Bursitis

Having pain at the front of your foot can be frustrating, disheartening and very limiting in terms of being able to complete daily tasks comfortably. With the foot being a complex structure with many joints, muscles, tendons, ligaments and nerves running through the forefoot, there are many problems that can arise, all of which require a unique and tailored approach to treatment.

Pain at the front of the foot is often labelled as ‘metatarsalgia’ by health professionals, despite this being a broad term that is not a specific condition itself, but encompasses a range of forefoot problems and conditions. It is often used while the formal diagnosis is uncertain.

Forefoot pain, or metatarsalgia, is common because of the large amount of weight the joints and tissues at the ball of your foot and the toes take on with every step. During every part of your gait cycle where one foot is in the air, the other is bearing your entire body weight. This is a very large demand on any structure of the body, and why it’s essential to always support our feet with the right footwear, take good care of our feet, and treat any aches or niggles as they arise - before they get worse.

As forefoot pain has a wide range of causes, we’ve focused on five of the top causes that our podiatrists see and treat in our clinic.

1. Capsulitis

Capsulitis means that the capsule surrounding one of your joints (in this case being present in the forefoot) has been damaged and inflammation has resulted. This can compromise the function of the joint, and you can become vulnerable to injuring the tissues and structures surrounding the joints, suffering joint dislocations, and experiencing a great deal of pain. 

Capsulitis is typically an overuse injury, meaning that it arises when the joint capsule is excessively overloaded over time. Overuse can occur from anything like having a long day hiking uphill and placing much more pressure on the forefoot than usual, wearing high heels which place the most pressure on the forefoot, having tight calf muscles that cause an early heel lift and greater pressure on the forefoot with every step, or from foot deformities like bunions or claw toes.

Capsulitis may also occur alongside synovitis, where the connective tissue that lines the joint capsule, called the synovium, becomes swollen and inflamed.

2. Plantar Plate Tear

Each of the joints at the ball of your foot is surrounded and protected by a joint capsule. The plantar plate is a thick tissue that sits at the bottom of each of these joints. As the ball of the foot takes a lot of pressure with every step, the plantar plate is often exposed to high loading forces. When the plantar plate is excessively overloaded, it can become damaged and may tear.

If you’ve injured your plantar plate, you may experience pain and swelling directly beneath a joint at the ball of the foot, you may notice a ‘V’ sign where the affected toe and the one next to it appear to drift apart, you may feel like you’re walking on the bones of your feet, and your pain is likely to worsen when you toes are pushed upwards (dorsiflexed) towards the sky. These symptoms occur because the plantar plate plays an important role in stabilising the toes, helping prevent your toes from being pushed too far upwards (hyperextending), helping you push up off the ground during walking and running, and more.

3. Morton’s Neuroma

A Morton’s neuroma, also known as an ‘intermetatarsal neuroma’, describes the irritation and swelling of the tissue that surrounds a nerve in your foot. As our nerves are responsible for our ability to feel, a swollen nerve can produce an array of unusual sensations in our feet, including tingling, burning and numbness. A Morton’s neuroma most often develops between the third and fourth toes and occurs when the nerve is repetitively compressed or irritated, resulting in swelling.

With a neuroma, you can often feel a distinct, painful mass between two long bones of the feet - and this mass may ‘click’ if you move the bones around it with your fingers, up and down. It may feel like you’re walking on a pebble. If you put your hands on the outer borders of your foot, and squeeze them together, this usually causes pain with a neuroma - as will anything that puts pressure on it like tight or heeled shoes.

Neuromas are often differentiated from other causes of foot pain by the presence of the nerve-related symptoms we mentioned earlier - numbness, tingling, pins and needles, burning and more. Muscle and joint problems don’t tend to carry these symptoms unless a nerve is involved.

4. Bursitis

Bursitis describes the inflammation of a bursa - a small, fluid-filled sac that sits between structures in the body to help prevent painful friction and rubbing, while promoting lubrication and healthy movement. There are bursa located all around our body, including the forefoot, particularly between the long bones of the foot. 

