Pain in the ball of the foot, also referred to as metatarsalgia, is a very common complaint for which patients seek treatment.  There are many ailments that can cause metatarsalgia, some of the more common being Morton’s neuroma, stress fracture, plantar plate tear, capsulitis, and arthritis.  Some of these conditions can be difficult for the patient themselves to distinguish between, which brings them to our office.  Each of these can have similar initial conservative treatments such as rest, NSAIDs, orthotics and ice, but each have their own specific treatments as well.

Stress fractures are very common in the metatarsals with the 2nd metatarsal being the most common.  Stress fractures are commonly caused by overuse and are many times seen in people who have recently had an increase in activity. This can include someone who previously had a sedentary lifestyle and started a new exercise program or highly trained athletes that have drastically increased their training level. This is in contrast to a traumatic fracture in which the patient will recall a specific injury. Patients with disease weakening the bones such as osteoporosis and rheumatoid arthritis are at risk of developing stress fractures as well.

Common symptoms of stress fractures of the metatarsals include sharp or aching pain in the forefoot that is not well localized that tends to get progressively worse overtime and is worse with activity.  There will also be swelling in the forefoot.  Many times this can be diagnosed by history, physical exam and x-ray findings.  A negative X-ray does not exclude a stress fracture as many stress fractures do not appear radiographically for two weeks after onset of symptoms.  If there is high suspicion with a negative X-ray and MRI may be ordered.

Treatment for metatarsal stress fractures includes ice, rest, and immobilization (usually in a removable cast boot).  These injuries are very responsive to conservative treatment and very rarely need surgery.  If you are experiencing forefoot pain and have recently increased your activity, it would be wise to see a Podiatrist to make sure you do not have a stress fracture.

FAQ

How can I prevent getting a stress fracture?

The best way to prevent getting a stress fracture is to gradually ease into a new exercise program as opposed to trying to do too much all at once.  For athletes and runners who want to increase their workout intensity or length, it is wise to gradually do this over a period of weeks increasing by 10% per week. For example if you are used to running 10 miles a week, increase to 11 the next week and 12 the following week and so on.

Does the type of shoe affect getting a stress fracture?

There are many conflicting studies on shoe wear and running injuries.  Recently, there was a push towards “minimalist shoe” running as a more natural way to run that may build foot strength overtime. With the increase in minimalist shoes there was also an increase in overuse injuries such as stress fractures.  Again many people were not easing into using these shoes but rather would perform their normal workout routine without giving time for their feet to adjust.  Some push for pronation control and cushioning but some studies have refuted this as well saying that comfort is most important.  Personally I prefer a supportive running shoe that has pronation control (since I pronate).  My best advice is to have a Podiatrist that is familiar with running and running shoes check you out.

Is there any way to return to sport more quickly after sustaining a stress fracture?

No matter what there will be a period of time that you will need to be immobilized and not be able to partake in athletic activities.  There are still many ways to stay in shape during this time such as swimming, riding a stationary bike and upper body workouts.  Bone stimulators may help elite athletes return to sport more quickly by using electrical stimulation to help induce and speed up the bone healing process.

Often times people as me why I chose the medical field of Podiatry.  My typical answer is that I have had injuries in the past that have needed surgery and wanted to be able to perform surgery on people that need it.  It also gives me the opportunity to work with athletes, which I enjoy.  Although these are true, another reason is to work with diabetics that have foot and other health issues that need addressed.  Diabetes is a disease that I am very familiar with as my father struggled to manage his diabetes.

Diabetes is currently one of the largest epidemics in the United States with almost 10% of the population (21 million people) having diabetes. This number has been on the rise over the past couple of decades, and an estimated 8 million people are living with diabetes that have not yet been diagnosed.

People with diabetes tend to develop problems with their feet for many different reasons but probably the most critical is due to diabetic peripheral neuropathy.  The high blood sugar in diabetic patients leads to peripheral neuropathy which affects the sensation and moisture in the patients feet.  Many people with diabetes have decreased sensation in their feet and may not even realize it.  This leads to developing ulcerations in areas of pressure and friction although it usually will not cause pain. This is why it is very important for people with diabetes to not walk barefoot and check their feet daily.  It is also important for them to be evaluated by a Podiatrist regularly to check for issues that may lead to wounds.

Wound healing in the diabetic patient is not an easy task.  People with diabetes are immunosuppressed due to their high blood glucose. I often tell patients “any day your blood glucose is over 150-175mg/dl is a day your wound will not heal”.  Other important factors are wound debridement and proper offloading of the wound to prevent pressure on the wound.

It is very important for someone with a diabetic foot wound to be evaluated and treated by a Podiatrist as soon as possible.  The longer the wounds are present, the more chance of them becoming larger, deeper, infected and developing eschar which all lead to higher rates of amputation.  Many patients with diabetes are covered by insurance for yearly diabetic shoes, which can help prevent these ulcerations from occurring.  I have a lot of experience with treating diabetic foot wounds and infections in my years working in a wound care center at Rush University Medical Center.  If you have a diabetic wound or are worried about developing one, you should call today to make an appointment.

Pain in the ball of the foot, also referred to as metatarsalgia, is a very common complaint for which patients seek treatment.  There are many ailments that can cause metatarsalgia, some of the more common being Morton’s neuroma, stress fracture, plantar plate tear, capsulitis, and arthritis.  Some of these conditions can be difficult for the patient themselves to distinguish between, which brings them to our office.  Each of these can have similar initial conservative treatments such as rest, NSAIDs, orthotics and ice, but each have their own specific treatments as well.

