Forefoot pain is experience by a large number of runners and can consist of everything from blistering of the toes, blackened toenails, irritation of nerve fibres (neuroma/neuritis) and stress fractures of the metatarsals. Some of these niggling complaints can be caused from ill-fitting running shoes or poor sock selection, where as overuse injuries such as stress fractures and bursitis are more likely related to running mechanics (how you’re running), biomechanics (the internal mechanics of your feet and lower limbs) and inappropriate training/loading strategies (e.g. increasing mileage or intensity of runs too soon).
In most cases, forefoot pain can be managed effectively with the right advice. This article address some of the more common forefoot conditions experienced by runners.
The Forefoot
Anatomically speaking, the forefoot consists of the metatarsal bones, the metatarsophalangeal joints (where the toes attach on to the foot) and all the toes. The forefoot is a tissue-dense area, meaning there are many muscles, ligaments, tendons, bursa, blood vessels, nerve fibres, fascia, fat pad and bones in the area. Any of these structures can become injured and cause pain.
The forefoot is responsible for taking the entire load of the body during the propulsive phase of gait, also referred to as toe-off. In-fact, the types of loads going through the forefoot on every step taken during walking can be up to one and a half times body weight, depending on the speed of walking, individual biomechanics and the type of terrain.
During running, the forefoot can be loaded in a variety of ways and is highly dependent on the individual’s running technique. Loads on the forefoot during running can exceed four to five times the body weight. Some runners will heel strike, others will strike more towards the middle of the foot (middle of the arch) and others will strike more towards the forefoot.
Where the foot strikes on the ground as well as where the foot strikes in relation to the runner’s centre of mass (centre of mass is close to your torso) will determine the magnitude and duration of forces being absorbed by the forefoot during running. Running downhill places higher stress on the forefoot and often the foot may slide marginally towards the front of the shoe increasing the pressure on the toes.
The potential to injure the forefoot is therefore quite high when we consider the large loads that can be absorbed by the forefoot and the repetitive nature of running.
Foot Size and Shape
Feet come in different shapes and sizes which means quite often its not the big toe that’s the longest toe. Some feet have a long 2nd metatarsal and therefore longer 2nd toe. Feet that have a longer 2nd toe need to have shoes that accommodate for the 2nd toe being longer than the first.
This is an important consideration when purchasing shoes as the shape of the toe box is different across the different brands of running shoes, therefore, footwear selection that matches the shape of your foot to the shape of your shoe is very important.
A wide forefoot that is not being well accommodated by the shoe will cause compression across the metatarsal heads and toes. This may result in burning sensations under the ball of the foot during running, irritation and compression of nerves or blood vessels in the forefoot, blistering on the toes, bruised toe nails and pins and needles in the toes or forefoot.
Overuse Injuries
The most common overuse injuries impacting the forefoot are pain across the metatarsal bones (sometimes referred to as metatarsalgia), metatarsal stress reactions and metatarsal stress fractures. These injuries result from excessive overloading of the metatarsal bones and is commonly related to training errors or sudden changes in training conditions.
Pain may be felt during the run, usually on the top of the foot or under the ball of the foot at a pin-point location (a spot that you could point to) and then settles once the run is finished. As the injury continues to worsen, pain continues to be felt after the run while at rest or while in bed. Pain at rest usually indicates a bony stress response and by this stage is considered a significant injury.
Other Forefoot Conditions
Blisters, Callouses and Morton’s Neuroma
Blisters can be a common complaint for runners particularly over longer distances. Blistering occurs when there is excessive friction between the layers of skin caused by an external source of friction (shoe or sock or innersole). Blistering can sometimes occur due to excessive sweating which causes the skin to become vulnerable to damage.
Socks that wick the moisture away from the skin can assist in preventing blisters and if the issue is blistering or rubbing between the toes, toe-socks (socks that fit your feet like a glove with a separate sleeve for each toe) can assist in preventing this issue.
Shoe fit is again an important consideration to prevent blistering as friction from an ill-fitting shoe can sometimes be the culprit. If shoe fit or sock selection is not resolving the issue, it may be necessary to use protection over the areas that are blistering, such as taping over the area making sure to cover an area much larger than the size of the blister.
Callouses develop as a result of high pressure (rather than friction) on the skin. The development of callouses serves as a protective function of the skin to protect itself from breaking down. Callouses usually develop over boney prominences like the edge of the big toe or little toe and over the heads of the metatarsal bones on the ball of the forefoot.
If callousing builds up too much it can become painful during running and weight bearing activities. Because callouses develop as a result of pressure, often the individual biomechanics of the foot are to blame and this should be assessed by a Podiatrist if painful.
A common condition impacting the forefoot is a neuroma, often referred to as a Morton’s Neuroma. A Neuroma is a benign growth on a nerve fibre, in the case of a morton’s neuroma the benign growth occurs on a nerve that travels in between the metatarsals and metatarsal heads. Depending on the location of the neuroma, it may become compressed and irritated by surrounding tissues during walking and running creating an inflammatory response around the neuroma.
Symptoms are usually pain in the ball of the foot that travels into one or more of the toes (usually the 3rd and 4th toe, but can be any of the toes). Pain is usually only when footwear is worn and during weight bearing activities and dissipates when the shoe is removed. There are several simple treatments available for morton’s neuroma with conservative options focused on reducing the mechanical irritation on the nerve fibre through footwear changes or the use of pressure relieving innersoles (orthotics). In some severe cases, surgery may be required to remove the growth on the nerve.
In summary, running causes extremely high forces on the foot and the forefoot has a very important job during the propulsive phase of running. Any pain or injuries impacting the forefoot can be thoroughly assessed by a Podiatrist with often simple solutions available to alleviate symptoms so that you can continue to pound the pavement.
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