Forefoot Pain
Forefoot pain has many causes. Some of the most common include:
A bunion is a bump on the side of the big toe joint. The bump is only a visible sign of the underlying problem, however. The bump is generally caused by a malalignment of the first metatarsal, the bone just before the big toe joint (metatarsus primus varus). It is rare for the bump to be caused by a growth or bone spur. This malalignment of the metatarsal results in malalignment of the great toe joint itself and the great toe. The great toe, rather than pointing straight ahead, is curved towards the 2nd toe (hallux valgus). Depending on the size of the deformity the big toe can impinge on the 2nd toe, causing pain between the toes, or push the 2nd toe out of the way and cause a hammertoe and possible instability to the 2nd metatarsophalangeal joint.
Bunions are generally the result of genetic instability and faulty foot alignment. Bunions are a progressive disorder. They will get bigger over time. Unfortunately, we are not able to predict how large or how bad they will be in the future. If they are causing pain, difficulty, or other problems they should be addressed.
Treatment:
While shoes DO NOT cause bunions, they do make them more symptomatic. At a minimum, wide shoes, or shoes with an anatomic foot shape, where they are wider and boxier in the forefoot are recommended. Shoe inserts and orthotics can help with pain on the bottom of the foot. Toe pads, toe splints, and toe socks can sometimes help with pain and are generally worth a try. Stay away from splints with rigid components as these are generally painful to use and cannot be worn with shoes. Foot exercises may be helpful if one is diligent in doing them. Rest, ice, and pain medication such as NSAIDs or acetaminophen can also be helpful in managing pain. Steroid injections can be helpful when pain is significant. Surgical correction can be helpful if conservative care does not provide adequate relief.
If you are having significant pain and discomfort, the bunion is limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Hallux (great toe) limitus occurs when the normal range of motion to the great toe joint is decreased or limited. This can be painful. This can be caused by abnormal foot mechanics, injury, inflammatory joint conditions, wear and tear, and arthritis. This is a progressive condition, and as the joint becomes stiffer, more rigid, and more arthritic, it is called hallux (great toe) rigidus.
When the joint’s range of motion is constrained by arthritis and bone spurs stiff shoes with a forefoot rocker and limiting motion to the joint are recommended. With more mild cases supportive shoes and custom orthotics can help promote improved joint motion and use.
Treatment:
Rest, ice, and pain medication such as NSAIDs or acetaminophen can also be helpful in managing pain. Glucosamine chondroitin is an over-the-counter supplement which can slow down the progression of joint wear and tear in the long term. Steroid injections can be helpful when pain is significant. Surgical correction, such as a joint clean out (cheilectomy), realignment, or fusion (arthrodesis) can be helpful if conservative care does not provide adequate relief.
If you are having significant pain and discomfort, your symptoms are limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Sesamoids are small bones embedded within a tendon. They generally help with mechanical advantage for tendon function. The patella is the sesamoid bone most people are familiar with. It is the bone located on the front of the knee, the knee cap.
The average foot has two small jellybean shaped bones located beneath the great toe joint. These sesamoid bones, in addition to improving the mechanical advantage of the flexor tendons to the great toe also function as a weightbearing surface beneath the great toe joint.
Sesamoid injuries can involve the tendons and connective tissue they are embedded in, or the bones themselves. The bone can be fractured, have a stress injury, or bone bruising. The sesamoid bones have a limited blood supply and therefore take a long time to heal (many months), particularly if weight and stress continue to be applied to them.
Treatment:
Depending on the severity of the problem complete offloading with a tall immobilization boot, crutches, and a knee scooter may be necessary. In less severe case aggressive offloading with custom orthotics and a maximalist style shoe with a forefoot rocker may be sufficient. Activities causing pain should be avoided. Rest and ice are also recommended. For more chronic cases steroid injections or surgical excision can be helpful.
If you are having pain and discomfort, your symptoms are limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Gout is an inflammatory disorder caused by the buildup of excess uric acid in soft tissue or within a joint. Uric acid is made by the body when processing purines. Purines can occur naturally in the body and are found in some foods. Uric acid passes through the kidneys and is excreted from the body in urine. When levels become high the uric acid can crystallize in joints and tissues. These crystals are sharp and cause a severe inflammatory response and pain. Gout most commonly affects the great toe joint but can affect other parts of the foot or extremities.
