My Feet are Killing Me – Forefoot Pain Explained

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Pain across the front of your foot – just behind the toes – can be very limiting to your activity. It is often hard to avoid and comes on slowly. Just a bit of an irritation to start with before really getting going and letting you know about it all of the time. Certain shoes or activities may bring it on or make it worse. I am going to give a quick run through of the different conditions that commonly present, some things to try at home and how we can help in clinic. If you have any further questions on how we could help, then let us know as we know anything that stops you doing what you love is very frustrating.

Pain can feel as if it is on top of the foot or under the foot. On top of the foot can be present a lot of the time and flares up with activity, then settles back to a painful ache with rest or a sharp pain that stops you in your tracks and often leaves you having to remove your shoes and wriggle your toes to alleviate the pain – which then disappears quickly, only to come back again when you get walking again. A third presentation, that is usually noticed under your foot, again presents as a pain that builds as you are walking on it and often feels as if you sock is rucked up under your foot.

Foot pain walking

Getting out doing what we love. Sunset from Bamford Edge

Let’s have a closer look at these one at a time.

Metatarsal Stress Fractures.

Usually 2nd and 4th are most commonly affected and present with pain across the tops of the long bones in your feet. This is often accompanied with swelling over the area. These very rarely show on X-ray, unless the fracture is large enough, or it is a healing fracture, and you may get to see thickened healed bone. They may show with an ultrasound scan or MRI. The area is very painful to touch, often with a localised point of pain. They can come on gradually or very suddenly. You may have been feeling some discomfort during but especially after runs or increased activity. Then one day, either during or afterwards, a really sudden increase in pain and swelling. It may not have been after a particularly long run or hard activity session. A stress fracture diagnosis is what no one wants to hear because the problem with bone is that you have to rest it to allow it to heal. You cannot exercise your way better, you need rest it and healing will happen much faster if you do not aggravate it. The less it moves the quicker it will heal.

The extent of the damage can be difficult to determine in clinic. Think about bone injury as being a spectrum. A broken bone at one end and a bone that is a bit sore because it has been loaded at the other end. Your injury will be somewhere in between these two extremes. A good gauge is how long is it painful for after the activity. The longer it takes to settle the more damaged it is. A few days or not really ever painfree – you are at the broken end, settles in a couple of hours, or a bit sore when you wake up but ok as you get moving – you are at the faster healing end.

A Quick Science Break

When we exercise we cause damage to tissues, all tissues. We cause our bodies physical damage and as we rest our bodies repair themselves stronger. So the next time we go and do some activity our bodies can take a bit more activity as it will take a bit longer to damage them. So we have to make sure we are having enough rest to allow the body to repair. This may be daily or it may be over a training period. Like build for 3 weeks then have an easy restful week.

If we start the next activity day or block and we have not recovered from the previous day / block then we are at risk of causing more damage than our bodies can repair. When we damage bone with activity there a group of cells that breakdown the damaged bone before the repair cells can get in and do the repair work. If you don’t allow enough time for the breakdown cells to get in and do their job then the repair cells never get a chance to do their thing of building you back stronger. You are always in the breakdown phase, and eventually something will have to give.

Now it won’t take long for the breakdown cells to do their job and the repair cells to get moving. The problem is it doesn’t take much for the new, not quite healthy bone to receive more damage and go into the breakdown phase again. The important thing is to allow time for the enough healthy bone to grow back so that it does not become damage easily. This time will depend on the original damage done. It may take a couple of weeks, or it may take 6 weeks.

You have to honest with yourself and think how much damage you have been causing by trying to exercise through the pain and how long has it been going on. The resting it and keep on poking it is a good guide – when it starts to feel different then is a good time to get going again – but so very easily. You have to do a little, expect it to hurt, bodies are good at protecting you by making things hurt more than the actual damage. But a little bit of hurting is ok. A pain scale out of 10 ,keep it at 3-4 and most importantly, is that it settles down quickly. No lingering pain into the next day.

Activity and exercise should increase gradually. A little and often is the best way. Keep distances / time short but try to do more of these. Only start to build distance and time once it has coped with 3-4-5 times a week. Then build. It is a harder way to do things, I know, but your body will respond. The idea of the shorter intervals is that you get a quicker recovery. The recovery is the important bit. This is key.

foot pain experts chesterfield

Easy Loading to start with, keep walks flatter and easy terrain.

The aim in the first 2 to 3 weeks is to limit movement. A walking cast you can take on and off can help if the pain is quite sever and you still need to be getting about on a daily basis. Supportive stiff shoes to help limit movement and arch supports can also help in some cases. No ICE, let the body heal. It needs a good blood flow and ICE will reduce this. Compression may be ok, see how it feels. Heat can work as healing starts to take place. No massage either at this stage, on the area or surrounding tissues. Let your body provide tension and support. Once healing is underway and you are active again, then massage can help. No pain killers – you need to know when it is painful and if you are causing more damage. Unless at night and you have done too much and not able to sleep, but only then, to allow you to get to sleep. Just don’t do as much the next day. Learn what is good for it and what hurts it and use this.

