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metatarsalgia, forefoot injuries, causes, diagnosis, treatment, avoidance, exercises

Metatarsalgia - Forefoot pain

Here's what to do to prevent and treat a condition that afflicts many athletes: metatarsalgia

Athletes in a variety of sports have noticed that when they increase their total training load or engage in an unusually long workout or competition, their feet are likely to pay the price. More specifically, they often begin to experience some discomfort on the bottom of one of their feet (or on the bottoms of both feet) - toward the front of the foot, near the toes. Such forefoot pain is known as metatarsalgia, which simply means pain caused by inflammation at the ball of the foot or at the juncture of the big toe or other toes with the rest of the foot.
An athlete suffering from forefoot pain will frequently feel very localised discomfort - as though there is a discrete foreign object in his/her shoe. 'It feels like I have a stone in my shoe,' is a frequent complaint. In some instances, though, the pain is a little more diffuse and is described as a burning or aching sensation. Occasionally, pain is felt throughout the sole of the foot.
As mentioned, athletic activities which place stress on the feet are linked with the onset of metatarsalgia. An unusually long run or race, an extended basketball practice, a prolonged soccer workout, a full day on the cricket field, can all induce forefoot pain, as can sudden and significant increases in an athlete's overall training load. Poorly designed or worn-out shoes are probably a factor, too. Metatarsalgia experts indicate that high arches, deformities of the toes, stiff ankles, irritated nerves in the forefeet, bunions, poor circulation to the feet (due to diabetes), gout, arthritis, weight gain, and shoes with too-high heels are also predisposing factors.

How to spot it
You can be fairly confident that you have metatarsalgia if one or more of your toe joints (ie, one or more of the joints between the toes and the main body of the foot) becomes inflamed, painful, and stiff. Swelling may be present, and if you have metatarsalgia you will often experience a burning sensation in the joint area. Generally, the swelling and pain become progressively worse with continued activity, especially if your shoes are fairly old or you have relatively poor foot and ankle strength. In full-blown metatarsalgia, the pain can be so intense that putting weight on the foot becomes nearly impossible.
If you go to your healthcare professional for a diagnosis and treatment, he/she should take a detailed personal and family medical history. You'll be asked if you have recently gained weight and whether closely related family members have had either diabetes or gout. Diabetes causes poor blood circulation to the feet, which can lead to pain similar to the discomfort of metatarsalgia; gout produces profound joint irritations which can mimic metatarsalgia, too. If there is indeed a family history of either of those conditions, urine and blood samples will often be taken to see if you are gout- and diabetes-free. An x-ray - and even an MRI - may be requested in order to inspect the troubled joint closely, especially if your doctor suspects you might have a stress fracture. In some extremely difficult-to-diagnose cases, tests of nerve function in the foot may be necessary.
Your doctor will also want to know about the duration of your symptoms and should ask you whether the pain is related to a single event. He/she will want to know what activities provoke discomfort, the exact location of your pain, and whether you have recently changed your workout schedule, your athletic shoes, or the surface upon which you train.

Start with box-toed shoes
Once the factors that seem to cause the symptoms are identified, your specialist will suggest changes in your approach to training. If it appears that footwear is related to your metatarsalgia (for example, your running-shoe midsoles might have 'blown a tyre' and lost their resiliency after months of training), getting new shoes is an obvious solution. Therapists who treat metatarsalgia report that shoes with 'boxy' toes tend to work better for forefoot-pain patients, compared to shoes with narrow, more pointed toes. Box-toed shoes seem to relieve the overall pressure on the forefoot and permit the toes to spread apart during walking, jogging, or running. This spread-out allows the toes to move in directions other than the ones that produce pain.
Naturally, it may be necessary to limit your training until your symptoms go away. Workouts may be made less lengthy and intense (in severe cases of metatarsalgia, training will have to cease until symptoms subside), and ice and elevation should be used after training sessions are over. The best policy appears to be to rub the painful area with ice for about 12 minutes at a time (while the foot is elevated), taking 20-minute 'recoveries' between icings. Weight loss may be helpful to the overweight athlete suffering from forefoot pain, and non-steroidal anti-inflammatory medications are often taken to provide pain control.
There are a variety of different orthotics which are used to treat