One of the most frequent causes of metatarsalgia is Morton’s neuroma.  Morton’s neuroma, also referred to as interdigital neuroma, is a fibrous enlargement of the nerve that runs between the metatarsals and then splits to provide innervation to the toes. It is likely the result of impingement and entrapment from a ligament that connects the metatarsals.  Symptoms include either a sharp or dull pain in the ball of the foot or toes; burning, numbness, or tingling in the toes; or the feeling of walking on a “stone” or a “bunched up sock”.  These symptoms are aggravated by activity and wearing shoes and relieved by rest and massaging the foot.

There are many different treatments for Morton’s neuroma including shoe gear modifications, padding, OTC or custom orthotics, steroid injections, alcohol injections, and if all else fails surgery.  When looking at medical studies, some have shown that approximately 40% of patients had relief with shoe gear modifications and orthotics alone, but this was a lower percent than with a steroid injection.  Another study compared custom orthotics and steroid injection and found higher patient satisfaction with steroid injection. Steroid injection for Morton’s neuroma has been shown to work better if symptoms have been present for less than a year, so it is important to recognize symptoms early.  Conservative treatment for neuromas is often very successful but occasionally patients will require surgery.  If you are having pain in the ball of your foot, my recommendation would be to see a Podiatrist sooner rather than later.

FAQ

How does shoe gear modification and orthotics treat Morton’s neuroma?

Shoe gear modifications include a supportive shoe with a wide toe box so that the metatarsals have room to spread out and not impinge upon each other.  Custom orthotics can have a “metatarsal pad” built into them to help splay the metatarsals to prevent the nerve from becoming impinged.  They also support the arch of the foot so that our foot functions properly  and biomechanics are restored when walking.

How do corticosteroid injections treat Morton’s neuroma?

Corticosteroid injections help treat Morton’s neuroma by decreasing the inflammation which is contributing to some of the impingement.  Steroids are strong anti-inflammatories and injections avoid the systemic side effects of  oral steroids, while delivering the medicine to a localized area.  The sooner they are given the more relief the patient will have.  Sometimes two or three injections are necessary but many times patients get significant relief from a single injection.

What if a Morton’s neuroma fails to respond to conservative treatment?

If a Morton’s neuroma fails to respond to conservative treatment then surgery may be necessary to relieve symptoms.  It is a very commonly performed surgery in which an incision is made in the top of the foot and the neuroma is isolated and removed.  This usually involves a simple recovery and the patient can walk in a surgical shoe the same day of surgery.  Patients find that this surgery relieves their symptoms but they may have numbness in this area after surgery.

Pain in the ball of the foot, also referred to as metatarsalgia, is a very common complaint for which patients seek treatment.  There are many ailments that can cause metatarsalgia, some of the more common being Morton’s neuroma, stress fracture, plantar plate tear, capsulitis, and arthritis.  Some of these conditions can be difficult for the patient themselves to distinguish between, which brings them to our office.  Each of these can have similar initial conservative treatments such as rest, NSAIDs, orthotics and ice, but each have their own specific treatments as well.

Plantar plate tears are a very common injury that has been diagnosed more frequently in recent years as more research has been done in this area.  I was very lucky to receive part of my residency training with the Weil Foot and Ankle group in Chicago, as they are in the forefront of research in this injury and actually developed one of the more common surgeries for this ailment.

Plantar plate tears most commonly affect the 2nd metatarsophalangeal joint (where the 2nd toe connects to the foot), although any toe can be affected.  They can occur from a traumatic incident such as a stubbing or twisting injury while running or hiking, but are usually due to a progressive injury overtime resulting from faulty foot biomechanics.  They are most commonly seen in someone with a long second metatarsal.

Symptoms of a plantar plate tear include pain at this joint with activity, and many times the toe will start to “hammer” or “float” and may no longer touch the ground in severe cases. The toe can also drift in the transverse plane.  Conservative treatment for plantar plate injuries has had some success in select patients and include immobilization, stiff soled shoes, NSAIDS, and most commonly taping/splinting the toe down.  If conservative therapy fails there is a common surgical procedure to correct this injury.  The sooner this injury is recognized, the more likely that the patient will not develop a longstanding deformity and that conservative treatment could be successful.

FAQ

What are the biomechanics behind the plantar plate injury?

The plantar plate is a fibrocartilage tissue that connects the metatarsal neck to the base of the toe at the bottom of the foot.  It is the main stabilizer of this joint in the sagittal plane.  Patients with a long 2nd metatarsal are more likely to develop a plantar plate tear as the plantar plate has to obtain more pressure, weakening it overtime and making it more susceptible to injury.  A bunion deformity can contribute to developing a plantar plate injury as well, again leading to increased pressure at the 2nd MPJ.

How are plantar plate tears diagnosed?

Plantar plate tears are often a clinical diagnosis after hearing the patients history and performing a physical exam.  On physical exam one of the most tell tale signs is instability at the 2nd MPJ while performing the Lachman test, which with one hand the physician stabilizes the metatarsal and with the other hand puts dorsal pressure on the toe checking the stability. Other signs are drifting of the toe in the sagitall and transverse planes and direct pain with pressing on the plantar plate. Many times MRI or ultrasound are used to confirm the diagnosis.

What does surgery for the plantar plate tear involve?

Surgery for the plantar plate tear involves making an incision on the top of the foot overlying the 2nd MPJ.  The 2nd metatarsal is then cut and shortened in order to better see the plantar plate, but more importantly to correct the underlying biomechanics that lead to the injury in the first place.  The plantar plate is then debrided and repaired/attached to the base of the toe using sutures passed through tunnels that are created in the bone.  Although there is always a possibility of recurrence, it is a very successful procedure.

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