Some people have a genetic predisposition to accumulate uric acid in the body. Some medications and health conditions, such as kidney disease, diabetic ketoacidosis, and insulin resistance, can also contribute to elevated uric acid levels. Eating foods or drinking beverages high in purines, which the body converts to uric acid, is a major risk factor.
Gout attacks are typically characterized by swelling, redness, increased skin temperature, and intense pain to the joint. Over time, severe gout can cause arthritis and damage to the joint or tophi. Tophi are hard nodules or bumps composed of monosodium urate crystals in the soft tissues and joints. These nodules are evidence of uncontrolled gout.
Increased Risk Factors:
• Aspirin, niacin, and some diuretics, obesity can increase the risk
• Some diuretics (thiazide (s?)), cyclosporines, low dose aspirin
• Diet high in purines
Foods High In Purines:
• Most seafood
• Shellfish (scallops, shrimp, crab, lobster, scallops, mussels, oysters)
• Some fish (anchovies, sardines, herring, codfish, trout, tuna, haddock)– Salmon is fairly low in purines and often safe to eat in moderation
• Meats
• Red meat (beef, veal, lamb, pork, ham, bacon)
• Organ meats (liver, kidney, sweetbreads, tripe, etc…)
• Game meats (goose, duck, venison)
• Turkey
• Gravy
• Alcohol (wine, beer, distilled alcohol)
• High fructose corn syrup, sugar, and fructose (candy, pastries, soda, fruit juices), avoid simple carbohydrates
• Highly processed foods
Preventation:
• Dietary restrictions:
• Avoid foods high in purines
• Avoid high fat foods. Saturated fats decrease the body’s ability to process and remove uric acid.
• Moderation. Smaller portions are often tolerated better than larger amounts of the same food.
• Keep a food diary. Tracking everything being eaten shortly before an attack can help you identify your personal food triggers.
• Good hydration
• Weight loss
Treatment:
For chronic cases uric acid lowering medications can be helpful, both in controlling uric acid levels and eliminating tophi. These should not be started during an acute attack as they can make the attack worse.
For acute flareups ice, elevation, rest, NSAIDs, medication (colchicine), steroid injection, good hydration, tart cherry juice, coffee, and vitamin C can be helpful. Avoid grapefruit while taking colchicine as the grapefruit can interfere with your body’s ability to process the medication.
X-rays and blood testing are recommended to confirm the diagnosis. If you are having significant pain and discomfort, redness, swelling, or increased skin temperature schedule an appointment now for an evaluation and discussion of your feet and treatment options.
A bunionette is a bump on the outside of the fifth toe joint. Bunionettes are not as common as bunions, which affect the great toe joint, but are very similar in cause, symptoms, and treatment. Bunions and bunionettes can both be present at the same time.
Bunionettes are often referred to as tailor’s bunions as tailors would sit cross legged all day long, pressing the outside edge of their feet down into the ground. This constant pressure and rubbing would lead to pain and irritation to the outside edge of the prominent fifth toe joint.
The bump is only a visible sign of the underlying problem however. The bump is generally caused by a malalignment of the fifth metatarsal, the bone just before the fifth or little toe joint. It is rare for the bump to be caused by a growth or bone spur. This malalignment of the metatarsal results in malalignment of the joint and hammer toe deformity of the fifth toe itself.
Bunionettes are generally the result of genetic instability and faulty foot alignment. Bunionettes are a progressive disorder. They will get bigger over time. Unfortunately, we are not able to predict how large or how bad they will be in the future. If they are causing pain, difficulty, or other problems they should be addressed.
Treatment:
While shoes DO NOT cause bunionettes, they do make them more symptomatic. At a minimum, wide shoes, or shoes with an anatomic foot shape, where they are wider and boxier in the forefoot are recommended. Shoe inserts and orthotics can help with pain on the bottom of the foot. Toe pads, toe splints, and toe socks can sometimes help with pain and are generally worth a try. Stay away from splints with rigid components as these are generally painful to use and cannot be worn with shoes. Foot exercises may be helpful if one is diligent in doing them. Rest, ice, and pain medication such as NSAIDs or acetaminophen can also be helpful in managing pain. Steroid injections can be helpful when pain is significant. Surgical correction can be helpful if conservative care does not provide adequate relief.
If you are having significant pain and discomfort, the bunionette is limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Hammertoes can affect all ten toes. Depending on which toe joints are affected and how these may also be called mallet toes and claw toes. Hammer toe is a general all-encompassing term for contracted toes which are not straight.
