Forefoot Pain

Forefoot pain encompasses diverse range of pathologies and it is estimated that around 80% of people will suffer from forefoot pain at some point in their life - females more likely than males. The most common reasons are plantar digital neuritis and problems associated with plantar plate dysfunction however, differential diagnoses, should be in your thoughts and, while this list is not exhaustive, it may include:

• synovitis
• bursitis
• capsule injury
• infection
• stress fracture
• avascular necrosis
• joint changes related to systemic disease ( i.e. R/A, O/A, metabolic) 

Plantar Digital Neuritis (Morton’s Neuroma)

Test for plantar digital neuritis (Mortons neuroma)

Plantar intermetatarsal nerve compression is also known by other descriptive terms such as; Morton’s neuroma, Morton’s metatarsalgia, interdigital neuroma, inter-metatarsal neuroma, plantar neuroma and plantar inter-metatarsal neuroma. It is a degenerative process rather than a neoplastic one and therefore is not a true neuroma. It is characterised by a painful forefoot, most commonly around the third intermetatarsalphalangeal space and more rarely in the second, first or fourth spaces. The neuroma itself is a benign fibrotic thickening of a plantar digital nerve due to irritation.

Previous studies have concluded 30-33% of the population will be affected by the condition with a mean age of 45-50 years and a prevalence 8-10 times more common in women than men due to women wearing high heeled, constricting toe box shoes. Diagnosis can usually be made reliably on history, presentation and testing without the need for further imaging

Plantar plate tear (Pre Dislocation Syndrome)

The plantar plate averages 2 cm in length,1 cm in width, and varies from 2 to 5 mm in thickness. The plate is thicker along the medial and lateral borders but also thickens directly beneath the metatarsal head. The major composition of the plantar plate contains type 1 (75%) and type 2 collagen (21%), which are woven together to create a dense fibrocartilagenous network that lends itself to weight-bearing function. The plantar plate serves as a cushion to support compressive forces transferred to the forefoot during weight bearing by functioning similar to the meniscus in the knee, also a structure characterized by type 1 collagen. Several structures interdigitate with the plantar plate including the plantar fascia, the tendon sheath of the flexor tendons, the transverse intermetatarsal ligament, the collateral ligaments, and the interossei tendons.

Drawer test for plantar plate integrity

The plantar plate has proven to be the most important isolated sagittal stabilizer of the MTP joint. Chronic injury to the plantar plate causes attritional and adaptive changes in the plantar plate (elongation, attenuation and eventually rupturing), capsule, ligaments, and intrinsic tendons, which results in dislocation and instability of the MTP joints. With rupture of the plantar plate, the proximal phalanx assumes a dorsally subluxed position. Hereby the extensor tendons cannot extend the proximal and distal interphalangeal joints and over time the plantar plate and the flexor tendons tend to shift dorso-medially. The drawer test is useful to assess structural integrity of the plantar plate (See video above).

Physical symptoms include pain at the MTPJ area of foot, however, symptoms are often vague. There can be swelling in area and increased pain on walking barefoot or when on tip toes. Patients often describe feeling like they are walking on a stone. Commonly, there is an associated deformity - but not always.

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient. 

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.  Leaflet on 'Pain in the Forefoot'

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice  
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Increased width and depth of toe box, low heel height.
  • • Give leaflet to reinforce verbal advice - NHSGGC Footwear Advice Leaflet 
  • • Alternative Shoe Lacing Options 
• Exercise Prescription
  • Stretching of calf muscles may help may help forefoot pain by reducing force on the met heads.
  • Intrinsic exercises

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Electrotherapy
• Extracorporeal shock wave therapy
• Supinatory Insoles
  • There is insufficient evidence to propose supinatory insoles for Morton’s neuroma
• No evidence to support NSAIDS in treating Morton’s neuroma (NICE, CKS 2010).
• Alcohol injection therapy
• Radio-frequency ablation
• Acupuncture
• Extracorporeal shock wave therapy
  • Low evidence of positive effect and evidence of adverse effects.

