Pain at the ball of the foot (forefoot pain):
Conditions discussed in this article are: metatarsal phalangeal joint synovitis, Turf Toe or big toe sprain, Hallux Limitus, Hallux Valgus, and Sesamoid injuries.
Aside from corns, warts and calluses, there are many causes of forefoot pain. The joints of the toes (phalangeal joints) and the metatarsals are put under extreme stress as they transfer force into the ground while jumping or absorbing impact from landing as a simple example. The health of the joints and surrounding fascial and muscular system play a huge roll in our continued mobility and ability to be able to participate in sports and higher impact activities. The foot/ankle/calf complex acts as the primary shock absorber for the body during lower limb movements, and as such is placed under plenty of stress throughout our day to day lives. Here we will focus on the forefoot and toes which, when landing, are the first point of contact with the ground and therefore are subject to injury and pain.
MTP joint synovitis
Usually occurring where the 2-4th toes meet the foot (metatarsal phalangeal joint or MTP joint) this pain is associated with irritation of the synovium (inner joint lining). These linings are generally placed under excessive pressure for a period of time and, as per other foot conditions, occur after a sudden increase in high impact loading, training frequency, or training intensity. Activities that involve landing or powerful toeing off such as jumping or sprinting are likely to cause this pain if the athlete is not accustomed to said activities or volumes. Other biomechanical and physiological conditions can also contribute to the development of MTP joint synovitis, such as high arches (pes cavus), claw or hammer toes, tight toe extensors (limited ability to curl toes), a longer 2nd toe than big toe, and larger than normal metatarsal heads (the knobbly bits at the end of your bones that form the knuckles). Separated, or ‘V’ toes, are an early sign of dysfunction in this area, along with localised pain with palpation and upon forced toe flexion.
In this situation Myotherapy can help by assessing and treating the underlying cause of the problem. We can’t make your short big toe grow or change your knobbly knuckles obviously! But a Myotherapist can treat and release short muscles and help to correct poor foot posture and function, as well as assess training load and recovery. Advanced soft tissue and joint mobilisation techniques are required to correct high arches, these are a Myotherapists specialty!
Turf Toe (First MTP joint sprain)
Occurring at the MTP joint of the big toe (1st toe) this injury typically occurs following a ‘bending’ injury to the joint that damages the joint capsule. In this case the big toe is forced to bend upwards (extend) past its normal range. Factors such as training or competing on artificial grass (turf), flat feet (pes planus), limited pre-injury toe extension, and limited ankle dorsi flexion can all increase the likelihood of this injury occurring. Redness and swelling can occur at the site of the injury and pain can be felt or increased with weight baring activities or moving the big toe.
Restricted movement of the big toe (Hallux limitus)
Having a big toe that doesn’t want to bend upwards (extend) as you walk, run, or jump can be an extremely unpleasant experience! A lot of the time the body will alter gait patterns to get around this restriction, an example of this is when the feet are turned out out or when the big toe moves inwards (see next point) making walking/running possible, albeit inefficient, and possibly leading to pain in the calf and hips. Pain is felt locally at the 1st MTP joint and is usually described as a deep aching feeling, however can be acutely painful when toeing off while walking/running/jumping. This condition requires prompt mobilisation of the 1st MTP joint to avoid further issues and/or the need for surgery as the condition become chronic and the joint fusses.
A crocked big toe (Hallux valgus)
Most people have seen a foot where the big toe is pressing into the toe beside it, and have maybe seen one where the second and third toes are also pressing into the toes beside them, giving the appearance of a set of toes that are pointing off to the side instead of straight out in front in line with the rays of the foot. Unfortunately, constantly wearing restrictive footwear is a huge issue here, with both fashion and sporting footwear being equally to blame! When you place the palm of your hand on the ground to weight bear, your fingers and rays naturally splay when absorbing the load of the body, your feet are designed to do exactly the same thing, but are far better at it! However, when feet are trapped in a shoe that doesn’t allow this, or worse, forces the toes to be pressed together (think any pointy dress shoes) then the natural movement of the big toe is restricted and forced to work in a compromised position, effecting the health of the joint, the bones, and the surrounding soft tissue. Over time the toe just adapts (pathologically) to this position and remains there, but like hallux limitus, can have serious repercussions on the joint long term and effect our ability to efficiently propel ourselves upwards and onwards without pain. As with the above conditions, mobilisation, as well as gait and muscle retraining, are required to realign the toe and correct co-factors such as flat feet. Removing (or limiting the use of) restricting footwear is also a must!
The sesamoid bones are two important little pee shaped bones that live at the base of the big toe. They play an important role in the mechanics of the big toe and foot. They can be injured or irritated by any number of activities but seem to be mostly related to biomechanical issues such as limited big toe extension. Conditions such as Hallux valgus can also predispose someone to a sesamoid injury. Pain will be felt on the ball of the foot at the base of the big toe when the foot is weight baring, with sufferers favouring the outside of their foot to avoid weight baring in the painful location. Pain will often cause a restriction in big toe movement and a weakening of the toes ability to tolerate loading.
In all the conditions discussed above the common theme is poor biomechanics and movement patterns, with a side of tight muscles and restricted joints! This situation can drastically increase the risk of injury or is itself the cause of many foot pain presentations. Correcting these issues, mobilising stiff joints and releasing tight and painful muscles are all skills of a Myotherapist. In fact, Myotherapists are the most suitable health practitioner to administer all of these interventions due to their specialised knowledge and training.
I hope these articles on foot pain have enlightened you about some of the common presentations of foot pain and given you some insight in how to best go about identifying and resolving the underlying causes. If you are experiencing foot pain book an appointment at Reawaken Myotherapy today and take control of your foot pain!
Written by Dan Hammond, Myotherapist (Bachelor Health Science – Myotherapy) and Master Functional Trainer (CertIV Fitness). 2018
Reference: Landorf w, Simons S, Jordan C, Rathleff M. Foot pain. In: Brukner P, Clarsen B, Cook J, Cools A, Crossley K, Hutchinson M, McCrory P, Bahr R, Khan K. eds. Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e New York, NY: McGraw-Hill. http://csm.mhmedical.com.ezproxy.endeavour.edu.au/content.aspx?bookid=1970§ionid=168696533. Accessed November 01, 2018.
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