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Managing forefoot pain

Consultant orthopaedic surgeon Mr James Calder outlines management options for the five most common causes of forefoot pain in the third of our series on orthopaedics

Consultant orthopaedic surgeon Mr James Calder outlines management options for the five most common causes of forefoot pain in the third of our series on orthopaedics

Forefoot pain is a common presentation in general practice. The five most common causes of pain and forefoot deformity – hallux valgus, hallux rigidus, lesser toe deformities, metatarsalgia and Morton's neuroma – are considered here.

Hallux valgus

This is one of the most common problems of the forefoot – it may lead to a painful bunion. There is often a strong family history. Shoes play a part in their formation but they are not totally to blame.

The bunion itself is a combination of the prominent medial bony eminence of the metatarsal head and inflamed soft tissue overlying it caused by rubbing on shoes.

As the weight-bearing area of the foot changes, more pressure may be placed on the lesser metatarsal heads leading to transfer metatarsalgia pain. There may be a build-up of hard skin beneath this (plantar keratosis) and eventually a hammer toe deformity may develop.

What's the treatment?

Wider-fitting shoes may help reduce pain and the size of the bunion. If there is significant pes planus, a medial arch support may help to reduce the deforming force. A chiropodist can pare down the keratosis and reduce painful loading of the second metatarsal head.

The best reason to consider surgical correction is pain. Surgery purely to improve the appearance is fraught with problems and patient dissatisfaction.

When there are secondary problems from the lesser toes – transfer metatarsalgia – the deformity is starting to decompensate and an alteration in pressure loading may cause the development of a hammer toe deformity and later dislocation of the second metatarso-phalangeal joint.

Surgery aims to help this, too. Modern operations now address the underlying anatomical alignment problems and not just the bunion, offering longer-lasting and more predictable results than was the case even 10 years ago.

Hallux rigidus

Osteoarthritis of the first metatarso-phalangeal joint may lead to stiffness of the joint and the development of osteophytes. These are often on the dorsal aspect of the metatarsal head and restrict joint dorsiflexion. This leads to pain particularly when walking or running and difficulty standing on tiptoes. With progression, there may be more global arthritis, severe restriction in movement and pain at rest.

What's the treatment?

An orthotic with a rigid support under the first metatarso-phalangeal joint may improve pain by limiting movement of the joint. A shoe with a rocker-bottom may help.

In early stages, removal of the dorsal osteophytes can lead to a dramatic improvement in both pain and movement.

The later stages are normally treated by fusion of the first metatarso-phalangeal joint, giving excellent pain relief. Patients are often concerned they will find it hard to walk because of a stiff toe. This is rarely the case as patients often have limited movement pre-operatively and flexibility of adjacent joints enables a normal walking gait and return to jogging and so on.

There are some patients who may be suitable for surface replacement of the first metatarsal head. This new technique allows movement in the first metatarso-phalangeal joint by removing and then replacing the arthritic cartilage.


This causes pain directly under the lesser metatarsal heads and is often associated with a build-up of hard skin (plantar keratosis). The pain is usually worse when walking barefoot or in heels. It is caused by uneven transfer of pressure across the forefoot and often occurs as hallux valgus progresses and the pressure is transferred from the weight-bearing first metatarso-phalangeal joint more laterally – transfer metatarsalgia. It usually affects the second metatarso-phalangeal joint but as the great toe continues to deviate, the third and fourth metatarso-phalangeal joints may become involved. As the condition worsens, a plantar ligament of the metatarso-phalangeal joints may rupture, leading to hammer toe deformity (see below) or divergent lesser toes.

What's the treatment?

Wearing flat, soft-soled shoes may reduce the pain and chiropody to pare down the plantar keratosis will help. An orthotic device to redistribute the pressure across the forefoot may reduce symptoms. If conservative measures fail, then a day-case operation – Weil osteotomy – to lift the metatarsal head and shorten it slightly may be performed. If hallux valgus is an underlying problem, this is usually corrected at the same time.

Hammer, claw and mallet toes

Hammer toes are often associated with hallux valgus and transfer metatarsalgia.

Claw toes may be congenital and also associated with neurological conditions such as Charcot-Marie-Tooth and may be present in pes cavus (high-arched feet).

Mallet toes are also congenital – often, a parent may have a mallet deformity of the same toe.

What is the treatment?

Surgery is not needed unless the patient is symptomatic. If there is metatarsalgia without hallux valgus, this may be helped with orthoses, which can redistribute pressure across the forefoot. Painful rubbing of shoes from the prominent proximal-interphalangeal joint or the end of the toe may be treated as a day case by simply cutting a tendon or, if the deformity is fixed, fusing the deformed joint straight. Once again, pain is the primary reason to consider surgery.

Morton's neuroma

This is the result of enlargement and inflammation of the interdigital nerve. The cause is repeated injury as the nerve gets trapped between the metatarsal heads when standing and walking. This most often occurs in tight shoes or those with high heels and thin, hard soles. It usually occurs between the third and fourth toes.

The symptoms of Morton's neuroma are pain and numbness in a specific spot on the ball of the foot, sometimes radiating to the toes. At times the pain may be absent and, at other times, severe enough to cause the individual to stop and take off the shoe. It may feel like a stone or marble under the foot, moving around and sometimes causing a sharp ‘snap' to be felt. This may often be demonstrated by pressing on the plantar aspect between the metatarsal heads and squeezing the sides of the foot – a positive ‘click' that reproduces the pain is called a Mulder's click. Ultrasound and MRI scans are rarely required as they not adequately sensitive or specific.

What is the treatment?

Advice to avoid tighter shoes is often impractical. Orthoses may be tried but are rarely successful or tolerated. An ultrasound-guided injection of steroid and local anaesthetic may help in nearly 30% of patients. Alcohol injections into the neuroma have also be tried with some success. Day-case surgical excision of the neuroma offers good long-term abolition of symptoms in patients who fail to improve with non-operative treatment.

Mr James Calder is consultant orthopaedic foot and ankle surgeon at The London Clinic

For more information about foot and ankle conditions visit the website of The Clinic for Foot and Ankle Surgery

Hallux valgus

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