'No carefully controlled, published scientific study has linked orthotics with metatarsalgia relief.'

metatarsalgia, and - anecdotally - such products are said to be helpful. Note, though, that no carefully controlled, published scientific study has linked orthotics with metatarsalgia relief. Orthotics are usually custom-made to fit the anatomy of a patient's foot and are inserted into the athletic shoes. The main feature of an orthotic made to
relieve forefoot pain is a supportive pad that fits under the joints of the toes with the foot.
How long will you have to reduce or stop your training once metatarsalgia arises? In uncomplicated cases caused by bad shoes or training errors, appropriate treatment can usually alleviate major symptoms in 10 to 14 days. Appropriate treatment includes using newer and more supportive shoes, icing, the use of anti-inflammatory drugs, a reduction in training intensity and volume, the temperate employment of exercises which strengthen the feet and improve range of motion at the toe joints, and perhaps the wearing of a temporary orthotic.

Don't train through it!
If a stress fracture is discovered, symptoms may hang around for four to eight weeks, and if obesity, diabetes, gout, or arthritis are present it is very difficult to predict how long the pain will last. Although athletes will be sorely tempted to 'train through' metatarsalgia, they need to realise that activity will increase the stresses on the point of injury and slow down the recovery process. Return to normal training and competition should be delayed until underlying causes of forefoot pain have been resolved and until major symptoms have disappeared.

Here are our best tips for preventing metatarsalgia from occurring:

(1) Wear athletic shoes which fit properly and which are appropriate to the activity. Don't go out for a 10k run while wearing a pair of tennis shoes, for example.

(2) Make sure that the insoles and midsoles of your athletic shoes have not broken down, and that they do retain a healthy measure of support. If your athletic shoes come with paper-thin insoles, don't hesitate to spend an extra 10 to 15 quid for more supportive structures. With regard to midsoles, it is generally believed that using midsoles for more than about 300 total miles of movement leads to a situation in which the midsoles have lost their 'compression-set resistance', which is just a fancy way of saying they have lost their resiliency and are no longer able to spring back to their normal configuration after the foot makes impact with the ground. This loss of resiliency may put extra pressure on the foot and metatarsal joints.

(3) Increase the intensity and duration of your training very slowly and cautiously. Whenever more-than-just-niggling forefoot pain appears, take a day off and then train lightly for a few days to keep inflammation at bay. As you resume normal training, use the stretches and exercises below to ward off future problems.

(4) Be particularly careful whenever you initiate new training methods. If you are a basketball player, for example, and you begin to work on your vertical jumping ability by practising repeated jumps against extra resistance, the increased number of high-impact landings and additional forces placed on the feet (if you are using a training device like a weighted vest, for example) will significantly increase your risk of metatarsalgia.

(5) If you are prone to metatarsalgia, use shoes with relatively boxy toes, and try to avoid shoes which seem to have increased heel height. The latter can pitch your feet forward, putting extra pressure on your metatarsal joints.

(6) Don't get fat.

(7) If you have a family history of diabetes, arthritis, or gout, report this to your doctor, who will want to evaluate you periodically for these conditions.

Follow these recovery exercises
How do you recover from metatarsalgia once you've got it? It is generally believed that increasing the range of motion of the ankle, maintaining elasticity of the Achilles tendon, strengthening the muscles and connective tissues of the foot, and enhancing the flexibility of the metatarsal joints help to spur recovery and reduce the possibility of recurrence. Below we have listed four 'classic exercises' which attempt to accomplish some of these goals, and we have added two additional exercises which will go a long way toward strengthening your feet in a functional way and reducing your risk of metatarsalgia.

