It’s no surprise that pain and injury to the ball of the foot is so common. They get jumped on, kicked against, shoved into and squished continuously throughout our day.
It is all of this, plus the body weight loads (which can be well in excess of 5 times your body weight) compounded over 10-15,000 steps per day that can lead to symptoms and problems arising.
Different types of forefoot conditions
To begin, let's split the ball of your foot and the problems that go with it, into two separate categories. The first, is all things big toe joints (first metatarsal phalangeal joint). The second, moreso around and in between the smaller joints (the second to fifth metatarsal phalangeal joint.
1st MTPJ (Big toe Joint)
OA/HAV
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Boney change involving lipping, growth and lateral deviation of the big toe
Capsulitis
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Inflammation & thickening around joint lining
Sesamoiditis
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Inflammation around 2 small bones under the big toe joint
Lesser MTPJ (small toe joints)
Bursitis
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Thickening and inflammation of the bursae (fluid filled sac) between the joints
Capsulitis
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Inflammation & thickening around joint lining
Plantar Plate injury
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Tear or rupture to the long ligament underneath these joints
Neuroma
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Thickening to the nerve bundle between the joints
Boney Pathology
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Stress reaction, Fracture, Necrosis of Metatarsal head
Why do we get forefoot conditions?
The simple answer is because of the amount of load, or more simply work, that the specific structure in the ball of your foot is having to do.
Currently, and potentially for a little while now the specific structure isn't able to tolerate the demands which are being placed on it, and therefore it is making changes to the integrity and function of itself to adapt.
Commonly this involves a thickening or breakdown of the tissue or bone in combination with inflammation and pain.
The major contributing factors to these conditions are:
Decrease strength
This is a big one. Our feet undertake an incredibly large amount of load with every step we take. Some of the joints within our feet take well in excess of 5 times our body weight.
Therefore if the soft tissue structures within our limbs aren’t strong enough to control these forces then they will fatigue early, adapt and create movement pathways compensating for this.
Simply, place the load elsewhere. As a result the foot and lower limb will be experiencing increased amounts of pressure and force through structures which aren’t specifically designed to tolerate it.
They can put up with this for a little while, however once a certain threshold is met, they will in the short term become inflamed, grump and sore. However in the longer term it will structurally adapt, and this is where a lot of the ongoing issues begin.
Reduction in pedal ranges
If specific joints within our feet, ankles, knees and hips aren’t able to flex, extend, roll or lift as much as we need them to, then we will find a way to create more range through other joints.
This is extremely true for the ankle and big toe joint. If these joints are limited then we are forced to place more pressure though the outside of the ball of our foot or the inside of our big toe.
It is this change to loading pattern outside of the most efficient pathway results in an acceleration in the above mentioned changes and increased risk of developing pain within the forefoot.
Increase in activity loads
As you can imagine, if there has been a sudden increase in demands on a certain structure, then this will put it more at risk of becoming overloaded or sore. Particularly those that are repetitive and highly loaded by nature. Activities that include:
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Jumping or bounding
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Sprinting or uphill running
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Barefoot or uneven surfaces
Will all contribute to an increase in load to the ball of your foot.
Footwear selections
A very common contributor. Here there are a couple of very specific characteristics that increase loads to the front of the foot. These are shoes that are:
Flexible or narrow
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Think ballet flats, thongs or clip ons
Higher heeled or unstable
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Think Stilettos, heeled boots
Studs
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Think football boots, cricket & golf shoes
Foot type & characteristics
Specific foot shapes and structures typically correspond to typical loading patterns, joint ranges and rates of movement. Here we are talking about Pes Cavus (higher arched) or Planus foot (lower arched) foot types which can increase the rate of development of conditions such as:
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HAV (Osteoarthritic change to the big toe joint or “bunions”)
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Clawing/retraction of digits
How to treat forefoot conditions
Strength
In particular Intrinsic foot and calf strength. These guys are the main controllers when it comes to the propulsive phase (when going up on our toes) though gait. If we do not have the strength to efficiently control this motion, then we will subject these structures on the ball of the foot to more work then they can tolerate!
Shoes
There are specific characteristics which can help when it comes to pain and load through the ball of the foot. So we are going to address both.
Look for:
Rigidity, Cushion & Width + Rocker ideally
This is because all of the above are going to help reduce the range demanded, load exposed to and compressive forces placed on the metatarsals.
Orthotics
Here we are able to specifically offload symptomatic tissue whilst helping to address some of the major contributing biomechanical factors.