What hurts under the forefoot
The forefoot carries a large part of your body weight as you push off with every step. When the load is too high or poorly distributed – because of narrow shoes, high heels, a lot of running or a stiff big toe – pain appears under the metatarsal heads, generally called metatarsalgia. It is usually a dull pain when walking that gets worse towards the end of the day and in shoes with a thin sole.
A particular form of forefoot pain is Morton’s neuroma, also called Morton’s neuralgia. It is a thickening of the tissue around the digital nerve running between the metatarsal heads, most often the third and fourth. The symptoms are typical of nerve irritation: burning, stabbing, a feeling of an electric shock or numbness in two neighbouring toes, often with a sensation of a pebble in your shoe. Typically, taking your shoes off and massaging the foot brings relief.
Assessment and when you need a doctor
At the visit we establish exactly where it hurts and examine the foot for overload of the metatarsal heads, nerve irritation, the alignment of the big toe and the other toes, and ankle mobility. We also look at the shoes you wear every day and run in, because they often turn out to be the main factor keeping the symptoms going.
Some symptoms need a medical assessment. Pain at one point on a single metatarsal, with swelling on the top of the foot and symptoms at rest too, may mean a stress fracture – especially after an increase in running or long walks. Numbness affecting the whole foot or both feet, or numbness combined with back pain radiating into the leg, suggests a different source, for example sciatica. When the picture is unclear, a doctor may order an ultrasound, which shows a neuroma well.
Footwear, insoles and exercise
The first and often most effective step is changing your footwear: a wide toe box that does not squeeze the toes, a lower heel and a sole that is not too soft. Many people are also helped by an insole with a metatarsal pad, that is, a small raised area just behind the metatarsal heads. Its position has to be chosen individually, though, which is why we discuss it at the consultation.
At the practice we use manual therapy for the foot and soft tissue work, and at the same time introduce exercises for the small muscles of the foot, the big toe and the calf. Good ankle mobility and a strong calf help spread the load better when walking and running. Physiotherapy will not remove a neuroma, but together with a change of footwear it clearly reduces the symptoms in many people. When there is no improvement despite several weeks of this approach, further treatment – such as injections or surgery – is considered by a doctor.
Getting back to activity
We increase walking and running gradually, watching how the foot responds in the evening and the next day. While the symptoms are worse, it is better to limit forefoot running, hill runs and jumping, and to plan longer walks in comfortable shoes. Checking your lacing helps too – a shoe laced too tightly at the front can squeeze the forefoot just as much as a narrow model. For runners we recommend fewer fast intervals and less running on hard surfaces for a while, and for people who work standing up – breaks and a change of shoes during the day. Shoes with a narrow, pointed toe or a very thin sole are best set aside for this period.
Other foot overload problems often occur alongside it, for example heel pain – in that case treatment covers the whole foot and calf. We set out the details at the visit.