These can be caused by mechanical imbalance between the muscles and tendons on the top of the feet and toes and the muscles and tendons on the bottom of the feet and toes. Due to the off axis anatomical pull of the tendons to the 5th toe some inward curl of the 5th toe is quite common. This is a progressive condition, and as the joints adapt to being in a contracted position the deformity becomes stiff and rigid.
Bunion and tailors bunion / bunionette deformities are frequent causes. Connective tissue disorders such as RA, DM, EDS can also result in contracture of the toes. Genetic alignment of the foot bones is also a contributing factor.
Treatment:
While shoes DO NOT cause hammertoes, they do make them more symptomatic. Tight shoes can cause painful impingement on the toes, calluses, redness and irritation, and even open sores. At a minimum, wide shoes, or shoes with an anatomic foot shape, where they are wider and boxier in the forefoot are recommended. Shoes with a stretchy upper and increased depth (vertical room for the toes) are also helpful. Shoe inserts and orthotics can help with pain on the bottom of the foot. Toe pads, toe splints, and toe socks can sometimes help with pain and are generally worth a try. Stay away from splints with rigid components as these are generally painful to use and cannot be worn with shoes. Foot exercises may be helpful if one is diligent in doing them. Rest, ice, and pain medication such as NSAIDs or acetaminophen can also be helpful in managing pain.
While the toes are flexible, they are more amenable to digital splints, padding, toe socks, and toe exercises. Once the joint contracture is stiff and not reducible conservative treatment is limited to some types of padding and shoes with enough room for the toes. Surgical hammertoe correction can be helpful if conservative care does not provide adequate relief.
If you are having significant pain and discomfort, your symptoms are limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Corns are calluses, and the terms are often used interchangeably. A callus is a thickened area of skin. Sometimes these have a central core of hard thickened tissue which can feel like a small pebble or sharp object is digging into the foot. Calluses are caused by pressure or rubbing, such as from bony prominences from hammertoes rubbing on shoes. Calluses are generally managed, rather than cured.
Treatment:
Wide shoes, or shoes with an anatomic foot shape, where they are wider and boxier in the forefoot are recommended. Avoid shoes with design elements over the callus which cause increased stiffness and pressure from the shoe. Shoe inserts and orthotics can help with calluses on the bottom of the foot. Toe pads, toe splints, and toe socks can sometimes help with toe calluses and are generally worth a try. Gentle daily sanding the callus with an Emory board or pumice stone can be helpful. Avoid any metallic or motorized tools when doing this. IF you have diabetes, neuropathy, or peripheral vascular disease discuss DO NOT sand the callus without being cleared to do so by your foot and ankle provider. Apply moisturizing lotion topically to the callus twice daily (not between the toes) to help keep the tissue more soft and supple.
Stay away from medicated callus removers. These have salicylic acid in them which is supposed to eat away the callused tissue. Unfortunately, the salicylic acid is not selective, commonly irritates the surrounding tissue, and often causes more problems than one is trying to fix, especially for those with diabetes, neuropathy, or peripheral vascular disease.
Under some circumstances correcting the deformity causing the calluses and corns such as bunions or hammertoes, can be done surgically. Generally however, calluses / corns are managed, not cured.
If you are having significant pain and discomfort, the corn or callus is limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
A neuroma is a thickening of nerve tissue generally caused by compression, irritation, or trauma to a nerve. Problematic neuromas are often described as a tingling, burning or numb sensation which can be painful. Patients commonly report the sensation of something being stuck to the ball of the foot, or the sensation of bunched up sock.
The most common site of neuroma formation in the foot is between the third and fourth toes where two nerves join together creating a thicker nerve which is more susceptible to impingement and compression between the metatarsal bones on both sides, the deep transvers intermetatarsal ligament from above, and the ground from below. Morton’s neuroma refers specifically to a neuroma between the third and fourth toes. Intermetatarsal neuromas can occur between the other toes as well. Narrow shoes and shoes with an elevated heel can make this worse.
Treatment:
Wide shoes, or shoes with an anatomic foot shape, where they are wider and boxier in the forefoot are recommended. Shoes with a lower heel are also helpful. Shoe inserts and orthotics can also help with mechanical decompression of the nerve. Metatarsal pads / bars can be helpful with mechanical decompression of the nerve if they are correctly positioned. If they are not properly positioned, they can increase pain and symptoms. Metatarsal pads / bars work best when they are incorporated into a custom orthotic prescription.
