There are many causes of pain in the ball of the foot. Metatarsalgia, neuromas, sesamoiditis, and 2nd metatarsal overload syndrome are the most common causes of pain in the ball of the foot.
Metatarsalgia causes a dull, achy pain under the ball of the foot which occurs with walking and is relieved with rest.
Neuromas (Morton’s Neuroma) also cause pain under the ball of the foot, but there is generally an accompanying burning into the 3rd and 4th toe. Sesamoiditis causes pain under the big toe joint, which is generally sharp with walking and dull and achy with rest.
Second metatarsal overload syndrome causes pain under the 2nd toe joint which can be sharp with walking and dull and achy at rest.
Types of Forefoot Pain
Causes: Faulty Foot Mechanics
Most of the conditions in the ball of the foot are due to faulty foot mechanics. The big toe joint is designed to carry much of the weight of the body during “push off” when walking. When the big toe joint does not carry this weight, the load is transferred to the lesser metatarsal phalangeal joints (MPJs).
During the gait cycle (walking cycle) the foot must transfer the weight from the heel to the forefoot. The calf muscle contracts and helps push the foot off the ground and propel the body forward. When the Achilles tendon and calf muscles are tight, this causes the heel to rise early and the foot to rotate out which increases the abnormal stress through the midfoot and increases abnormal pronation.
These forces contribute to midfoot collapse, the elevation of the first ray, and the transfer of weight to the lesser metatarsal phalangal joints (MPJs). Mouse over the image to the left to see a demonstration of midfoot collapse, elevation of the first ray, and resultant pressure transfer to the lesser metatarsals.
Metatarsalgia is used as a catch-all term for pain in the ball of the foot. Although faulty foot mechanics are considered the most common reason for the development of pain in this area, trauma, infection, repetitive stress, arthritis, and previous foot surgery could also contribute to pain in this area.
Pain is generally deep and dull with walking and occurs at the 2nd, 3rd, and 4th metatarsal phalangeal joints (MPJs). If you look at the image to the right you can see the metatarsals labeled, along with the MPJs. The pain is described as being diffuse, meaning it covers a broad area, but will occasionally be sharp and localized to one area.
Hammertoes can be associated with metatarsalgia. There is a retrograde force from the hammertoe which pushes back on the metatarsal phalangeal joint.
This causes excess pressure and pain and inflammation in the area. The most common area for this is the 2nd toe joint. Hammertoes can contribute to 2nd metatarsal overload syndrome.
For those with more flexible feet, when the weight is transferred to the ball of the foot, the 1st metatarsal elevates more than usual, and places a tremendous amount of force on the 2nd MPJ, as seen in the illustration above. This excess stress can result in callus development under the 2nd MPJ and pain and inflammation at the joint. The image to the right shows a common area of callus development.
Mouse over the image to see the 2nd metatarsal phalangeal joint (2nd MPJ), the joint affected in this condition. The pain is generally dull and achy when sitting or standing and can be dull or sharp when walking. It is generally sharper during propulsion, the puff-off phase of gait. At this point during walking, the most force and pressure are on the ball of the foot and for those with flexible feet and hypermobility of their first ray, the weight of the body is placed on the 2nd MPJ.
The hypermobility of the first ray is demonstrated in the image above. When the first ray is hypermobile, it cannot support the weight of the body during propulsion and the weight transfers to the 2nd MPJ.
Long 2nd metatarsal: Individuals with a long 2nd metatarsal or a short 1st metatarsal are at greater risk for developing 2nd metatarsal overload syndrome. Take a look at the X-ray shown to the right. The second long bone, called the 2nd metatarsal, is much longer than the 1st metatarsal.
Generally, the 2nd metatarsal is slightly longer than the first, but this is excessive and used to demonstrate a point. When the 2nd metatarsal is longer, the 1st metatarsal phalangeal joint cannot do its job. This causes excess pressure under the head of the 2nd metatarsal, at the joint, and results in irritation, inflammation, and pain at the joint.
Plantar Plate Tears
The plantar plate is a thick, fibrous structure at the base of each joint in the ball of the foot. The fibrous band stabilizes the toe, preventing elevation and rotation. When a tear of the plantar plate occurs it causes instability, deviation of the toe, and results in pain and inflammation around the joint.