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Biomechanical assessment and prescription of Foot Orthosis

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records
• Limited evidence from small case series supports the use of footwear modifications and metatarsal pads

Corticosteroid injection

• Ultrasound guided injection may be considered in cases which are complex and a normal injection has failed or is assessed as having a high likelihood of failure.
• Steroid injections are indicated for metatarsalgia caused by capsulitis, and presence of synovitis
• offer short term pain relief but do not reduce the need for surgical intervention

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further investogation

The other reason for referral to Orthopaedics is for “Further Investigations”. 

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to orthopaedics:

• Before referring to orthopaedics ensure the following:
• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic Clinician if you are unsure whether to refer. 

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Arias-Martin, I., Reina-Bueno, M. and Munuera-Martinez, P.V., 2018. Effectiveness of custom-made foot orthoses for treating forefoot pain: a systematic review. International orthopaedics, 42(8), pp.1865-1875.
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Baquie, P., Quigley, N., Baquie, L. and Blackney, M., 2009. Persistent foot pain. Australian family physician, 38(9), p.670.
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Bardelli, M., Turelli, L. and Scoccianti, G., 2003. Definition and classification of metatarsalgia. Foot and ankle surgery, 9(2), pp.79-85.
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Bencardino, J., Rosenberg, Z.S., Beltran, J., Liu, X. and Marty-Delfaut, E., 2000. Morton's neuroma: is it always symptomatic?. American journal of Roentgenology, 175(3), pp.649-653.
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Bennett, G.L., Graham, C.E. and Mauldin, D.M., 1995. Morton's interdigital neuroma: a comprehensive treatment protocol. Foot & ankle international, 16(12), pp.760-763.
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Briggs, P.J., 2006. Morton's neuroma. British Journal of Hospital Medicine (2005), 67(2), pp.68-71.
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Caio Nery, M.D., Hilary Umans, M.D. and Daniel Baumfeld, M.D., 2016. Etiology, clinical assessment, and surgical repair of plantar plate tears. In Seminars in musculoskeletal radiology (Vol. 20, No. 2, pp. 204-212).
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Coughlin, M.J., 2000. Common causes of pain in the forefoot in adults. The Journal of bone and joint surgery. British volume, 82(6), pp.781-790.
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Dedmond, B.T., Cory, J.W. and McBryde Jr, A., 2006. The hallucal sesamoid complex. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 14(13), pp.745-753.
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Deland, J.T., Lee, K.T., Sobel, M. and DiCarlo, E.F., 1995. Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot & Ankle International, 16(8), pp.480-486.
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Deshaies, A., Roy, P., Symeonidis, P.D., LaRue, B., Murphy, N. and Anctil, É., 2011. Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head. The Foot, 21(4), pp.172-175.
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Dhinsa, B.S., Bowman, N., Morar, Y., Chettiar, K., Wiffen, L., Armitage, A. and Skyrme, A., 2010. The use of collagen injections in the treatment of metatarsalgia: a case report. The Journal of Foot and Ankle Surgery, 49(6), pp.565-e5.
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DiPreta, J.A., 2014. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Medical Clinics, 98(2), pp.233-251.
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Doty, J.F., Coughlin, M.J., Weil, L. and Nery, C., 2014. Etiology and management of lesser toe metatarsophalangeal joint instability. Foot and ankle clinics, 19(3), pp.385-405.
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Fadel, G.E. and Rowley, D.I., 2002. (iv) Metatarsalgia. Current Orthopaedics, 16(3), pp.193-204.