Rest, ice, and pain medication such as NSAIDs or acetaminophen can also be helpful in managing pain. Steroid injections can be helpful when pain is significant. Serial cortisone injections can also help decrease inflammation to the nerve and associated inflammatory thickening of the nerve.
Surgical correction, such as a neuroma decompression or excision (neurectomy) can be helpful if conservative care does not provide adequate relief.
If you are having significant pain and discomfort, your symptoms are limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options.
Toe and metatarsal fractures are common and, unfortunately are frequently dismissed with the rationale “nothing can be done for them”. This is not the case.
If there is displacement, crookedness, or malalignment the fracture may need to be reduced. If there is gapping or if the fracture is unstable surgery may be necessary. Ignoring a fracture can result in chronic pain, deformity, transfer metatarsalgia, arthritis, delayed healing, or non-union.
Fractures involving or through a joint (intra-articular) significantly increase the risk of arthritis and pain in the future. Ensuring optimal alignment of joint fractures is important to decrease the risk of future pain and post-traumatic arthritis to the affected joint.
Treatment:
Is it a sprain, a strain, a fracture, a bone contusion, or a stress injury? The severity of the injury determines the extent of treatment necessary. Rest, ice, and immobilization are helpful. Immobilization can range from strict non-weightbearing with crutches and a knee scooter, a tall immobilization boot, surgical shoe, or stiff soled shoe and orthotics. Vitamin D and Calcium supplementation can be helpful with bone healing.
Depending on the orientation of a toe fracture, buddy taping the injured toe to a non-injured toe can be helpful. In some cases, buddy taping the injured toe to a non-injured toe can make the problem worse. X-ray examination of the foot can help determine if buddy taping is appropriate for a toe fracture, and if so to which toe. If buddy taping is appropriate, a thin layer of padding is recommended to avoid irritation between the toes.
X-ray examination of metatarsal fractures is recommended to help determine if protected weight bearing is permitted, or whether non-weightbearing or surgical reduction and fixation are recommended.
Crooked or abnormal appearance of the toe or foot should be evaluated. If you have had an injury, pain, or discomfort schedule an appointment now for an evaluation and discussion of your feet and treatment options.
A stress fracture is a hairline crack in a bone. This is often difficult to see on x-rays, and CT or MRI imaging may be appropriate. Left untreated these hairline cracks can propagate and become fully developed fractures. Stress fractures are generally the result of overuse injuries, and among soldiers have been called March Fractures. Overuse can occur by increasing physical activity too quickly, too much, or by engaging in uneven physical activity, such as with the weekend warrior. Stress injuries are common when starting a seasonal sport when one has not been as active in the off season. Overuse can occur when old worn-out shoes which no longer protect the feet as they did when newer are used for physical activity.
RED-S
Relative Energy Deficiency in Sport (RED-S) syndrome is a condition which increases the risk of illness and injury such as stress fractures. RED-S syndrome is characterized by insufficient caloric intake to meet the body’s demands for daily activities and athletic training (disordered eating) resulting in low energy availability, hormonal imbalance (such as menstrual dysfunction or amenorrhea for women and low testosterone for men), immune dysfunction, low energy, and low bone density. In addition to injury this syndrome can result in low energy, slower recovery, decreased performance, illness, depression, and irritability. In the past RED-S was called the Female Athlete Triad before it was understood to affect male athletes as well.
Prevention:
• Supportive shoes with regular replacement
• Custom orthotics
• Cross training
• Gradually increase physical activity, by no more than 10% per week
• Vitamin D and Calcium supplementation
• Balanced diet
• Adequate rest and recovery between workouts
Treatment:
Is it a sprain, a strain, a bone bruise / contusion, stress fracture, or full-fledged fracture? The severity of the injury determines the extent of treatment necessary. Rest, ice, and immobilization are helpful. Immobilization can range from strict non-weightbearing with crutches and a knee scooter, a tall immobilization boot, surgical shoe, or stiff soled shoe and orthotics. Vitamin D and Calcium supplementation can be helpful with bone healing.
Examination is recommended to help determine if protected weight bearing is permitted, or whether non-weightbearing or surgical reduction and fixation are recommended. If you are having pain and discomfort, your symptoms are limiting physical activity, or affecting your quality of life, schedule an appointment now for an evaluation and discussion of your feet and treatment options, and to discuss how best to return to sport.
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