Pain in Bottom of Foot

author : AMSSM

comments : 2

What treatments will work to improve metatarsal pain

Question from member Steve Stenzel:

For the last month or so, I've had pain on the bottom of my left foot. The Doc said I needed Metatarsal Support, so I'm wearing this dense little pads in my "walking around" shoes and in my running shoes. It helps with the pain, but it's really not getting any better. Can anyone recommend any exercises or therapies that I should be doing?

Answer from James Suchy, MD 
Member AMSSM

Hi Steven,

I suspect your pain is in the ball of the foot or plantar metatarsal region. As you may know, your metatarsals are five bones in the forefoot that connect to your toes. Based on your description, your diagnosis MAY BE metatarsophalangeal instability, primarily because your doctor recommended metatarsal support. However, there are many causes of metatarsal pain, including pain that could be indistinguishable from metatarsophalangeal instability without further information including physical exam and imaging. Since I have limited information, I’ll explain a few of the most common causes of metatarsal pain and their treatment below.

I also want to strongly encourage you to talk with your doctor about this pain if it’s not getting better. It’s not uncommon for doctors and athletic patients to have different recovery expectations. You may expect the pain to resolve in several weeks while the doctor may have expected several months. Perhaps athletic participation is very important to you, and you’d like to expedite the process as much as possible to get back to running. Inform your doctor about your athletic goals and your frustration with the lack of improvement. It’s important for you both to be on the same page regarding your expected recovery and knowing when a therapy has failed and it’s time to consider another option. Many of the feet conditions below are chronic or long standing and even in successful cases recovery can take months.

Note: The connection that each metatarsal bone makes with each toe bone is called a metatarsophalangeal joint, or MTP joint, for short. Each toe has its own MTP joint.

Metatarsophalangeal instability – chronic inflammation of the MTP joint, usually of the second toe, with subsequent tearing of the plantar plate, a ligament-like structure that attaches at the base of the toe bones and prevents overextension of the toes. Typically people experience tenderness on the bottom base of the second toe. It may feel something like walking on a rock. In later stages, deformity develops with the affected toe crossing over/under other toes, as supporting ligaments are torn. Predisposing anatomic features include hallux valgus (see below), a long second metatarsal, high heels, or tight shoes. In athletes, this may result from an acute injury. An MRI is most helpful in confirming the diagnosis, especially in mild cases where deformity has not set in. In mild cases, your doctor would start by recommending tapping of adjacent toes or using a metatarsal pad. Flexibility exercises that focus on elongating the hamstring, plantar fascia, and Achilles tendon can reduce pressure and possibly pain on the forefoot. For instance, your plantar fascia can be stretched by standing on a stair with only the ball of your foot and lowering your heel until you feel a stretch in the arch. You can stretch the Achilles tendon by stepping one foot towards a wall, placing your hands on the wall, and then leaning in until you feel a stretch in the calf muscle. You can find many different stretches for these areas online. When conservative care fail, surgery to restore alignment of the joint is the next step.

Hallux valgus – the big toe crossing over/under the second toe. The first thing you may notice is a hard bump forming at the side of the big toe. Commonly referred to as a bunion, this deformity is simply the big toe’s MTP joint pushing on the skin. You may develop pain from irritation of the bunion by tight-fitting shoes. This condition should be readily apparent just from looking at your foot, but an x-ray may be used to determine the severity of misalignment. This condition commonly affects people with a family history of hallux valgus. Treatment starts with wider shoes, which give the bunion more space. Bunion pads can also help cushion the bunion and prevent irritation. Foot exercises may be recommended to stretch the surrounding muscles, tendons, and ligaments. Orthotics or splints can be considered after this, however a recent study showed an improvement in pain only in the short term. If all this fails or the deformity is severe enough, surgery to reshape the bone and joint may be considered; however chronic stiffness at the big toe’s MTP joint may occur after surgery.