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Farris, D.J., Kelly, L.A., Cresswell, A.G. and Lichtwark, G.A., 2019. The functional importance of human foot muscles for bipedal locomotion. Proceedings of the National Academy of Sciences, 116(5), pp.1645-1650.
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Federer, A.E., Tainter, D.M., Adams, S.B. and Schweitzer, K.M., 2018. Conservative management of metatarsalgia and lesser toe deformities. Foot and ankle clinics, 23(1), pp.9-20.
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Fishco, W.D., 2007. How to address predislocation syndrome of lesser MPJs. Podiatry Today, 20, p.76.
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Frey-Ollivier, S., Catena, F., Hélix-Giordanino, M. and Piclet-Legré, B., 2018. Treatment of flexible lesser toe deformities. Foot and Ankle Clinics, 23(1), pp.69-90.
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Garcia, L., Abramov, R., Iversen, S., Sohal, A.S. and Weiss, L., 2010. Poster 189: Peripheral Vascular Disease Presenting as Metatarsalgia: A Case Report. PM&R, 9(2), pp.S86-S87.
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Goldmann, J.P., Sanno, M., Willwacher, S., Heinrich, K. and Brüggemann, G.P., 2013. The potential of toe flexor muscles to enhance performance. Journal of sports sciences, 31(4), pp.424-433.
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Greenfield, J., Rea Jr, J. and Ilfeld, F.W., 1984. Morton's interdigital neuroma. Indications for treatment by local injections versus surgery. Clinical orthopaedics and related research, (185), pp.142-144.
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Gregg, J., Marks, P., Silberstein, M., Schneider, T. and Kerr, J., 2007. Histologic anatomy of the lesser metatarsophalangeal joint plantar plate. Surgical and Radiologic Anatomy, 29(2), pp.141-147.
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Hassouna, H. and Singh, D., 2005. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthopaedica Belgica, 71(6), p.646.
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Hughes, R.J., Ali, K., Jones, H., Kendall, S. and Connell, D.A., 2007. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. American Journal of Roentgenology, 188(6), pp.1535-1539.
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Kelly, L.A., Kuitunen, S., Racinais, S. and Cresswell, A.G., 2012. Recruitment of the plantar intrinsic foot muscles with increasing postural demand. Clinical biomechanics, 27(1), pp.46-51.
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Kilmartin, T.E. and Wallace, W.A., 1994. Effect of pronation and supination orthosis on Morton's neuroma and lower extremity function. Foot & ankle international, 15(5), pp.256-262.
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Kim, M.H., Yi, C.H., Weon, J.H., Cynn, H.S., Jung, D.Y. and Kwon, O.Y., 2015. Effect of toe-spread-out exercise on hallux valgus angle and cross-sectional area of abductor hallucis muscle in subjects with hallux valgus. Journal of physical therapy science, 27(4), pp.1019-1022.
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Lee, M.J., Kim, S., Huh, Y.M., Song, H.T., Lee, S.A., Lee, J.W. and Suh, J.S., 2007. Morton neuroma: evaluated with ultrasonography and MR imaging. Korean journal of radiology, 8(2), pp.148-155.
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Maas, N.M., van der Grinten, M., Bramer, W.M. and Kleinrensink, G.J., 2016. Metatarsophalangeal joint stability: a systematic review on the plantar plate of the lesser toes. Journal of Foot and Ankle Research, 9(1), p.32.
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Makki, D., Haddad, B.Z., Mahmood, Z., Shahid, M.S., Pathak, S. and Garnham, I., 2012. Efficacy of corticosteroid injection versus size of plantar interdigital neuroma. Foot & ankle international, 33(9), pp.722-726.
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Matthews, B.G., Hurn, S.E., Harding, M.P., Henry, R.A. and Ware, R.S., 2019. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis. Journal of Foot and Ankle Research, 12(1), p.12.
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McClelland, D., Darb, A. and Hay, S., 2002. Rheumatoid nodule as a cause of Morton's metatarsalgia. Foot and ankle surgery, 8(2), pp.111-113.
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Mendicino, R.W., Statler, T.K., Saltrick, K.R. and Catanzariti, A.R., 2001. Predislocation syndrome: a review and retrospective analysis of eight patients. The Journal of foot and ankle surgery, 40(4), pp.214-224.
