Foot pain in the forefoot, which can be an annoying and persistent pain in the frontal foot region, is medically known as metatarsalgia due to the metatarsal region being the main area of pain. Metatarsalgia is not a specific condition but rather a symptom of some other condition. Metatarsal pain can be caused by a series of problems which include nerve inflammation, inflammatory arthritis or a nerve outgrowth called a neuroma (Morton’s neuroma or Morton’s metatarsalgia). This condition can present in anybody but is more likely in middle-aged people and anyone pursuing high impact sporting activities.

In the actions of running and walking the body weight is transferred forwards from the rear foot to the forefoot and the first two metatarsal heads receive the majority of the force. Up to 275% of the weight of the body can be applied to the metatarsals in running, with an estimated load of over a hundred tons per foot on running a mile. The main loaded areas during fast moving and running is the forefoot. The small digital nerves running to the toes can develop inflammation, called neuritis, secondary to the biomechanical loads applied to the foot, resulting in foot pain, pins and needles and numbness.

There are typically four women to every man in numbers of sufferers from Morton’s neuroma, being most common in the forties and aggravated by tight footwear. It occurs typically in one foot and most commonly in the third metatarsal interspace between the third and fourth. Under microscopic examination it is likely that no nerve abnormality, such as a nerve overgrowth known as a neuroma, will be shown to explain any of the presenting symptoms. There is a smaller gap between the second and third metatarsals which may make this interspace more likely to develop problems with the nerve.

Narrow fronts to shoes can increase the compression between the heads of the metatarsals and in high heels the increased extension of the toes can stretch the nerves under the heads and may increase stresses when walking. Pain and pins and needles in one space between the metatarsals is the commonest symptom with some referral down to the involved toes. Symptoms can vary over a long time, with a worsening on wearing tight shoes and an easing out of footwear. Management involves foot care by reducing the compressive stresses in the forefoot to allow a reduction in pressure on the interdigital nerve.

Foot care may require the patient to alter the type of shoes normally worn but this can be difficult if the patient wants to continue with fashionable footwear. A physiotherapist or a podiatrist can assess and prescribe a metatarsal pad insole or other more complex orthotics. Some patients will find their symptoms eased by conservative strategies like this and accept the result. Local anaesthetic or a corticosteroid can be injected into the painful region but are seldom curative alone. Foot surgery for Morton’s neuroma is variable but a simple approach is to cut the ligament connecting the metatarsal heads and allow the nerve more space, keeping the nerve intact.

A progression from the initial operation is to remove the nerve thought to be giving the trouble, excising the potentially abnormal nerve length. However, regrowth of the nerve can occur and cause a neuroma, an oversensitive nerve outgrowth. The success of the two different operation types has not been established, with around 80% good results claimed for both procedures. Patients should limit their weight bearing on the foot for a week or two and then steadily return to wearing shoes again. An absence of feeling in the area between the metatarsals occurs when the nerve is removed but this is rarely a problem.

After operation there may be persistent symptoms or there may be a period of improvement followed by a recurrence of symptoms. The nerve may stay irritable if the decompression option has been taken and if the nerve has been removed the cut end may grow a neuroma which can be worse than the original presenting problem. A neuroma can be excised to treat this condition in the hope that it will not recur. This foot pain condition continues to be called Morton’s neuroma because there is no general agreement on its cause or its pathology.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Birmingham, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

categories: Back pain,injury management,sciatica,Piriformis Syndrome,pain management,sciatica,back injury,back pain relief,Frozen Shoulder,Alternative medicine,physiotherapists,physiotherapy,Health,physical fitness