Forefoot Pain - Neuroma

This can be either a sharp, shooting type pain or a numb, burning type pain in the forefoot region. It is often located either between the 1st and 2nd toes or the 3rd and 4th toes (3rd / 4th area more common). It usually presents itself after long periods of weight bearing in tight shoes (particularly high heel shoes) or when kneeling down (i.e. when hyper-extending the toes). It sometimes feels as if there is something sticking in the bottom of the foot yet nothing is present.

Conditions associated with nerves can attract ambiguity in the form of conflicting symptoms (i.e. sharp shooting pain; numbness) and the referred nature of the condition (i.e. irritation at one location referring pain to another location). With this in mind, the following may be of help in understanding this common foot / forefoot pain...



♦ Cause:

The cause of this pain is impingement of a nerve (see above picture), usually the medial plantar nerve which runs in between the metatarsals (long bones of the foot). Some say that it is the metatarsal heads impinging the nerve; but, it is more precisely the metatarsal transverse ligament impinging the nerve via the coming together of the base of the phalanges (toe bones) which, in most cases, is either the 1st or 2nd or the 3rd or 4th . The impingement of one of these nerves can cause thickening of the neural sheath over time, which then leads it to be progressively / easily irritated as the condition progresses. 


♦ Treatment:

I will list the options from conservative to invasive:

- Not wearing inappropriate footwear (i.e. high heels, narrow toe box)... contributing to excessive hyper-extension of toes and / or cramping of toes.

- Fabrication of a wedge to fit between the offending toes where the symptoms are present. This separates the phalange bones thus reducing the chance of nerve impingement. 

- Fabrication of a non-casted orthotic or insole with a device / pad known as a metatarsal dome (see picture below) attached on top of the orthotic / insole to support / lift at least one - two of the metatarsal bones away from the affected nerve branch; provide support for the 'transverse metatarsal arch' conducive alignment of metatarsals... (it should be stated that anatomically a true 'transverse metatarsal arch' doesn't really exist - albeit, the term does provide a convenient pictorial analogy).

- A custom-made orthotic which reduces pronation thus supporting the foot and not allowing the bones of the forefoot to become hypermobile (excessive movement) particularly under the stress of pushing off for the next step. The orthotic may also have a metatarsal dome added or built into the device. 

- Cortisone injection to reduce inflammation of the area has also proven to be successful. However, this form of treatment primarily focuses on the symptoms and not the cause.  

- Surgery to remove the excess tissue around the impinged nerve thus reducing its size. This is a last resort treatment and should also be accompanied with treatment that addresses the underlying cause of the condition.