Hallux rigidus – The name actually means rigid big toe! It is progressive arthritis at the big toe’s MTP joint. You would have pain and stiffness at the base of the big toe, exacerbated by upward flexion of this toe, which may feel limited in its range of motion. Visually, you may notice a hard bump forming at the base of your big toe on the top of your foot. You might change the way you walk to relieve pressure on the MTP joint, however this could cause ankle injury and pain in the other metatarsals of the foot. A physical exam is enough to diagnose this condition, but your doctor may get an x-ray to look for signs of joint arthritis and determine severity. This condition commonly affects athletes who do repetitive squatting motions, such as dancers. Treatment options include footwear to reduce motion of the big toe’s MTP joint, such as orthotics or stiff rocker bottom sole shoes, as well as pain medication and steroid injections. Sodium hyaluronate is a newer type of injection that may also provide benefit. Surgery to resurface or replace the arthritic joint may be the only option in severe cases.

Sesamoiditis – the sesamoids are two small, round bones underneath your big toe’s MTP joint that sit within a tendon, and provide mechanical advantage to the toe. When these bones are painfully injured either by fracture, inflammation, or other causes, it’s known as sesamoiditis. You would experience pain with pressure directly on the sesamoid bones, such as while wearing high heels or forcefully pushing your big toe into the ground. An x-ray is necessary for initial assessment of the sesamoid bones. Sometimes differentiating sesamoiditis from pain in the MTP joint itself can be difficult and your doctor may recommend injecting pain medication into the joint to make sure that’s not the cause. This condition commonly affects athletes who make forced repetitive connection between the ball of their foot and the ground, such as ballet dancers. Treatment begins with sesamoid padding to relieve pressure on the sesamoid bones, which may take many months to improve. If this fails, your doctor may recommend further imaging with an MRI or CT scan to clarify the diagnosis and rarely prepare for surgery to remove one or both sesamoid bones.

Metatarsal shaft stress fractures – microscopic trauma to any metatarsal bone that can progress to a complete fracture. In this condition, your metatarsal pain would have gradually worsened over time with physical activity and you’d have tenderness if you pushed on the affected metatarsal. Stress fractures can occur for many reasons but most commonly are seen in people who have dramatically increased their exercise load or have a history of bone disease, such as osteoporosis. Your doctor may make the diagnosis based on your history and physical exam. X-rays can help to confirm the stress fracture but may not be visible if less than 2-6 weeks old. An MRI or bone scan in this case can be used to definitively diagnose an acute stress fracture. The mainstay of treatment is avoiding any activity that exacerbates the pain for 1-2 months with a gradual return and increase in the physical activity, using pain as an indicator.

Morton neuroma – the result of enlargement and entrapment of a nerve between the metatarsals. We don’t completely understand why this occurs but we know that tight-fitting shoes and foot deformities such as a high arch are associated. Athletes and non-athletes alike can be affected, but this is most commonly seen in middle-aged women. You would notice a burning pain or tingling sensation between the webbing of your second and third toes that may worsen with weight bearing activity. Squeezing the sides of the foot with one hand, while pinching the space between the metatarsals with the other hand, consistently reproduces this pain. An ultrasound can easily diagnose this condition and distinguish it from other similar causes of pain. Therapy includes changing tight footwear, hamstring stretching, and pain medication. When this fails, surgery can remove the problematic nerve or an injection of alcohol at the site can chemically destroy it.

Metatarsalgia- a painful condition resulting from inflammation of the metatarsal bone and surrounding supportive structures due to stress over time. It occurs in runners, jumpers, and contact sports. Common causes are similar to many of the above conditions including inflexibility of the lower extremity, anatomical variation in the foot, chronic stress, and poor footwear. Treatment includes ice and pain relievers, physical therapy, and orthotics or supportive devices including a metatarsal bar support. Rarely is surgery required.

James Suchy, MD
Institution:
University of California, Irvine
Department of Family Medicine

Co author Caitlyn Mooney, MD

References:
Fields, Karl B., MD. "Evaluation and diagnosis of common causes of foot pain in adults." UpToDate. N.p., 1 Nov. 2016. Web. 15 Dec. 2016.
<https://www.uptodate.com/contents/evaluation-and-diagnosis-of-common-causes-of-foot-pain-in-adults>.

Heidelbaugh, Joel J., MD, Beth Choby, MD, and Kate Tolhurst, MD. "Metatarsal Pain: Etiologies and Treatments." AAFP. N.p., 10 Dec. 2010. Web. 15 Dec. 2016.
<http://www.aafp.org/test/fpcomp/FP-E_379/pt4.html>.

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date: January 31, 2017