There are a couple of legitimate reasons why someone could experience pain in the ball of their foot. It could be a Morton’s Neuroma, Metatarsalgia, torn Plantar Plate ligament, or a Stress fracture in the metatarsal. Since I treat patients daily with each of these conditions and there appears to be much confusion on the internet regarding all of them let’s examine what each of these is, as well as what they are not.
- Morton’s Neuroma – Mortons Neuroma is in response to pressure, irritation or injury to quote the Mayo Clinic. I repeat “In response to pressure, irritation or injury.” This means Morton’s Neuroma IS NOT A PRIMARY CONDITION! It is in response to a primary condition and results in the nerve swelling. Much in the same way a disc in your lower back can bulge then put pressure on the nerve. It is not the nerve’s fault….but the disc’s. This makes the disc the PRIMARY CONDITION and the nerve SECONDARY! A Morton’s Neuroma then is a swollen nerve that results in the feeling of a pebble in your shoe or stepping on a marble. Often you may feel burning pain shooting into your toes, most commonly the 2nd or 3rd toes.
- Metatarsalgia – I hate this diagnosis. The prefix “meta” stands for Metatarsal. Metatarsals are the bones that make up your foot. The suffix “algia” means pain. So Metatarsalgia simply explains that you have pain in your Metatarsals! It does nothing to explain WHY YOU HAVE PAIN. You could have pain due to a stress fracture in the Metatarsal or a bruised or torn Plantar Plate Ligament. Most will experience pain under the 2,nd 3rd or 4th Metatarsals.
- Plantar Plate Tear/Sprain – The Plantar Plate Ligament stabilizes your Metatarsal bones to your toes. Due to repetitive and or excessive bending the Plantar plate ligament can be bruised or tear. Tearing of ligaments is very serious and can be a progressive disorder. This means if you have a small tear that you allow to worsen the tear will increase in size resulting in possible permanent disability. You may feel pain under the ball of your foot along with a burning sensation into your toes at random times. You may also experience intense pain that causes you to limp.
- Stress Fractures –Although a common diagnosis, it is also a common misdiagnosis. Stress fractures can not typically be seen on X-ray and require MRI to diagnose accurately. The symptoms that one feels with Metatarsal stress fractures are very similar to the symptoms of each of the above diagnosis and the reason for so much confusion. Pain walking barefoot, burning into the toes, pain with running or jumping and the sensation of a rock in your shoe.
In my clinic I treat and fix this condition on a regular basis. First I perform a thorough history and physical examination. It is common during the history to learn that the person has experienced some other significant injury initially which then caused them to alter their mechanics. By altering their biomechanics they put pressure on areas of the foot that are not designed for it, resulting in injury to the Metatarsal region. The physical examination consists of measuring the 3 arches of the foot, palpating the Metatarsal Heads to see where they are painful, and stretching the 2nd, 3rd and 4th toes to see if there is pain. If there is pain while palpating and pushing on the Metatarsal Heads I can confirm a correct diagnosis of bone bruise, ligament bruise or ligament tears. When stretching the toes backward if there is pain I can confirm that there is most likely a tear in the Plantar Plate Ligament. While this is a terrible injury to suffer with there is a way to fix it without surgery. Although surgery is sometimes an option if severe enough.
Ligament tears come in 4 degrees of severity.
* Grade I – Is like a bruise or a paper cut. This type can and will heal properly.
* Grade II – This is a partial tear. The ligament is still connected to the bone but has torn through. Imagine a piece of paper that you tear a hole in the middle but it does not extend to the borders. This is similar to a grade II. This type of tear can and will heal without surgery if treated properly.
* Grade III – This is a partial avulsion from the bone. Part of the ligament has disconnected from the Metatarsal. This injury MAY heal if treated properly without surgery. It is critical to have this accurately diagnosed to avoid it progressing to a grade IV.
* Grade IV- This is a complete rupture of the Plantar Plate Ligament. This injury will most likely require surgery if you want it to heal properly.
In summary this is what we know: Metatarsalgia only means you have pain in your Metatarsal region, typically the 2,nd 3rd or 4th metatarsals. The pain is usually caused by a bone bruise, ligament bruise, tear, or possibly a Metatarsal stress fracture. Often the diagnosis is a Morton’s Neuroma which we know is a SECONDARY CONDITION IN RESPONSE TO INJURY, PRESSURE OR IRRITATION!
What this means is the primary cause is most likely a bone bruise, ligament bruise, ligament tear, or stress fracture. A thorough history and physical examination will usually reveal the true nature of the injury.
Once the proper diagnosis is established then a proper course of treatment can be followed. For instance, you would not treat a paper cut the same way you would treat a severe jagged cut to your skin. In the same way you would not treat a bone bruise or ligament bruise the same way you would treat a ligament tear or stress fracture! Only with an accurate diagnosis can the best course of treatment by dictated. Once the severity of the injury is also diagnosed there are different courses of non-surgical therapy available to the patient:
- Precise and exact placement of Metatarsal pads in all their shoes
- Over the counter orthotics
- Custom orthotics
- Manipulation of the Metatarsals
- Ultrasound of the Metatarsals
- Kinesiotaping (also known as KT Tape and Rock Tape) of the Metatarsals to promote proper alignment
- Foot exercises to help strengthen the ligaments and muscles of the foot
- Or a specific combination of some of the above mentioned.
In severe cases I write an MRI prescription as well as immobilize the patient’s foot by placing them in a walking boot with a stiff rocker bottom. By not allowing the Metatarsals to stretch, the ligaments are allowed to begin to heal.
In the worst cases I have had to place a patient in this type of boot for up to 3 months. Almost all patients with Grade I, II, or III tears of the Plantar Plate have healed. Those with Morton’s Neuroma have reported reduced symptoms by up to 100%.
All runners have returned to running.
Surgery is not the only option, and often it is not an option at all.