This condition is most common in the 2nd metatarsal phalangeal joint and is a result of faulty foot mechanics, hypermobility of the 1st ray, and chronic 2nd metatarsal overload.
Chronic overload causes repetitive microtrauma to the joint and surrounding tissues, especially the plantar plate. Traumatic injuries can cause plantar plate tears, but they are not as common as chronic, repetitive stress as a result of abnormal foot mechanics.
Sesamoiditis is the pain and inflammation of two small bones under the big toe joint. These bones act like ball bearings in the foot and allow the big toe to glide up and down smoothly. These two small bones carry a significant amount of weight. When overstressed, they can become inflamed and painful.
This condition typically develops as a result of repetitive stress and is common in dancers, sports with quick sprints, sports involving a squatting position (catchers in baseball), or sports with repetitive push off on the ball of the foot, such as pitchers in softball. Individuals with high arch feet are more prone to developing this condition.
The pain is generally dull and achy when sitting and standing and sharp and sometimes stabbing when pushing off the great toe. Rest and ice tend to improve the pain and walking, running, squatting, and pushing off aggravate the pain. Area of pain in sesamoiditis
A neuroma is an inflamed nerve that causes pain in the ball of the foot which radiates to the third and fourth toes. The second and third toes are also commonly affected and this is called Morton’s Neuroma.
The pain is typically worst with standing and walking and relieved by rest. Walking in soft shoes, high-heeled shoes, narrow shoes, going up and downstairs, and squatting will all aggravate the condition.
Some will complain of deep achy pain, others complain of constant burning. It’s common to experience radiating pain, electrical pain, sharp shooting pain, or numbness. Some individuals feel as if they are walking on a lump, a ball, or a lamp cord, others complain of a “twang” in the ball of the foot. More on neuromas.
Treatments for Ball of foot Pain
All of the foot conditions listed above have separate and specific treatments. But, there are some common treatments that will benefit all people with pain in the ball of their foot.
It is important to wear a rigid, supportive shoe with a wedge at the heel. This does not mean a “high heel” shoe, but a lift at the heel or wedge shoe which is about 1″ in height.
This helps to distribute the pressure between the heel and the forefoot and decreases any stress on the calf muscles. Many of the foot problems listed above are worsened with soft, flexible shoes. The shoe should only bend at the toe, not in the middle of the shoe. To test a shoe, hold the heel and place the toe area on the floor. Press down on the shoe. If it collapses, it is too flexible.
At first, it may not seem logical that stretching the calf muscles will help with pain in the ball of the foot, but after reading the information presented above it should make more sense.
Stretching the calf will help to decrease abnormal pronation, decrease the midfoot collapse and relieve the excess pressure on the ball of the foot. Calf stretching should be performed at least three times a day. Click here to view pictures of a daily sequence of calf stretches.
For both metatarsalgia and neuromas, metatarsal pads can be a very effective treatment. The pads help by distributing the pressure more evenly under the ball of the foot and taking pressure off the area of pain. One of the most common errors with this treatment is pad placement.
The pad is NOT placed under the area of pain. The pad is placed behind the ball of the foot as seen in the picture of a HaPad Metatarsal Pad to the right. This is also helpful for neuromas because the pads spread the metatarsals, preventing rub and irritation of the inflamed nerve.
Padding can also be very effective for sesamoiditis. Specific pads, designed for off-loading the great toe joint help to distribute pressure away from the 1st MPJ. The common pad designed for sesamoiditis is called a dancer’s pad. The pad obtained its name because sesamoiditis is common in dancers.
Dancers spend a tremendous amount of time on the ball of their feet and specifically their great toe joint. This pad can be fabricated out of felt or purchased. The pad can be placed on the foot, on an insert, or inside the shoe. Many podiatrists can design a removable and reusable dancer’s pad
There is not a “magic bullet” treatment for any of the conditions discussed here. Rest, ice and anti-inflammatory medications may decrease pain and inflammation and may be appropriate treatments in addition to the solutions mentioned above. But, they are not addressing the cause of the problem.
Finding the cause of the problem by identifying the aggravating activity, poor quality shoes, and/or faulty foot mechanics and then addressing these problems, will give better long-term results for problems that occur in the ball of the foot.
If your symptoms do not improve within a few weeks, make sure to make an appointment with your podiatrist.