Hello, my name is Dr. Jairo Cruz Jr of Advanced Podiatry, and I’m here to talk to you today about ball of foot pain. Recently, a few patients have been coming in with specifically pain in the ball of the foot right underneath the second toe. There’s many different diagnoses that can cause that type of pain and I figured I would talk about the most common ones in order to educate the population as to why this is occurring to their foot.
So, what the patient will typically come in with is a complaint saying that every time they take a step, they feel pain on the bottom of their foot and it’s kind of a diffuse pain across the ball of their foot maybe involving the first, second and third digits, and the adjacent metatarsals of that area.
So, I do my initial exam and I check for pulses and neurological sensation and the regular things of that nature. But then, on my musculoskeletal exam, I become very focused on where the pain exactly is. What I typically do is I will push on each metatarsal head—if you have trouble visualizing what a metatarsal is, here is a model of the foot and these are the digits or the toes, and then the bones behind it are the metatarsals—so what I’ll do is I’ll isolate each metatarsal, and push with my thumb on each one in order to determine where the pain is coming from or where the maximum point of tenderness is on the foot.
What I’ll also do is once I identify where the pain is—it’s typically the second metatarsal—I’ll also take the toe of the second metatarsal and dorsal-flex it up, so that I can see if moving the toe’s tendons causes an increase in symptoms or increase in pain at the bottom of the foot, and typically it does if it’s a certain type of condition which we’ll talk about a little later.
Also what I do is I squeeze the foot together—squeeze the metatarsal heads together—in order to feel if there’s any kind of palpable click in the remainder of the foot. And again, that’s diagnostic for another pathology which we’ll talk about it in a little while as well.
But initially on my exam, I will determine again where the point of maximal tenderness is and therefore there will leave me to my diagnosis typically within the first three minutes of the visit.
So, let’s go with the first option. Let’s say it’s the second metatarsal that hurts and that with pain directly upon palpation of that area it hurts. And also, there’s pain with dorsal-flexion or raising of the second toe when I complete that maneuver and the patient complains of pain.
What I’ll then do is I’ll have the patient stand up and I’ll look to see whether or not when they stand is their toe when standing up and deviated any which way? So, it may be up and deviates to the lateral side or the medial side. But it’s usually deviated in some way, shape or form if it’s this type of problem which I’m suspecting.
And the problem I’m suspecting is that it’s a type of sprain of a ligament at the bottom of the second metatarsal or the toe joint of the second toe. So, when there’s a compromise in the ligament, the structures of that area, the toe can raise up spontaneously and also deviate left or right depending on which side the pathology is, and that typically is a great sign for me to say, okay, I know what the diagnosis is: it’s a sprain or in other words a plantar plate rupture, and therefore we can begin treatment of that pathology.
So, what do we do specifically for a plant or plate rupture? Initially, obviously we exhaust all conservative measures. So, what we do is we tape the toe in a downward position or in plantar flexed position, so that it re-approximates or brings together the ligament on the bottom of the metatarsal toe joint. By re-approximating those two edges, we can allow the body to heal it and therefore decrease symptoms of the patients.
Also what we’ll do is we’ll place the patient in an orthotic, the orthotic essentially is a device that supports the foot. And what the idea is, is to support the bottom of the foot, so that less pressure is occurring at the second metatarsal, at that bone, so that again we offload the foot in order to make the foot feel better. And this allows the foot to properly heal.
Another thing we may do is we may use cortical steroid injections to decrease inflammation in that area. So, essentially the doctor will administer a small amount of cortical steroid into the second metatarsal and therefore decrease symptoms.
Icing, decreasing the swelling, decreasing inflammation with rest, and icing, and elevation of the limb also does work at home and the patient is encouraged to do so frequently.
The other thing that we may add to the therapy line is that we may add padding to the bottom of the foot as well. So, we have straps and pads available at our office that allow for a decrease in pressure of the second metatarsal.
