Forefoot Pain

Plymouth Orthopaedic and Sports Injury Clinic

General advice

A lot of force goes through the forefoot when you walk so losing weight and keeping fit may be of benefit. Finding comfortable shoes with space for the toes may relieve some of your symptoms. Shoes with a rocker bottom may be helpful in relieving pain. A tight calf muscle may make forefoot pain worse so stretching this tight muscle may improve the fore foot pain.

Morton’s Neuroma

The nerves which supply the toes with skin sensation run between the metatarsals. These nerves branch at the level of the toe and travel down either side of the toe. At the level where they branch the nerve can get caught between the bones and this irritates the nerve. The nerve becomes scarred and becomes thicker. This thickened nerve can get caught between the metatarsals and this can become painful. Some patients describe walking on “a pebble”. Because the nerve is involved some patients experience altered sensation in the toe or pain “shooting “ along the toe.

A Morton’s neuroma may be identified on an ultrasound scan. If one is present then an injection of local anaesthetic and steroid may help. The steroid injection may cure the condition in 30 – 50 % of cases. However the pain may return.

The pain may not be relieved completely. This may be because there is another reason for the pain in addition to the Morton’s neuroma. In this situation then further assessment may be needed.

Surgery for Morton’s neuroma involves removing the nerve

This is usually done under a light general anaesthetic, as a aday case procedure. An incision is  made on the top of the foot at the site of the neuroma between the metatarsals. The nerve is removed along with the scar tissue.

Post-operative care for Morton’s neuroma excision

Your foot will be protected with a light dressing for two weeks.  A wedged shoe will allow you to fully weightbear, whilst unloading the forefoot.  You may need crutches for balance.  The majority of patients will be able to walk in a wide shoe from two weeks post surgery and can drive safely at that time.  Normal activity should resume six weeks post surgery.

The pain in the fore foot may not be completely relived by excising the Morton’s neuroma. This is because there is another reason to cause pain. However the majority of the pain will be relieved. Further treatment with specialist insoles or stretching may be required.

Intermetatarsal Bursitis

Between the foot bones called metatarsal bones are little bags of fluid called bursa. These can become inflamed. This can be diagnosed with an ultrasound scan and treated with an injection of steroid. Other treatment may involve insoles and physiotherapy.

Hammer Mallet or Claw Toes

This is a condition where the smaller toes become deformed. The deformed toe may rub on shoes. The deformed toe may be painful or may press against other toes.

The cause for this condition may be related to conditions such as hallux valgus or rheumatoid arthritis. However there may not be any obvious cause.

Non surgical treatment of claw / hammer toes

Wearing correctly fitting shoes with space to accommodate the toes may produce comfort for your toes. Toe splints are available commercially and may provide comfort. Special insoles may help the toes to sit in a better position. These may be provided by a podiatrist or orthotist.

Surgical treatment of claw / hammer toes

A toe which is bent may be straightened with an operation. The most common operation to achieve this is a toe fusion and may also include an operation to lengthen a shortened tendon.

The toe fusion will involve removing the bent joint. The remaining bone is joined together and stabilised with a wire. There may be a need to lengthen a short tendon. This wire will stick out of the toe for 6 weeks. After 6 weeks the bones will have healed together and the wire may be removed. The toe will remain swollen for a few months and will settle down.

It is usually possible to improve the toe shape with this procedure. The operated toe will be shorter. However it is not possible to make the toe perfect. This is an operation to improve the function but not the cosmetic appearance.

Post operative care for surgical treatment of claw / hammer toes

You will be able to mobilise fully weight bearing in a special sandal immediately . You may need a set of crutches to help you walk if your foot is sore. You will need stitches to be removed at 2 weeks . Your wire will need to be removed at 6 weeks. This can be done in clinic without an anaesthetic. The wire removal is usually not painful and is usually very quick.

Metatarsalgia

Metatarsalgia is a condition where the metatarsals bones and the overlying skin are painful. There is often a build up of hard skin on the bottom of the foot. The toes may be affected as well. The first stage in making a diagnosis is taking a good history and examining your leg.

Non - surgical treatment of metatarsalgia

Losing weight, finding shoes and calf stretches as explained above will contribute to the comfort of your feet.

Orthotic ( Insole) treatment of metatarsalgia

Special insoles may be very helpful in relieving pain. A thorough assessment by a podiatrist or orthotist is essential to prescribing the correct insoles for an individual foot. It is essential that once your insoles are fitted that you wear then in gradually. This allows your feet to be accustomed to the changes that the orthotics will make to your feet .

Surgical treatment of metatarsalgia

Surgical treatment of metatarsalgia is a last resort after all conservative non-surgical treatment has been exhausted. The surgery is designed to change the shape of the metatarsals to relive the pressure . This may include one or all of the metatarsals. This is usually performed under general anaesthetic. There are up to three incisions on the top of your foot. The metatarsal bones are cut and the shape is changed. The bones are then fixed with screws or staples. The wounds are then stitched. The foot is then bandaged. You will then mobilise in a special shoe for 6 weeks. You may need crutches for this time to help you walk.

Post operative care for surgical treatment of metatarsalgia

You will be able to mobilise fully weight bearing in a special sandal immediately. You may need a set of crutches to help you walk if your foot is sore. You will need stitches to be removed at 2 weeks . You will have an X-ray at 6 weeks and hopefully will be able to wear shoes at this time. Your foot may be swollen and painful for up to 6 months following surgery.