What are the most common forefoot conditions causing pain?
The forefoot is classified as the metatarsals and the toes as well as the joint, nerves and other soft tissues or that area. There are numerous conditions that can affect the forefoot, however the most common are:
- First MTP joint arthritis
- Morton’s neuroma
- Freiberg’s disease
What is first MTP arthritis?
The first metatarsal-phalangeal joint (MTP) is the joint between the first metatarsal and the big toe. This is a reasonably sized joint and can suffer from arthritis like many other joint in the body. You may also get a stiff joint called a hallux rigidous (and many people especially women can get a bunion in this joint). As with other arthritic joints the toe can feel stiff and sore first thing in the morning and also when the weather is cold and wet. There may also be some pain and stiffness on exercise and the toe does not quite have its full range of movement.
What treatment is there for first MTP arthritis?
Painkillers and anti inflammatories can help settle any pain and stiffness in mild to moderate arthritis and physiotherapy to help loosen the stiff joint as well as give exercises may help strengthen the area. Sometimes people require an ultrasound guided steroid injection into the big toe joint which can help mild to moderate symptoms.
Ultrasound guided injections for MTP arthritis
What is Morton’s neuroma?
Morton’s neuroma involves a thickening of the tissue around one of the interdigital nerves that leads to your toes. It is most commonly affecting the nerve between the third and fourth toe, sometimes between the second and third time. The reason why this happens is not fully understood but it is generally believed to occur from a lack of space for the nerve to travel between the metatarsals which causes friction on the nerve and then a thickening of the nerve. Rest factors that can contribute to Morton’s neuroma include a pronated foot or wearing particularly narrow shoes which squash the metatarsal heads together.
It is characterised by a shooting, burning pain extending between the third and fourth or second and third toe accompanied with some numbness. There may also be an associated bursitis (a swelling in the bursa next to the nerve) which further decreases space for the nerve and contributes to the irritation. Morton’s neuroma diagnosed by the symptoms, and it is often times tender to palpate on the sole of the foot over the metatarsal heads most commonly between the third and fourth but sometimes also between the second and third metatarsals. When we perform a test where we squash the metatarsal heads together and then press into the interdigital space we sometimes hear, and the patient will feel a click. This is called a positive Mulder’s sign and it’s also diagnostic of Morton’s neuroma. We can ultrasound scan the nerve as well and this can sometimes show the thickened interdigital nerve and or bursitis.
What treatment is there for Morton’s neuroma?
Conservative management of Morton’s neuroma includes seeing a podiatrist and having a metatarsal dome put into your shoes to help spread the metatarsals and lessen the irritation on the nerve. It will also include changing your footwear and avoiding any narrow shoe types of squash your foot together. You may also benefit from physiotherapy and anti-inflammatories. If this is not helping we would try and ultrasound guided steroid injection into the area to see if this helps to settle the symptoms. Lastly you may need to see a foot and ankle surgeon to discuss surgical options.
What is Freiberg‘s disease?
This is often confused or misdiagnosed as Morton’s neuroma, however this is a particularly distinct condition affecting the second MTP joint, sometimes the third MTP joint. It is a pain that is felt in the knuckle joints of these toes. It is caused by a process of avascular necrosis in the head of the metatarsal bone leading to pain and inflammation in the joint. It is diagnosed with an x-ray which shows a flattening of the metatarsal head and as this progresses over time we can see gross degeneration and arthritis develop in the second or third MTP joint.
What treatment is there for Freiberg’s disease?
The treatment of Freiberg’s disease depends on the stage of the condition. It would always be wise to speak with a podiatrist and have a biomechanical gait scan to see if there are any changes that can be made to your footwear or whether you will benefit from orthotics. Taking a course of non-steroidal anti-inflammatories to lessen any pain and inflammation is also advisable in the early stage. In later stages it may be that you require an ultrasound guided steroid injection into the second or third toe MTPJ, however there is an argument that this could potentially lead to progression of the condition. Finally with progressive disease you would need to see if an ankle surgeon and discuss surgical options to manage this condition.
