Do you feel like you’re walking on a small rock or pebble that’s stuck inside your shoe?
The first step (and you might have already done this) is to check for a small rock or pebble inside your shoe. If you do find a small rock or pebble, then case closed! This is a really short blog for you.
Frankly, it’s is not a bad idea for everyone to shake out or look and feel inside their shoes. You may just find that lost earing, spare change, or the pet tarantula you have been looking for.
But the odds are that you’ve already checked your shoes and found nothing. So what could be causing that pain and irritation beneath the base of your toes?
There are several potential causes for such an isolated pain. Let’s start with one that probably is not the problem but gets blamed more often than it should. To put it into perspective: for every 100 people we treat for forefoot pain, only 1 is a this:
Neuroma (Morton’s Neuroma)
A neuroma is a fibrous growth or scarring that develops around a nerve. This is usually from repetitive impact or an injury. Layer after layer of fibrotic tissue is added over time. A digital nerve is normally the size of a pencil lead but can grow to the size of a pencil if left untreated
Neuromas are a scapegoat diagnosis for all forefoot pain. We see many patients whose general practitioner (or Dr. Google) diagnoses a neuroma, only it’s not.
(And we don’t blame those general practitioners. They didn’t study the foot and ankle as much as us, and they referred their people on to someone who has!)
A neuroma is not that common of a finding, but here are some common symptoms for this problem:
- You may feel a “funny bone” type of sensation that tingles and runs down to adjacent toes.
- As the neuroma develops, the symptoms may progress to a burning or searing pain.
- The symptoms typically occur between the third and fourth toes.
That is a lot of time spent on something that may not be your problem. One of my favorite idioms from my Dad: If it looks like a horse, and smells like a horse, and sounds like a horse…. it probably is a horse and NOT a Zebra.
On to the horse!
Capsulitis is the inflammation of ligament-like tissue that surrounds a joint. This problem involves the metatarsal joint or “table leg” of the foot. So think of the foot as a table with 5 legs. When one table leg is forced to bear more weight, it gets angry.
Symptoms to look for:
- Tenderness directly under the toe joint or metatarsal head
- Pain in the ball of the foot, especially while walking barefoot on a hard surface
- Swelling at the base of the toe
- Tenderness that can extend to the top of the joint in severe cases
- A callus or thickened skin in the area in chronic cases
This condition favors the second toe, although it occasionally occurs in the third or fourth toes as well. Capsulitis of the second toe is often associated with having a long toe (AKA Morton’s toe) or having a bunion.
Pandemic Problems and “More”
We noticed a spike in capsulitis right after the pandemic made much of the work force migrate home. People stopped wearing shoes and spent more time on hard floors. It’s easy to underestimate just how many steps you take at home. You may forget how much pressure your foot takes but the foot won’t!
“The More” happens when the metatarsal continues to get beat up. The body starts with a warning of escalating pain. If the extra stress continues, the bone will try move out of the way to escape the repetitive trauma. This evolves to a stress fracture. It is very much like bending a metal coat hanger until it weakens and breaks. There will be a significant increase in swelling and pain at this stage. This is the proverbial jumping from the frying pan into the fire.
Sesamoiditis is a capsulitis of the big toe. The sesamoids are 2 gliding bones under the 1st metatarsal that act as a floating pedestal. They look like round headlights on an x-ray. The sesamoids’ function is amazing. I will save this for a future blog.
Excessive pressure is the main cause for problems. The sesamoids can fracture from direct impact. This injury occurs when the hallux is bent upward with a heavy ground impact. Coming down with a rebound or walking down a large step in high heels will do the damage. And once the sesamoids are fractured, they will always look fractured.
You seldom see swelling or bruising with sesamoiditis. You are more likely have difficulty bending and straightening the big toe.
We have discussed joint and nerve pain, but the lumps you feel may be an actual bumps. A few conditions may be responsible for this.
Rheumatoid nodules are marble-sized lumps that form in the forefoot. There is usually a history of rheumatoid arthritis associated with this. Rheumatologist do such a good job managing this disease that I rarely see this type of nodules. They also can occur in the hand.
Plantar fibromatosis is a lumpy growth in the fascia. It appears right between the big toe joint to the mid arch area. It will feel like a bunch of small peas or grapes under the skin
Porokeratomas are sealed sweat glands that become clogged. They can feel like small ball bearings. They can appear in both the palms of the hands and the bottom of the feet. These can be very painful if located in a weight-bearing area.
Finding Relief from Pain at the Base of the Toes
Consistent pain in the ball of the foot will definitely get your attention. Ignoring the problem may extend the duration to resolve the problem. If you are avoiding activity because of the pain, you should seek professional care.
The first step is correctly identifying the condition and its underlying causes. If you have capsulitis, for example, what is contributing to it? Is it your shoe choices? Your activities? An abnormality in your foot structure? Some mix of the three? Something else entirely? Did you think there’d be so many questions? But it’s OK, because we’ll find the answers.
Once we have a firm understanding of what’s going on, we can make our best recommendations for treatment. The keys to recovery often lie in protection, offloading, and/or correction.
In some cases, the use of accommodative orthotics can protect vulnerable areas. We may also recommend changes to your footwear and workout schedule. A specific stretching program might be recommended to further reduce stress and impact
A cortisone injection may be selected for short term relief. This may be helpful as we work toward longer-lasting goals. We may sound like a scratched DVD but this is why early treatment is important – to avoid this.
Only in very rare cases will surgical intervention be needed. The goal is to shorten a metatarsal bone to offload excess pressure. This would be like shortening a long table leg. In most cases, conservative treatments provide the best results.
If the problem is plantar fibromatosis, we can take different actions to address them. These lumps can be shrunk via injection therapy and rarely need to be removed. A physical therapy technique called crass fiber massage is very effective. Large rheumatoid nodules may need to be removed. Porokeratomas can often be addressed conservatively if found early.
Every path has its bumps and rough patches, but you should never feel like you’re always walking on them. Please never delay in contacting us anytime of persistent foot or ankle trouble is interfering with your life.