Ball-Of-The-Foot Pain (Metatarsalgia)

Metatarsalgia or ball of the foot pain is very common and will affect around 80% of the population at some point in their life. It is made up of a group of conditions that can cause pain and inflammation around the bones and joints in the ball of the foot.   Finding comfortable footwear can be difficult.

Treatment protocols for ball-of-the-foot pain almost always start with basic principles and we would encourage you to consider trying some self-help treatment before making a referral to your local Podiatry department.

What are the common conditions that cause ball-of-the-foot pain?

The most common conditions affecting the ball of the foot are Fat pad atrophy, Capsulitis, Inter metatarsal bursitis and Plantar plate injury.

Fat pad atrophy 

Fat pad atrophy is a term used to describe thinning and degeneration of the fat pad that sits under the ball of your foot. The fat pad is the soft tissue layer in between the skin and the bones. It has a honeycombed structure with fibro-elastic chambers containing fat globules which helps with shock absorption and the spreading of pressure across the ball of your foot during activity. Thinning of the fat pad can lead to reduced shock absorption, making the foot more vulnerable to repetitive micro-trauma and developing inflammation, bruising, swelling and pain.

Thinning of the fat pad is a natural process and begins around the age of 30. It can take several years before the fat pad becomes thin enough to cause pain to develop. Fat pad atrophy is more common in people with Diabetes.

Capsulitis 

Capsulitis is a term used to describe inflammation of a joint capsule. A joint capsule is a covering that surrounds a joint and consists of a thick outer layer which gives it its strength and a thinner synovial layer which produces the fluid to lubricate the joint. Micro trauma or damage to the joint capsule can result in excess fluid being produced which causes the joint to swell and become painful when weight bearing.

In your foot it most commonly affects the joint next to the big toe but can affect any joint within the body.

Intermetatarsal bursitis 

Intermetatarsal bursitis is an inflammation of one of the bursa that sits between the joints in the ball of the foot. A bursa is a small sac of fluid that can help to increase shock absorption and reduce friction, its position within the ball of the foot is important as it helps prevent the bones from rubbing together.

When the bursa becomes inflamed it can swell and become painful when weight bearing. Tight fitting shoes can increase the compression of the bursa resulting in pain.

Plantar plate injury 

The plantar plates are deep ligaments that form the bottom part of the joint capsule within each of the joints in the ball of the foot. The plantar plates help to stabilize the foot and toes when weight bearing and also provide the attachment of the plantar fascia into the base of the toes.

Repeated micro trauma can lead to tearing or partial tearing of the plantar plate. If left untreated this can cause deformity of the affected toe.

Classic signs and symptoms of Metatarsalgia

• A sharp, stabbing, burning or tingling sensation affecting the ball of the foot and into the toes
• Pain that increases with weight bearing activity and improves with rest
• Sensation of walking on a `pebble’ or `lump’
• Increased pain when walking barefoot, especially on a hard surface

What causes the problem?

The most common cause of pain in the ball of the foot is from a sudden increase in pressure or activity resulting in micro trauma and inflammation.

Other contributing factors

• Over weight
• Age- the fat pad under the ball of the foot becomes thinner and this can increase pressure at the front of the foot.
• Increased swelling in feet
• High arched feet
• Tightness in the muscles in the back of the leg
• Weakness within the muscles in your foot/leg
• Unsuitable footwear that is too narrow or has a thin sole i.e. High heeled shoe
• Foot deformities such as Hallux Valgus (bunion), hallux limitus and hammer toe deformities
• Inflammatory conditions i.e. rheumatoid arthritis, psoriatic arthritis etc.
• Previous foot trauma i.e. metatarsal fracture, nerve injury 
• Spending long periods standing, walking or running, especially with a sudden increase in these activities

 What can I do to help?

Unfortunately there is no quick or easy fix and your symptoms won’t improve overnight. It is important though that if you have any of the contributing factors you make the necessary changes to help with your recovery.

The advice below is aimed at reducing the pressure and inflammation from around the affected joints with a main focus on footwear and decreasing any tightness in the calf muscles. Tight calf muscles can increase the pressures through your fore foot. Your pain should improve but may take time to get better.

The one person who can help you get better is you!

Weight management 

Increased weight will place extra stress on the joints and soft tissues in your feet. Losing even a small amount of weight can make a difference.

If you need help with weight-control, you can find information, advice and groups you can join to help you manage your weight better. Follow this link to an NHS BMI Calculator (https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/) to guide you on whether you should consider weight management.

Footwear  

With ball of the foot pain it is important to make sure that your footwear fits well and are not too tight across the fore foot. Narrow footwear will increase compression through the joints and increase your pain. Shoes with a deep and wide toe box are preferable.

Avoid high-heeled, narrow or pointed-toe shoes as these could further increase the pressure on the joints. Footwear that have thin, hard soles should also be avoided as these will not provide enough cushioning or shock absorption that can also increase the pressure on your joints. Shoes with laces or adjustable straps are best.

Pain Management

Pain medication can help reduce your symptoms, allow you to move more comfortably which will aid your recovery. Your community Pharmacist can provide guidance on specific medication or other methods of pain relief (always read the label and manufacturer’s guidelines).

Stretching and strengthening exercises 

Stretching exercises for the muscles in the back of your leg can help reduced the loading pressures through your forefoot and increase the flexibility of the foot and ankle. Strengthening the small muscles in the foot is important as this will improve the strength and stability of your foot and help reduce your pain. Your podiatrist will advice you on which exercises are suitable for you.

