Q. I'm having pain at the base of my toes when I walk. What could it be and what can I do about it?
A. You are describing a very common problem in the part of the foot that we call the forefoot. In this part of the foot there are five long bones called metatarsal bones that angle down to meet the toes. There's a lot of force applied to this area of your foot with each step while walking or running so injuries to this area are very common. Three common conditions that will cause pain in the forefoot are metatarsalgia, Morton's neuroma and capsulitis.
Metatarsalgia is a term used to describe foot pain that is coming from the metatarsal bones as a result of excessive pressure being applied to these bones. In some cases, this can lead to a stress fracture in these bones if it isn't corrected.
Symptoms may include a dull ache or sharp pain on the bottom of the foot. Typically, symptoms of metatarsalgia increase with the amount of time spent on the feet and are relieved by rest.
The first metatarsal bone sits behind the big toe and is thicker than the rest as it takes most of the load while walking. The other four are smaller and fairly close in size. In some people their second metatarsal bone will be longer and this will lead to an increased load bearing on this individual bone and pain will be the end result over time.
Treatment of metatarsalgia focuses on correcting the biomechanics of the feet so that the extra pressure being applied to the metatarsal bones is relieved. This can be achieved with a metatarsal pad or increasing the cushion in the forefoot of your shoe. Sometimes a custom orthotic with a metatarsal pad included is required. You should look for shoes with a forefoot rocker sole and a generous toe box that will decrease the load on the forefoot (orthopedic footwear).
A Morton's neuroma is a painful condition that is caused by the irritation of a nerve as it passes between two metatarsal bones, most commonly the third and fourth. Terms that end in "oma" are often used to describe a tumor, but this is a nerve entrapment and not an actual tumor.
Symptoms include a dull, achy sensation and sometime numbness in the forefoot that will increase with more time spent on your feet. Often the pain is worse in narrow footwear or shoes with a heel. You might also have a sensation that you're walking with a pebble in your shoe or occasionally get an electric shock sensation.
The majority of patients with a Morton's neuroma can be successfully treated with a simple change of footwear to something with very little heel and a wide toe box so that the metatarsal bones have lots of room to spread out while you are on your feet. Well-positioned shoe padding - metatarsal pads - can also be helpful. These pads are placed in your shoe just behind the weight-bearing surface of the metatarsal bones where they will help to separate the metatarsal bones while walking and relieve the pressure on the affected nerve. These pads can be placed separately or positioned correctly in a custom orthotic so they can be easily moved into different shoes.
If these interventions are not completely successful, your physician may also consider a steroid injection to reduce the inflammation and swelling of the nerve, which will decrease the pain.
Capsulitis describes an inflammatory condition that can occur in the "capsule" of almost any joint in the body. The capsule is a thin layer that surrounds the entire joint. In the foot, this condition produces pain most commonly in the joint between the second metatarsal and the second toe due to excessive pressure being applied to this joint while walking. This discomfort is particularly pronounced when walking barefoot on hard surfaces and is usually relieved with rest.
The main goal in treating forefoot capsulitis is to find ways to remove the excessive pressure on the affected joints. The metatarsal pads and forefoot cushions can achieve this, but proper placement of the pads is important. A properly sized shoe with a rocker sole can also off-load the forefoot. For some people custom orthotics with special modifications to address the joints with the capsulitis are very helpful.
As with the Morton's neuroma, if conservative measures don't completely relieve the pain, then injecting steroid into the affected joint can be very effective. This should only be done in conjunction with taking steps to reduce the load on the affected joints.
In summary, forefoot pain is a common condition. Fortunately, most causes of this pain can be treated with careful attention to your foot biomechanics. You should have your gait and feet assessed by a certified pedorthist who can determine if custom orthotics or special padding in your footwear might be helpful.
Secondly, your footwear should be properly fitted with consideration to features of the shoe that will help relieve the pressure that's placed on your forefoot while you walk: low heel, wide toe box and a rocker sole. Many of these features can be found in orthopedic footwear, which are covered in many third party health plans.
Allison Rockwood is the manager of Soles in Motion (www.solesinmotion.ca) located at 121 Ilsley Avenue in the Burnside Business Park in Dartmouth, 468-7911, which offers personalized, professional footwear fittings for a wide range of athletic, walking and orthopedic footwear and sandals. Also available are assessments by a certified pedorthist for custom orthotics. Bring in a copy of this article and receive 10 per cent off (excluding bracing, orthotics, medical compression stockings, electronics and running clinics).