Bursitis occurs when a bursa is overloaded, which may occur from excess pressure of walking, standing for long periods, or even from rubbing from tendons or other structures. This results in swelling, pain and tenderness in the area, which can make it difficult to walk and wear shoes comfortably. As inflamed bursae can press on a nerve, you may also experience neural symptoms like tingling, burning or numbness. Sometimes, both bursitis and a neuroma can occur simultaneously.  

5. Arthritis

Arthritis is another common cause of pain at the front of the foot. While there are over 100 different types of arthritis, the three that we see and help manage most commonly include:

• Osteoarthritis: Osteoarthritis is the wear and tear arthritis that develops slowly over time as the cartilage that covers your bone ends wears down. The cause is largely from natural use over many years, though injuries, alignment issues within the joint and other diseases may result in it developing at a faster rate. We often see arthritis in the big toe joint, which not only causes pain but can significantly affect a person’s gait.

• Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune disease that affects the joints. It occurs when your body’s immune system attacks the joints and causes damage, inflammation and pain. If the effects of rheumatoid arthritis remain uncontrolled, it can cause permanent changes in the appearance of the joints, especially at the feet and hands, and particularly in the metatarsophalangeal joints in the ball of the foot.
• Gout: Gout is an inflammatory arthritis that results from a high concentration of uric acid in the blood. It is associated with a high intake of purine-containing foods like red meats and shellfish. Gout feels like sharp, painful crystals in the joints. Often, this is in the big toe or the joints of the feet and can be incredibly painful during a flare.

As forefoot pain can have a wide range of causes that go far beyond the five we’ve provided today, caring for your feet at home is focused around managing your symptoms to give you relief until you can book in with your podiatrist. You may be able to try:

• If your forefoot feels inflamed, you can apply ice to the area for 15 minutes at a time, taking a break between icing sessions. Be careful not to apply the ice directly to the skin, instead wrap it in a tea towel or other protective layer. Alternatively you can place your foot in an ice bath for the same time, doing so a few times per day.
• To help with pain, you may use non-steroidal anti-inflammatories (NSAIDs) to help give you some relief
• Avoid any action that exacerbates your pain. This will likely include standing on your tiptoes
• Keep your feet supported in good shoes, even inside the home. This can help reduce the stress on the damaged, painful area, and help reduce your symptoms
• If you already have orthotics at home, wear them, and continue to do so if they are helping you get relief from your symptoms

Importantly, book in with a podiatrist at your earliest convenience. Due to the location of the injury or pain, if you continue to walk and apply pressure to your forefoot without seeking the right medical care, there is a strong chance that your injury and pain may worsen. Booking an early appointment will help get you out of pain and back to walking comfortably as quickly as possible.

If you’re experiencing pain at the front of your foot, your appointment will start with a comprehensive assessment to understand which structures have been injured, and how and why this has occurred. Once we know this, our podiatrists will put together an evidence-based management plan that supports you in getting the best outcome for your pain and injury, while helping reduce the likelihood of the problem recurring in the future. This may involve:

• Footwear advice or modifications: to ensure your footwear is supporting your recovery and keeping you pain-free, instead of contributing to the development or perseverance of the problem
• Custom foot orthotics: to help offload the painful structures in order to alleviate pain and support healing, while also supporting an optimal gait
• Immobilsation: in severe cases, like with a fracture of a soft tissue tear, immobilising the foot using a moon boot or CAM walker may be the gold standard approach to helping you get the best results
• Stretching and strengthening program: many contributing factors to forefoot pain include tightness of weakness in the muscles and tissues. Part of your assessment always looks at whether any discrepancies are present, and then addresses them appropriately
• Strapping: by strapping the foot in a specific way, we can help alleviate pain and help offload the affected area. An example is using ‘plantarflexion’ taping for a plantar plate tear, and ‘buddy strapping’ for a turf toe
• Temporary offloading/padding: by placing temporary felt padding inside of your shoes, we can help offload the painful area beneath your forefoot to give you relief, while supporting healing