Padding and Strapping

Some people find benefit from wearing padding on the bottom of their foot or on an insole to help cushion and reduce the pressure on the joints. Padding comes in a variety of materials and can be bought from your local pharmacy or online. Strapping/Taping can be used to help support the toes to help reduce movement which can reduce the strain through the soft tissues. This can be a useful short term treatment that can help reduce your symptoms. Your podiatrist can advise you on this.

Activity management

Return to activity gradually. Avoid activities that increase your symptoms. Rest, or at least reduce your activity level as this will allow your symptoms to settle naturally. If you engage in sports and activities that require a lot of pressure to be placed on the ball of the foot, you are at a higher risk of symptoms developing and your recovery will be slower.

Injury Management

If you have severe sudden foot pain or have had an episode of trauma we would advise that you seek medical treatment straight away. If you have developed a new lump or bump or there has been a change in a pre-existing one contact your GP as soon as possible.

If your symptoms are not related to any of the above and has been present for less than 48 hours please contact your GP.

After 48 hours it is normal to still be experiencing symptoms.   It is important to slowly begin weight-bearing through your painful foot as prolonged rest could lengthen your recovery period and may impact on your health and wellbeing.

If you are in pain do not try and do all your normal daily activities such as housework, at once. Break the harder jobs down into smaller jobs and do something gentler in between.

Extensive walking or standing should be avoided if it aggravates your pain. It is recommended you modify activities rather than to fully stop all forms of movement or exercise.  Swimming or cycling are an alternative to walking or running as these activities are non-weight bearing.

After periods of activity you may experience an increase in pain. Appling some ice can be useful in reducing some of the inflammation in and around the ball of the foot. This can be achieved by:

• Wrapping crushed ice in a damp towel. A damp towel between the ice and the skin will help to avoid an ice burn. 

• Hold it for 20 minutes against the painful area. Alternatively, you could try sports sprays and gel/cool packs, which will do a similar job.

Patience

Have patience, most people’s symptoms should start to improve within three months of following this advice.

What else can be done?

 If you have followed the above advice for the recommended three months and your pain has not started to improve, please refer yourself at your local Health Centre. 

Frequently Asked Questions

The information below will answer many of the questions you may have in the early part of your treatment.  We aim to ensure your specific needs are considered throughout your treatment.     A shared decision making process is used by our teams.  This means you will be informed about the treatment options open to you the risks and benefits of each option.  You will be supported to make a choice about which treatment best meets your needs.

 We hope the following questions that have been developed on the back of MSK focus groups, will provide you with some answers with provide you with key information around your condition.

 • What is wrong? Why? What is the cause? Metatarsalgia is a term for a group of conditions that can cause pain and inflammation around the bones and joints at the ball-of-the-foot and can also cause difficulty in finding comfortable footwear. The most common cause of pain in the ball of the foot is from a sudden increase in pressure or activity resulting in small injuries and inflammation. Tight fitting footwear can play a big role in aggravating your symptoms.

• What is the possible impact on my health and function? It can restrict your day to day activities and limit your ability to walk or exercise, which in turn can lead to strains elsewhere in the body.

• Will I get better or worse? The good news is that your pain should start to improve by following the advice that is aimed at reducing the pressures on the front of your foot. It should be noted that it is normal to have periods of increased pain during activity through the recovery process.

• Is it curable? Unfortunately there is no quick or easy fix and your symptoms will not improve overnight and we would advise on completing the conservative advice in the first instance. The advice above is focused on reducing the pressure and inflammation from around the front of your foot. Your pain should improve but it may take time to get better.

• How long will it take to get better? There is no overnight cure for this condition however, your symptoms should start to improve within three months of following this advice.

 • What are you (the health professional) able to do about my problem? By using our self-help tool, we would like to help you to better understand your condition and provide you with the tools which should help support your recovery.

• What is the treatment that is most appropriate for me? Treatment protocols for metatarsalgia almost always start with basic principles and we would encourage you to consider trying some self-help treatments in the first instance before making a referral to your local Podiatry department. 

• What can I do to help myself to alleviate it? We would encourage you to consider trying some self-help treatment in the first instance before making a referral to your local Podiatry department.

• How can I reduce or control my pain? Footwear and activity adaption along with ice and pain medication can help reduce your symptoms, allow you to move more comfortably which will aid your recovery. Your community Pharmacist can provide guidance on specific medication or other methods of pain relief (always read the label and manufacturer’s guidelines).

• How can I maintain my function and do the things I want to and need to do? If you are in pain do not try and do all your normal daily activities such as housework, at once. Break the harder jobs down into smaller jobs and do something gentler in between. Extensive walking or standing should be avoided if it aggravates your pain. It is recommended to modify activities rather than to fully stop all forms of movement or exercise.  Work out what you can do relatively pain free and use that as a starting point. Then over time build up your activity. Track and write down your progress to keep you motivated.

• What activities can I do and how should I adapt them (e.g. sports, work)? Avoid high impact activities like running as this will significantly increase load through the front of your foot. We would encourage you participate in lower impact activities like walking, swimming, cycling etc until your pain is at a manageable level.

When can I go back to sport? The return to sporting activity is guided by your symptoms and the type of sport you like to do. We would advise a gradual return to your sport as you will have lost condition during injury and recovery.

• Have I made an improvement? Most people’s symptoms should start to improve within three months of following the self-help advice.  You should note that although you may still have episodes of pain,  they will becoming less frequent and severe.

Why am I not improving? Where have I gone wrong? Am I doing the right things? There could be a number of reasons why your symptoms may not be improving. If you have followed the self-help advice for three months and your pain has not started to improve please refer yourself to your local Health Centre.