We can help with diagnosis and a plan of action. Once you are moving we can look at why you may have caused the problem with gait analysis and help with preventing a recurrence of the problem. There are a few factors that you may need to address going forward. These can include: footwear both for activity and for day-to-day use, training planning – or lack off – remember to build in rest periods, day to day stressors – other things going on in your life will impact on your ability to recover, underlying medical conditions could impact healing, diet is a big factor as well – we have to be fuelling our activities and recovery and phycological factors may be impacting on our need to train or be active. I know my morning dog walks set me up for the day and without these I don’t always feel as good as I think I should.

Early morning visit to Parkhurst Hill with Pip

Neuromas.

The most common is between the 3rd and 4th metatarsal space and is called a Morton’s Neuroma. There are two pairs of nerves between the metatarsal heads (the end bits where the metatarsals meet the toes) and these can become trapped. Either your shoes are too tight that you went dancing in at the weekend or when you are walking or running or the way your foot works is causing you to trap the nerves. These start with the area between the metatarsals becomes inflamed and this starts to put pressure on the nerves. Constant irritation starts to form a thickening in the area and on the nerve. This causes more irritation and a growth starts to grow on the nerve which then can become trapped at times when walking or with activity.

This can causes a sharp pain which can stop you in your tracks. Sometimes the irritation builds as you are walking and may give a feeling of tingling or burning in your foot and toes. Sometimes a sensation of numbness starts to become apparent in the area when walking. Taking shoes off and wiggling toes can help.

Treatment will consist of avoiding shoes that are aggravating the problem. Once the neuroma has formed it will often need interventions to help. An ultrasound scan can be helpful in diagnosing. Although they can be hard to spot and give false readings. Clinic assessment is often the best way to come up with a diagnosis and plan. Treatment of these neuromas will involve either preventing it from getting worse if caught early enough or addressing the actual neuroma lump if it has grown to a size that is giving you lots of trouble lots of the time.

Early stages of presentation we would look to see which part of your walking or running is causing the problem and address this. This could be using orthoses and/or a metatarsal pad. The orthoses are designed to address the toe off rotation onto the outside of your foot and the metatarsal pad lifts and separates the metatarsal heads.

If the neuroma has grown to a sufficient size that it is letting you know it is there most of the time then this can be addressed with either a steroid injection or surgical removal. Sometimes they have grown large enough that the off-loading methods will not be enough to address the problems.

Plantar Plate Injuries

The plantar plate is the thick band of tissue under the foot where the toes meet the metatarsals that holds everything together. There is a lot going on in a small space and everything has its own space and place to work. There are ligaments and tendons both in a transverse direction across your foot and long the length of your foot. The muscles sit deep in the arch of your foot. The area has lots of fascia (strong connective tissue), nerves and blood vessels. This area of your foot can be subjected to high loading forces with running and jumping. Toes need to be stable on a stable forefoot. Any rotations at this stage of gait can lead to problems.

As we have seen above, stress fractures of the metatarsals and nerve entrapment between the metatarsal heads can also be a result of these rotations at this stage of gait. Compression and shear forces in the plantar plate can be another complication. Some really unlucky people have a bit of everything going on. The feeling of a sock rucked up under the foot is a common presentation. This then leading to, sometimes, a very painful foot that is uncomfortable to bear weight.

Classic area that is painful with a plantar plate injury

Assessment will check the area. A common site of pain is just behind the toes, where they meet the foot. The toes are sometimes raised in non-weight bearing and in stance and swelling under the foot can be a sign of an irritated plantar plate. Toes should ideally be contacting the ground with firm pressure in standing, If the plantar plate is irritated then this may not be the case. We can also test the ligaments in a non-weight bearing position to check if they have become stretched.

Treatment can be tricky with these. An ultrasound scan can be helpful to assess the level of damage of the various structures. As you are always standing on it, it can be difficult to rest it. Padding in shoes, orthoses to address the shear forces and footwear changes to a rocker sole can help. Taping the toe so it does not ride up can also be effective at reduce the strain on the ligaments. If these measures do not help then surgical repair may be required.

4. Sesamoid problems

Under the big toe joint are two little bones that can become painful if they are subjected to high loads. This can be an issue with high arch feet as this area is often more prominent. These two little bones sit in the muscles tendons and are used to help the big toe function as they act like a fulcrum over the joint. If this part of the foot is not working well then they can become trapped under the joint and not function in the way they should. They can be irritated or become fractured.

The position of the sesamoid bones – the medial one is often more of an issue.

Treatment is firstly to reduce the load on them. Reduce the amount of time on feet and off load with padding. Orthoses or insoles can also be used for a more permanent solution. Assessment would try to determine how much you are loading and the timing. Our Footscan (Services – Colpod therapy (colpodtherapies.co.uk)) system would help to provide this information. X-ray can detect if the bone is fractured, and this may need surgical repair or removal. They can be tricky to heal up as you are standing on them for a lot of the time. Time off activity is advised if they are particularly painful for extended periods of time.

Where to go from here.

This is a summary of the main issues with the forefoot. There are other problems that we have not covered above. If you need any assistance then please contact us or see someone local to you. Early diagnosis and treatment can prevent a lengthy problem from occurring.

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