Classic Exercise No 1 - The Achilles-Tendon Stretch
Stand with the toes and balls of your feet on a kerb or step. Then, drop your heels down as far as possible, without causing significant pain, of course. Rest in this position for a few seconds, and then rise up on your toes, holding this position for a few seconds as well. Carry out three sets of 12 reps of this exercise per day, with 15-30 seconds of rest between sets. Over time, make the exercise progressively more difficult by wearing a weighted vest with increasing amounts of weight or by holding dumbbells in your hands.

Classic Exercise No 2 - Ankle Flexion
Simply sit on an elevated flat surface with the leg associated with the affected foot crossed over the opposite thigh. Grab the affected leg at the ankle with the hand of the opposite side, and grasp the toes of the affected foot with the same-side hand. Gently pull the toes of the injured foot inward towards the lower leg, until you begin to experience pain. Back off slightly to lessen discomfort, and hold this position for five to 10 seconds. Relax for 10 seconds before repeating, and perform this sequence for three sets of eight reps.

Classic Exercise No 3 - Ankle Extension
Sit on an elevated flat surface with the leg of the affected foot crossed over the opposite thigh. Grasp the affected-side leg at the ankle with the same-side hand, and grasp the toes of the affected foot with the opposite-side hand. Then, gently pull toes and sole of the affected-side foot toward the body to the point of significant pain. Hold this position for five to 10 seconds, and then relax for 10 seconds. Use three sets of eight reps per day.

Classic Exercise No 4 - The Ankle Turn-In
Sit on an elevated flat surface with the leg of the affected foot crossed over the opposite thigh. Hold the affected leg at the ankle with the hand of the same side, and grasp the toes of the affected foot with the opposite-side hand. Cautiously bend the foot upward at the ankle towards the inner leg to the point of significant pain. Again, hold this position for five to 10 seconds, with 10 seconds of relaxation following. Perform this sequence 10 times, three times daily.

Although the above exercises should help improve the flexibility of the ankles and feet, they are not very functional, ie, they do not resemble movements that occur in any known sporting activity (few athletes carry out their activities in a seated position while holding one foot). With the exception of exercise number one, there is no weight-bearing involved, and there is little emphasis on balance and coordination, little integration of various muscle groups, and probably diminished 'carry-over' to real-world sporting activity. The following two exercises take care of those problems and do a great job of improving foot and ankle strength and resiliency.

Functional Exercise No 1 - Toe Pulls
To perform this exercise, stand barefoot with your feet hip-width apart. In an alternating pattern, curl the toes of your right foot and then your left foot down and under, as though you were grasping something with the toes of each foot. Try pulling yourself across the floor (smooth surfaces work best) for a distance of three to six feet as you become more skilled at this exercise. Start with 25 reps per foot, and work up to three sets of 75 reps per day (a rep is one 'grasp' of one of your feet).

Functional Exercise No 2 - Downhill Hops
Running or hopping downhill increases the ground-reaction forces experienced by the foot and leg, compared with running or hopping on level ground (or uphill). Forcing the feet and ankles to respond to these higher forces has an overall strengthening effect. Going downhill also increases the stresses on the forefeet in particular, which is strengthening in the long term but potentially pain-producing in the short term, so be cautious with this exercise. Start with a moderate downslope
of about 3%, and hop downhill on your right foot for about 20 metres or so, staying relaxed at all times, looking ahead (not down at your right foot), and achieving good springiness with your right ankle. Jog back up, repeat with the left foot, and your first set is complete. Rest for a moment if necessary, and then carry out one or two more sets. As you get

'If your athletic shoes come with paper thin insoles, don't hesitate to spend an extra 10 to 15 quid for more supportive structures.'
stronger and more coordinated, you can increase your speed of hopping, the length of the downslope, and of course the percentage declination. Don't try for long leaps as you go downhill; you are looking for quick, efficient bounces that minimise energy cost. In effect, you should 'pogo-stick' your way down the hill, using the elastic energy of your ankles and legs as much as possible, instead of working hard to hop forward.

Owen Anderson



metatarsalgia, forefoot injuries, causes, diagnosis, treatment, avoidance, exercises