Background

Pain in the forefoot inclusive of the toes and metatarsophalangeal joints is an extremely common presentation to podiatrists. It can affect two main anatomical areas; the first metatarsal and phalanges (big toe), or the lesser metatarsals and phalanges (smaller toes). The locations and the corresponding features can help us establish the cause and help inform initial management.

Symptoms of various forefoot pain can appear quite similar, but careful history taking can help differentiate the possible diagnoses. Gout, Rheumatoid arthritis and septic arthritis and synovitis can also cause forefoot pain and are important differentials, but are not the main focus of this blog.

Where is the pain?

The plantar aspect of the foot under one or more metarsal heads is generally where primary metatarsalgia will occur. The first metatarsal head is the site of hallux values, rigid and sesamoiditis. Plantar plate tears are commonly seen at the second metatarsal head. The third and fourth metatarsal heads are typically the sites where Morton’s Neuroma symptoms occur.

What does it feel like?

Neuroma pain can be often described as “like walking on a pebble”, and exacerbated by walking barefoot. Sometimes there is numbness extending to the toes, with neuropathic type pain such as ‘burning’ or ‘electric shock’ type symptoms being indicative of a neuroma. Swelling or oedema associated with plantar plate pathology or hallux rigidus can also present with neuropathic symptoms. Stress fractures often have “dull ache” type symptoms. 

When does the paint occur?

As forefoot pain is often exacerbated with footwear with high heels and/or narrow toe boxes for extended periods of time, footwear can be a useful diagnostic clue.

Pain with propulsion, where the forefoot plants and the heel rises during gait is often a feature of metatarsalgia. Anatomical variations resulting in plantarflexion of the MTPJ excessively can be a factor. Sesamoiditis pain can often occur during the “toe-off” stage of stance phase during gait.

Increases to training load and exercise intensity can exacerbate stress fracture pain, alleviated by rest. Similarly with sesamoiditis it can worsen with prolonged weight bearing, but improve with rest.

Clinical Examination and Special Tests

Assessment of the foot morphology should be performed, to see if any particular element of the foot structure is contributing such as a flat foot type, poor transverse arch or retracted/claw toes. This may increase pressure over the metatarsal heads,  and callosity on the dorsal and plantar aspects of the foot should be noted.

Swelling should be assessed and may be present over the plantar aspect of the sesamoid bones in sesamoiditis.

Pain with palpation in the 2/3 and/or 3/4 intermetatarsal spaces can be present in the case of neuroma. Stress fracture over the metatarsal heads can also produce point tenderness with palpation, although stress fractures can often have an insidious presentation, and so a clinician should have a low threshold for imaging to confirm this diagnosis.

Use the Silfverskiold test to assess the gastrocnemius and discern tightness in the upper calf versus lower calf. Dorsiflex the foot with the knee extended, if there is more range of motion with the knee flexed, it is likely the gastrocnemius has excessive tension. In forefoot pain, gastrocnemius contracture is common and therefore stretching of this muscle group may be helpful in reduction of symptoms.

The Mulder’s test, can be used to diagnose a Morton’s neuroma, although it can produce a false positive in healthy feet. A compression of the forefoot with pressure to the affected webspace can produce a painful and palpable ‘click’. 

Assessing range of motion of the 1st MTPJ can distinguish hallux rigidus from values. Rigidus will marked by reduced dorsiflexion of the joint and pain in this motion. In contrast, pain with resisted plantarflexion of the 1st MTPJ is indicative of sesamoiditis.

The use of the ‘anterior drawer’ test is highly specific to plantar plate damage that had led to instability of the MTPJ. Stabilisation of the metatarsal head, with traction applied to the proximal phalanx along the shaft. If positive, it should produce pain and vertical displacement.

What should you do?

Acute, severe pain may require earlier imaging to exclude bony pathology. Many management options can be utilised but improvement may take several months, and trial and error may be needed to deduce what is effective.

Imaging

Plain film x-ray can be used to assess the severity of hallux values, with sesamoid-specific views able to requested in the case of suspected pathology related to this area. Picking up bony fractures in the early phase of injury on plain radiography is poor, as such MRI can be helpful to rule this out. Likewise for non-bony related issues such as neuroma, MRI or ultrasound can confirm a clinical diagnosis.

Self-care

The wearing of well cushioned, low-heeled and wide toe box footwear can be helpful. Metatarsal pads that are well placed on an insole can be used to alleviate plantar pressures. They are generally placed proximal to the affected metatarsal head. Additionally, stretching of the gastrocnemius can be helpful to reduce calf tightness, improve ankle mobility and reduce pressure on the forefoot.