. Shoes that are too tight can contribute to the progression of the condition. Bunions are often bilateral and are usually seen in people who are middle-aged or older. Patients generally complain of pain on the inner side of the foot that worsens with narrow pointy shoes. While examining the patient, it is important to determine if the big toe can be brought back to its normal alignment (this means that the deformity is flexible, modifying the treatment options) and if lesser toe deformities are also present. Pain on the top of the first MTP joint may indicate that joint arthritis is present.
Other common injuries and conditions that cause forefoot pain include:
- Hallux rigidus
- Lesser toe deformities
- Ingrown toenails
- Stress fractures
- Referred pain or neuropathy
A full medical history and a physical examination is key to reach a definitive or a probable diagnosis. Plain X-rays, US, CT and MRI are different imaging studies that can be used. For metatarsalgias, bunions, lesser toe deformities and hallux rigidus, weight bearing AP/lateral/oblique radiograph views are sufficient. For Morton’s neuroma, an US is usually needed to confirm the diagnosis if the symptoms are not clear. Also, US guided injection with local anaesthesia and corticosteroid targeted to block the common digital nerve has a twofold effect: it is diagnostic and therapeutic. For sesamoiditis, an MRI or CT is necessary to clearly delineate the bones and the anatomy.
Regarding treatment, there are different measures that can be taken. I consider that patient education and shoe/lifestyle modifications are crucial for a successful outcome. A course of analgesics, anti-inflammatories, ice and rest often relieve symptoms. Wearing supportive footwear with shock-absorbing insoles or arch supports might minimise symptoms. For Morton’s neuroma, neuromodulator medication like pregabalin has proven efficiency. Weight reduction plays an important role for metatarsalgias.
In any situation, when the patient wishes to remain active when recovering, cross-training is essential. Running and jumping should be avoided, and encourage cycling, swimming or any non-impact activity to stay fit and active, and also to reduce the irritation.
Finally, surgery will be considered once a supervised conservative plan has failed after 3 to 6 months.
Dr Martin Di Nallo
(Orthopaedics – Foot and Ankle)
21 St Jude Street
Bowral NSW 2576
P: 02 4861 6698
F: 02 4861 6692