It is very common for us to see patients complaining of pain in the balls of the feet and toes.  There are many contributing factors and several pathologies which commonly cause this type of pain.  Problems that we see include Neuroma’s (Nerve impingements at the ball of the foot), Capsulitis/joint pain involving the metatarsophalangeal joints (where the toes meet the foot),  Stress Fractures of the metatarsals, and structural deformities (such as hammertoes and bunions).

One common cause of this type of pain is wearing high heels.  When you wear high heeled shoes, or even cowboy boots, body weight is shifted to the ball of the foot, thereby shifting all of the stresses to the ball of the foot and the metatarsophalangeal joint region.  Pointy-toed shoes and tight shoes may also be a contributing factor.   Hammertoes, bunions, and arthritic changes may cause changes in position of bones and changes or decreased joint range of motion which may also contribute to other pathologies, such as nerve impingements and abnormal mechanics of the foot and ankle that result in pain.

What is a Neuroma?  A Neuroma is an impingement of the plantar (bottom of the foot) nerves at the ball of the feet which may result in a bulbous and painful swelling and irritation of the nerve.  Common symptoms are burning pain, pain at the ball of the foot, and tingling and numbness at the ball of the foot and sometimes into the toes.  People often come in with strange sensations, such as a feeling of ‘a sock or material bunched up under or between the toes.’   Initial treatments for neuromas include injections with cortisone, oral anti-inflammatory medication, and biomechanical off-loading using orthotics and metatarsal pads.  If conservative treatments are ineffective, patients may opt for a series of Alcohol sclerosing injections to shrink and kill the nerve, or surgical excision of the nerve.  These treatments, however, are destructive and leave a patient with permanent numbness, so they are a last resort.  Contributing factors are high heels, flat feet, and hammertoes.

What is capsulitis?  Capsulitis is inflammation and irritation of the joint capsule.  This can occur at any joint, and usually arises from abnormal biomechanics of the foot and ankle.  The joint capsules are surrounded by blood vessels and nerves, and abnormal pressures may irritate them and cause inflammation, which, in turn, causes pain.  Conservative treatments include injections with cortisone, oral anti-inflammatory medication, and biomechanical off-loading using orthotics and metatarsal pads.  Surgical considerations include correction of hammertoes, and sometimes shortening of metatarsals to alleviate pressure at the ball of the foot.

What is a stress fracture?  A stress fracture occurs when there is abnormal stress or biomechanical pressure repetitively over the same bone.  This most often occurs in the metatarsals, which are the long bones before the toes.   Pain can be burning, throbbing, aching, and usually occurs after an episode of prolonged activity or exercise.  Poor shoe gear (particularly high heels and ‘minimalist’ type athletic shoes (barefoot running shoes) are a major contributor, also.  Treatments include immobilization for 2-6 weeks, depending on the severity of the situation.  Bone growth stimulators may also be used in cases where delayed healing has occurred.  Surgery is only performed in unusual circumstances.

How do Bunions and Hammertoes contribute to these problems?  Bunions change the weight bearing distribution at the ball of the foot and transfer more stress to the lesser toes and the lesser metatarsals which can contribute to any of the problems above.  Similarly, hammertoes create retrograde pressure against the metatarsals, producing more stress on the plantar nerves, the joint capsules, and the metatarsals, themselves.