Often simply dismissed as ‘metatarsalgia’ (a Greek work meaning ‘sore long bones of the foot’), forefoot pain always has specific, varying causes that arise from individual anatomical structures within the foot. These structures are often formed from different types of tissue, operate under different stresses and therefore require both a precise diagnosis and a specific treatment plan in order to resolve the pain. Below are some of the more common presentations of forefoot pain seen at Prahran Foot Clinic.
Bunions are an often-hereditary deformation of the first toe joint in the forefoot. With severity of the condition ranging from initial rubbing discomfort from shoes, through to debilitating joint pain and an unsightly deformity, bunions are among the more unpopular genetic gifts bestowed by one’s parents.
They most commonly develop due to poor ligament support within the foot, seeing the first metatarsal shaft (the long bone in the forefoot) rotating internally. This in turn results in a gradual, inwards movement of the great toe and eventually the deformity we come to recognize as bunions. If left untreated the deviating great toe can continue to shift under or over the neighboring lesser toes, and eventually can lead to the complete dislocation of the big toe joint.
Research has shown custom foot orthotics can be effective at halting or slowing the progression of this condition. They are also an excellent method of reducing the joint pain often accompanying more progressed cases.
The same excessive bone movement seen in bunions can also be the cause of soft tissue structures between long bones of the foot to become inflamed and painful. Both irritated nerves (neuromas) or inflamed bursas (bursitis) can cause a wide variety of symptoms usually involving the lesser toes. Commonly patients will report nerve related pains, such as shooting pains down the toes, tingling or numbness.
Manipulating the bones within the forefoot can often provide the podiatrist with a good indication that an offending neuroma/bursitis is present, however scans are always used to confirm the diagnosis. Conservative treatment by using custom orthotics to gently separate the long bones of the forefoot from making contact with the inflamed structure are very effective.
Plantar Plate Dysfunction/Joint Effusion
The joints that make up the area we know as the ball of the foot are surprisingly complex. Understanding their intricate anatomy is key to successfully resolving pain in the area.
These joints comprise of the metatarsal (the long bone of the foot) and the phalanges (the toe bones), which are bound together by a ligamentous capsule to form the metatarsophalangeal joint (this is the larger joint seen in the illustration below). Within this joint capsule the lubricating synovial fluid ensures smooth joint motion. A small cartilaginous plate (the plantar plate) sits below these joints and ensures joint stability and integrity.
For a variety of reasons ranging from overuse in sport to day-to-day damage from poor support footwear, these joints can become unstable and painful. Most commonly a rupture in the joint capsule will see synovial fluid leak into surrounding areas (known as a joint effusion), or in more severe cases the plantar plate itself can be torn.
A full plantar plate tear can involve up to a three-month healing process while the cartilage gradually repairs. For these joint conditions, changing to firm footwear while treating with specialized joint taping, therapeutic ultrasound, dry needling and custom orthotics are usually sufficient to eliminate symptoms.