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Mickle, K.J., Caputi, P., Potter, J.M. and Steele, J.R., 2016. Efficacy of a progressive resistance exercise program to increase toe flexor strength in older people. Clinical Biomechanics, 40, pp.14-19.
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Naraghi, R., Bremner, A., Slack-Smith, L. and Bryant, A., 2016. The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma. Journal of Foot and Ankle Research, 9(1), p.46.
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Nunan, P.J. and Giesy, B.D., 1997. Management of Morton's neuroma in athletes. Clinics in podiatric medicine and surgery, 14(3), pp.489-501.
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Poon, C. and Love, B., 1997. Efficacy of foot orthotics for metatarsalgia. The Foot, 7(4), pp.202-204.
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Rasmussen, M.R., Kitaoka, H.B. and Patzer, G.L., 1996. Nonoperative treatment of plantar interdigital neuroma with a single corticosteroid injection. Clinical Orthopaedics and Related Research®, 326, pp.188-193.
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Richardson, G.E., 1999. Hallucal sesamoid pain: causes and surgical treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 7(4), pp.270-278.
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Rome, K. and McNair, P. eds., 2014. Management of Chronic Musculoskeletal Conditions in the Foot and Lower Leg E-Book. Elsevier Health Sciences.
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Rout, R., Tedd, H., Lloyd, R., Ostlere, S., Lavis, G.J., Cooke, P.H. and Sharp, R.J., 2009. Morton's neuroma: diagnostic accuracy, effect on treatment time and costs of direct referral to ultrasound by primary care physicians. Quality in primary care, 17(4), pp.277-282.
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Saygi, B., Yildirim, Y., Saygi, E.K., Kara, H. and Esemenli, T., 2005. Morton neuroma: comparative results of two conservative methods. Foot & ankle international, 26(7), pp.556-559.
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Sharp, R.J., Wade, C.M., Hennessy, M.S. and Saxby, T.S., 2003. The role of MRI and ultrasound imaging in Morton’s neuroma and the effect of size of lesion on symptoms. The Journal of bone and joint surgery. British volume, 85(7), pp.999-1005.
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Taddei, U.T., Matias, A.B., Ribeiro, F.I., Bus, S.A. and Sacco, I.C., 2020. Effects of a foot strengthening program on foot muscle morphology and running mechanics: a proof-of-concept, single-blind randomized controlled trial. Physical Therapy in Sport, 42, pp.107-115.
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Thomson, C.E., Beggs, I., Martin, D.J., McMillan, D., Edwards, R.T., Russell, D., Yeo, S.T., Russell, I.T. and Gibson, J.A., 2013. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. JBJS, 95(9), pp.790-798.
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Thomson, C.E., Gibson, J.A. and Martin, D., 2004. Interventions for the treatment of Morton's neuroma. Cochrane Database of Systematic Reviews, (3).
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Van Leeuwen, K.D.B., Rogers, J., Winzenberg, T. and van Middelkoop, M., 2016. Higher body mass index is associated with plantar fasciopathy/‘plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British jour
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Wagner, E. and Ortiz, C., 2011. The painful neuroma and the use of conduits. Foot and Ankle Clinics, 16(2), pp.295-304.
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Waldecker, U., 2001. Plantar fat pad atrophy: a cause of metatarsalgia?. The Journal of foot and ankle surgery, 40(1), pp.21-27.
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Waldecker, U., 2004. Limited range of motion of the lesser MTP joints—a cause of metatarsalgia. Foot and ankle surgery, 10(3), pp.149-154.
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Williams, G., Kenyon, P., Fischer, B. and Platt, S., 2009. An atypical presentation of hallucial sesamoid avascular necrosis: a case report. The Journal of foot and ankle surgery, 48(2), pp.203-207.
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