PARDEE FOOT CLINIC
Neuromas :: Metatarsalgia :: Sesamoiditis :: 2nd Metatarsal Overload Syndrome
There are many causes of pain in the ball of the foot. Metatarsalgia, neuromas, sesamoiditis and 2nd metatarsal overload syndrome are the most common causes of pain in the ball of the foot.
Most of the conditions in the ball of the foot are due to faulty foot mechanics. The big toe joint is designed to carry much of the weight of the body during "push off" when walking. When the big toe joint does not carry this weight, the load is transferred to the lesser metatarsal phalangeal joints (MPJs).
During the gait cycle (walking cycle) the foot must transfer the weight from the heel to the forefoot. The calf muscle contracts and helps push the foot off the ground and propel the body forward. When the Achilles tendon and calf muscles are tight, this causes the heel to rise early and the foot to rotate out which increases the abnormal stress through the midfoot and increases abnormal pronation. These forces contribute to midfoot collapse, elevation of the first ray and transfer of weight to the lesser metatarsal phalangal joints (MPJs). Mouse over the image to the left to see a demonstration of midfoot collapse, elevation of the first ray and resultant pressure transfer to the lesser metatarsals.
Metatarsalgia [Metatarsalgia area of pain and bones labeled]
Metatarsalgia is used as a catch all term for pain in the ball of the foot. Although faulty foot mechanics are considered the most common reason for development of pain in this area, trauma, infection, repetitive stress, arthritis and previous foot surgery could also contribute to pain in this area. Pain is generally deep and dull with walking and occurs at the 2nd, 3rd and 4th metatarsal phalangeal joints (MPJs).
Hammertoes can be associated with metatarsalgia. There is a retrograde force from the hammertoe which pushes back on the metatarsal phalangeal joint. This causes excess pressure and pain and inflammation in the area. The most common area for this is at the 2nd toe joint. Hammertoes can contribute to 2nd metatarsal overload syndrome.
2nd Metatarsal Overload Syndrome
[Callus under the 2nd toe joint] For those with more flexible feet, when the weight is transferred to the ball of the foot, the 1st metatarsal elevates more than usual, and places a tremendous amount of force on the 2nd MPJ. This excess stress can result in callus development under the the 2nd MPJ and pain and inflammation at the joint.
Sesamoiditis is the pain and inflammation of two small bones under the big toe joint. [Area of pain in sesamoiditis] These bones act like ball bearings in the foot and allow the big toe to glide up and down smoothly. These two small bones carry a significant amount of weight. When overstressed, they can becomes inflamed and painful. This condition typically develops as a result of repetitive stress and is common in dancers, sports with quick sprints, sports involving a squating position (catchers in baseball) or sports with repetitive push off on the ball of the foot, such as pitchers in softball. Individuals with high arch feet are more prone to developing this condition. The pain is generally dull and achy when sitting and standing and sharp and sometimes stabbing when pushing off the great toe. Rest and ice tend to improve the pain and walking, running, squatting and pushing off aggravate the pain.
[Area of pain with a neuroma in the ball of the foot] A neuroma is an inflamed nerve which causes pain in the ball of the foot which radiates to the third and fourth toes. The second and third toes are also commonly affected. The pain is typically worst with standing and walking and relieved by rest. Walking in soft shoes, high heeled shoes, narrow shoes, going up and down stairs and squatting will all aggravate the condition. Some will complain of deep achy pain, others complain of a constant burning. It's common to experience radiating pain, electrical pain, sharp shooting pain or numbness. Some individuals feels as if they are walking on a lump, a ball or a lamp cord, others complain of a "twang" in the ball of the foot. More on neuromas.
All of the foot conditions listed above have separate and specific treatments. But, there are some common treatments which will benefit all people with pain in the ball of their foot.
It is important to wear a rigid, supportive shoe with a wedge at the heel. This does not mean a "high heel" shoe, but a lift at the heel or wedged shoe which is about 1" in height. This helps to distribute the pressure between the heel and the forefoot and decrease any stress on the calf muscles. Many of the foot problems listed above are worsened with soft, flexible shoes. The shoe should only bend at the toe, not in the middle of the shoe. To test a shoe, hold the heel and place the toe area on the floor. Press down on the shoe. If it collapses, it is too flexible.
At first it may not seem logical that stretching the calf muscles will help with pain in the ball of the foot, but after reading the information presented above it should make more sense. Stretching the calf will help to decrease abnormal pronation, decrease the midfoot collapse and relieve the excess pressure on the ball of the foot. Calf stretching should be performed at least three times a day.
For both metatarsalgia and neuromas, metatarsal pads can be a very effective treatment. The pads help by distributing the pressure more evenly under the ball of the foot and taking pressure off the area of of pain. One of the most common errors with this treatment is pad placement. The pad is NOT placed under the area of pain. The pad is placed behind the ball of the foot as seen in the picture of a HaPad Metatarsal Pad to the right. This is also helpful for neuromas because the pads spread the metatarsals, preventing rub and irritation of the inflamed nerve.
[Dancer's Pad offweighting the great toe joint in sesamoiditis] Padding can also be very effective for sesamoiditis. Specific pads, designed for off-loading the great toe joint help to distribute pressure away from the 1st MPJ. The common pad designed for sesamoiditis is called a dancer's pad. The pad obtained it's name because sesamoiditis is common in dancers. Dancers spend a tremendous amount of time on the ball of their feet and specifically their great toe joint. This pad can be fabricated out of felt or purchased. The pad can be placed on the foot, on an insert or inside the shoe. Many podiatrists can design a removeable and reusuable dancer's pad
Rigid prefabricated orthotics help control pronation, support the midfoot and distribute forefoot pressure more evenly.