The other thing we have to look at after utilizing conservative methods is why this pain is occurring. Yes, the pain can occur because of overuse or because of a traumatic incident or an injury, and also it can happen just with daily walking. But sometimes, there’s a bio-mechanical cause to the problem meaning sometimes the first toe has a hyper-mobile or increased range of motion. And what that means is the first toe which is typically the area of the foot where we push off during gate, it decreases pressure by lifting up or dorsiflexing. So, when it lifts, it puts more pressure on the second during the gate cycle. So, with the increase in pressure, it can cause these types of injuries or this type of pathology because of the overuse or increased use of the second metatarsal because of the fact that the first metatarsal—the area that usually takes the brunt of the weight—is now abnormally moving out of the way and therefore causing undue pressure on the second and adjacent metatarsal heads.
The other problem is that the second metatarsal or this bone right here—this second metatarsal, here’s the first, the second, the third, the fourth and the fifth—the second metatarsal is typically the longest metatarsal. And with that sometimes it can be even longer, abnormally long, and cause increased pressure inherently. So, a person can be born with this condition and therefore they’ll develop symptoms overtime throughout their life and therefore need to seek treatment for this type of pathology.
Again, conservative measures are typically exhausted before we consider any kind of surgical intervention. And if surgical intervention is warranted, it’s usually because the pain is not getting better, the patient’s lifestyle is being altered and they can’t perform their daily activities of life, or their quality of life has decreased because of the pain of the second metatarsal.
That being said, surgical options will then be considered for repair of the ligament or the deformity of the toe or metatarsal and therefore the toe will be remedied that way.
Now, let’s say it’s not a plant or plate, the next differential diagnosis would be an neuroma. So, a neuroma is a nerve, to break down the word it’s nerve and oma or nerve tumor, and essentially what that means is there’s nerves running in between each of these metatarsals, and sometimes if we wear certain types of shoes, tight shoes, or if we wear high heels, or anything that makes the toes crunch together, it can cause pressure on those nerves that are running in between the metatarsals. And what will typically be felt by the patient is pain, shooting pain, radiating pain, numbness, tingling, burning in the area of again the second metatarsal, usually this area of the ball of the foot.
Upon a clinical examination, I’ll typically push again on the areas to find the point of maximal tenderness, and I won’t find that direct pressure pain on the second metatarsal head, it will be absent typically. Now, of course the human body can suffer any multiple injuries, so it can be multiple injuries at once but if we have the second metatarsal pain in conjunction with neuroma, well that’s entirely possible. But typically, you will see only pain and palpation when we press in between the metatarsal bones, not on the bone directly itself so in between the metatarsal bones is where we’ll feel the pain or where the patient will feel the pain upon the palpation of that area.
Also, what will happen is when I do the squeeze test of squeezing together the metatarsal heads, you can feel a palpable click in between the metatarsals where the neuroma is present, that’s caused a Mulder’s sign. That’s a pretty good indication that there is something going on in between the metatarsal, be it a neuroma or maybe some other inflamed soft tissue.
But nonetheless, most commonly it’s a neuroma, and that will lead me to go to get an MRI. I utilize the MRI imaging because I want to make sure that it is what it is. I don’t like to rely strictly upon clinical exam, I like to have radiographic evidence of the disease as well so that the patient knows, and that if surgical intervention is needed, we know the size of the neuroma and the baseline size of the neuroma, so therefore surgical intervention if needed can be planned appropriately to remove that neuroma.
Again, surgical intervention is typically last resort, so conservative therapy obviously exhausted. And conservative therapy is pretty much similar to the treatment of the plant or plate in that cortical steroid injects can be utilized in between the metatarsals where the XX is found to decrease the inflammation of the nerve. If we decrease the inflammation of the nerve or the swelling of the nerve, then we can have less symptoms.
Also, if we add a strap and pad to the bottom of the foot to cushion the bottom of the foot, we can decrease pressure to the area of the painful area and therefore decrease symptoms.
