Forefoot pain is a very common reason for patients to present at Bio Allied Health. The pain can be severe and often debilitating. There are many anatomical structures at the front of the foot, which can be a complex region to make the correct diagnosis.
Health professionals who treat the foot often zone straight into a neuroma. At Bio Allied Health the first step is a thorough assessment to see if the foot problem is actually a neuroma.
There are other conditions that lead to forefoot pain and can plague this region, including:
- capsulitis or synovitis of the joints
- bursitis
- stress fractures
- arthritis
- Freiberg’s infraction.
An X-ray and ultrasound of the foot may be recommended.
What is a neuroma?
There are many nerves in the feet, as feet are one of the primary sensory structures of our body. They allow us to take a step on uneven terrain and adapt to this without falling over, plus they can sense pain and avoid damage.
The anatomy of the foot is such that in certain situations the nerves at the front of the foot can be entrapped. Health professionals are commonly taught that the nerve becomes entrapped in-between the two metatarsal bones that sit either side of the nerve. This is actually not the most common cause. The nerve actually sits under these bones and hence, it is actually quite hard for it to become entrapped. The diagrams that show neuromas are often incorrect, and can be one of the reasons why some treatments fail. The neuroma actually sits lower and further down towards the toes.
The nerve mainly becomes entrapped under a ligament. The ligament is known as the deep transverse metatarsal ligament. This ligament runs between the the two metatarsal bones and during certain activities the nerve can become entrapped.
What causes a neuroma?
There are many causes of Morton’s neuromas and they can involve anything that pulls the nerve against the ligament:
- a foot that flattens out too much (excess pronation) can pull the nerve backwards and forwards across the ligament
- retracted or hammertoes can pull the nerve up onto the ligament
- high arch (supinated) feet can pull the nerve onto the nerve
- sports that require a lot of time on the ball of the foot
- high heels shoes
- and many more causes can lead to the entrapped nerve.
Enlarged nerve
Once the nerve has become caught under the ligament, it rubs backwards and forwards, causing irritation and inflammation. This initially leads to neuritis; however, if the entrapment continues, the nerve can become chronically enlarged with a fibrous tissue build-up. This is known a peri-neural fibrosis. It is this enlarged fibrous tissue that actually leads to the neuroma. Once this tissue builds up a viscous cycle develops, as the bigger the nerve, the easier it is to become entrapped.
Treatment options
The treatment is varied, but it basically falls into 3 interventions:
1) Insoles, paddings and shoe advice. These may be simple deflecting temporary padding or custom made orthotics. The most appropriate depends on the severity of the neuroma and the condition that is leading to the problem. Icing and anti-inflammatory tablets or gels may be used. Rest may be necessary, and shoes may be discussed. In most situations this will suffice, and the neuroma will settle.
2) If the above is not allowing resolution of the pain then a corticosteroid injection (steroid injection) can be carried out. This is quite a quick solution and can be carried out in the office. It is important to take it easy for a few days afterwards as the area may flare up over the next few days and it can take a few weeks to have its full result.
3) In rare situations, if all non-surgical means have been unsuccessful, surgical removal of the damaged nerve may be an option. The procedure for this has improved over the years and is now carried out via a small incision and recovery is typically quick. A referral for this can be written if all non-surgical options have been unsuccessful. Non-surgical options will be exhausted before we move to this, and in the vast majority of cases this is unnecessary.
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