Ball of Foot Pain

author : AMSSM

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Pain at the ball of the foot, or the forefoot, is a common complaint in athletes. Learn about the causes of this pain which can stem from stress fractures, neuromas and more.

Member Question

I have been having some chronic pain at the ball of my right foot. It ranges anywhere from 2-4 on a scale of 1-10 depending on what shoes I'm wearing and what activity I may be doing or have just done.  I have tried icing and massaging it with a tennis ball with no improvement even as I've gone cold-turkey on run and bike training here at the season's end.  Is there anything I can do?

Answer from Jon Kolberg MD
Member AMSSM 

Pain at the ball of the foot, or the forefoot, is a common complaint in athletes. The forefoot is the part of the foot in front of the ankle consisting of groups of bones that include the metatarsals (five long bones in the forefoot) and phalanges (the bones that make up the toes). There are many medical issues that can arise in this region due to trauma, overuse, or other factors. Forefoot pain can range from mild pain causing a slight limp to severe pain that prevents walking.  Common causes include: stress fracture, interdigital neuroma (also known as Morton neuroma), and sesamoiditis.

Stress fractures

A stress fracture is one of the more concerning potential causes of your discomfort. Metatarsal stress fractures result from repetitive stress to the forefoot, usually from running, jumping, dancing, and other repetitive weight-bearing activities. Patients with stress fractures of the metatarsal shaft describe a history of gradually worsening pain in the forefoot. Initially the pain is intermittent and occurs only with use. The patient may present with poorly defined forefoot pain or point tenderness over a metatarsal shaft. If the causative activity continues, the injury can progress, with swelling, severe pain even with normal activities, and frank fracture. 

Diagnosis is made using history, physical exam, and potentially imaging studies. They usually respond well to cessation of the causative activity. Crutches and partial weight-bearing for several weeks may be helpful in patients who have pain with walking. A short-leg cast and non-weight-bearing may be used for short periods of time in patients with severe pain.

Interdigital neuroma

Interdigital neuromas are thought to be due to swelling and scar tissue formation on the small interdigital nerves. They most commonly involve the third webspace, but may also be seen in the second and fourth. Symptoms associated with a neuroma may include sharp or shooting pain, numbness, or pins and needle sensation.  Many patients describe it as feeling like something is wadded up under the toes. It frequently can be temporarily relieved by removing the shoes and massaging the area.

Neuromas can be caused by trauma or chronic irritation. Chronic irritation can be in the form of wearing shoes that are not wide enough in the forefoot area causing compression of nerve. The irritation may also occur from abnormal mechanics of the foot causing excess motion of the metatarsal bones. 

Diagnosis can be made by using elements of the history and physical exam, or by imaging studies such as ultrasound or MRI.  Conservative treatment may include use of properly fit shoes (well cushioned with wide forefoot), metatarsal foot pads (to evenly distribute pressure to the metatarsal heads), and physical therapy (to address mechanics and strengthen the intrinsic muscles of the foot).  If conservative treatment fails, injection therapy and surgery are also considerations.

Inflammation

Inflammation or injury of the sesamoid bones located on the plantar surface of the big toe joint can also cause pain in athletes. The sesamoids are pea-sized bones that function as pulleys for tendons (just as the patella does for the knee extensors) and assist with weightbearing. The athlete with sesamoiditis typically complains of pain at the area of the big toe joint with weightbearing that is exacerbated by walking, and even more so by running. Exquisite tenderness of the sesamoids is present, and is exacerbated by pushing off with the great toe. Imaging may be required to differentiate between sesamoiditis and a stress fracture.  Both may require a short period of immobilization followed by prolonged rest from weightbearing activity. Athletes can use alternative, nonweightbearing forms of exercise to maintain fitness. Treatment with custom orthotics, soft pads cut to relieve pressure on the sesamoids, and in severe cases, glucocorticoid injections may be helpful.  Consultation with a foot surgeon is reasonable in persistent cases.

These are just a few of the potential causes of your pain, however there are many other potential causes of forefoot pain.  Discussion with your family physician or local sports medicine physician is advised.  A specific diagnosis can then be made, after a full history and physical is performed.  Appropriate treatment can also then be discussed.

Jon Kolberg MD
Sports Medicine Fellow
Oregon Health

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date: January 18, 2013