Again, orthotics allow for the dispersal of weight across the foot evenly and therefore there’s no crunching or squeezing of the toes—or the metatarsal heads—together if we use the orthotic. The orthotic is a great device for a multitude of pathologies, and with the orthotic it’s very effective and we encourage it greatly for the patient.
The patient again also can ice and take ibuprofen or anti-inflammatories depending on their symptoms and utilize them at home in order to decrease the symptoms of the patient.
Typically, surgical intervention is not required, but if surgical intervention is required, we consider excision of the nerve in total. If needed, again if the quality of life and the daily activities life is limited and therefore inhibited by the pathology, then we consider surgical intervention. But again, it’s avoided at all costs because if we can avoid surgery, great, we don’t need to do the surgery and we’ll just treat it conservatively.
The next most common cause of pain in the ball of the foot is synovitis or capsulitis of the metatarsal heads or the joint, the metatarsal phalangeal joint. Again, the metatarsal phalangeal joint is across here. The toes meet the metatarsal heads and they create the metatarsal phalangeal joint. Well, sometimes, that capsule can be inflamed because of any kind of trauma, or increased activity, or a change in activity, or a change in shoe gear. Quite a common occurrence in my practice is that a patient will go to a wedding or an event on the weekend and wear some kind of dress shoe, and by the end of the weekend they’re in complete pain and they can’t walk because of the fact that the shoe caused pain and symptoms to occur.
So, the simple answer of course is don’t wear those shoes anymore but usually the pain doesn’t go away right away and they need some kind of conservative intervention. So, if that’s the case and it is capsulitis, then again conservative treatment can be utilized.
So, along the same lines again, orthotics, padding to the area, injections if needed to the area to decrease inflammation, and then oral anti-inflammatories, ice, and resting of the limb are all good things to try to see whether or not you can improve the pain.
For all of these pathologies, if the pain is high enough and the patient cannot tolerate the pain and need to be off the foot, obviously at first I’m going to suspect something worse than either an sprain, or plant or plate rupture, or capsulitis. I’ll consider more along the lines of fracture to the area or something more acute, assuming that the history of the patient and the chief complain of the patient correlates with a history of trauma and therefore immediately I’ll get an X-ray and an MRI in order to determine whether or not there’s a stress fracture to the metatarsal or any other kind of fracture, or dislocation, or fracture of the digit.
These cases are more severe and therefore I treat them more like a severe condition, so I’ll have them completely non-weight bearing with either a walking boot or a cast with crutches or a knee-scooter in order to offload them from the pain. It’s a simple concept if we stay off the foot and allow the foot to heal, then the foot will heal eventually.
Sometimes, the foot needs a little help with surgical intervention but nonetheless the body can heal itself quite well on its own and therefore non-weight bearing is an excellent option of conservative therapy with any kind of severe pain to the foot.
The one thing I forgot to mention regarding conservative therapy of the plane or plate rupture is taping of the foot or the toe down in a plantar flex position. I like to describe that as a crossover taping for the toe. I’m going to add a diagram to show you how it’s done, so that you can be well versed in how to tape the toe in a downward direction or a plantar flex direction in order to reduce pain of the second metatarsal phalangeal joint. I’ll have that included in the video as a separate diagram so that it’s easily able to mimicked at home.
If you have any problems regarding these types of symptoms, be it ball foot pain, numbness, tingling, shooting pain in the ball of the foot, severe pain in the ball of the foot, swelling, a deviated digit or a raised digit when standing or at rest, please don’t hesitate to call and make an appointment at (813) 875-0555. This is a common occurrence that we see almost every other day and we treat it effectively with conservative measures. So, we’re not going to jump to surgical methods right away. If it’s warranted, again because of lifestyle changes or because of the pain and daily activities of life cannot be completed because of the pain, then surgical intervention is definitely considered. But nonetheless, conservative methods are quite effective assuming that the instructions are followed at home and the patient is inherent to the care plan.
But again, the podiatrists at Advanced Podiatry are very well versed in this type of injury and we can treat you efficiently and effectively. I look forward to seeing you and getting you back on your feet.
Thank you for your time.