UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation and diagnosis of common causes of forefoot pain in adults

Author
Karl B Fields, MD
Section Editor
Patrice Eiff, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM

INTRODUCTION

Foot pain is common among adults and a frequent reason for primary care visits. Nevertheless, as the differential diagnosis for foot pain is broad and exposure to foot-related problems is often limited during medical training, many clinicians may not be adequately prepared to assess the patient with foot complaints.

This topic reviews the common causes of forefoot pain in the adult, including descriptions of important conditions and a discussion of how to reach a diagnosis. An overview of foot pain generally, including more detailed discussions of foot anatomy and biomechanics, and how to conduct a history and examination of the patient with foot complaints, is provided separately (see "Evaluation and diagnosis of common causes of foot pain in adults"). A topic devoted to running injuries, including foot-related problems, is also available. (See "Overview of running injuries of the lower extremity", section on 'Foot and ankle injuries'.)

ANATOMY AND BIOMECHANICS

The anatomy and biomechanics of the foot are reviewed separately. (See "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation", section on 'Anatomy' and "Evaluation and diagnosis of common causes of foot pain in adults", section on 'Basic foot structure and biomechanics'.)

EPIDEMIOLOGY OF LOCALIZED FOREFOOT PAIN

The forefoot is the most common location for foot pain in adults. Problems with toes and toenails affect between 60 and 75 percent of older individuals. Common problems include bunions (hallux valgus), hammertoes, and bunionettes, and a majority of adults have corns or calluses located on their toes or plantar foot surface [1]. Forefoot pain causes disabling symptoms in up to 36 percent of individuals older than 70. Women are more commonly affected [2].

Certain activities and occupations place significant stress on the feet. In a study of female professional Flamenco dancers, 80.7 percent had metatarsal pain while dancing and 84.1 percent demonstrated plantar hyperkeratosis [3]. Ballet and some forms of martial arts also expose the forefoot to greater risk of injury. Intense training and marching by soldiers and police officers is associated with stress fractures of the forefoot [4]. The surface on which activities are performed may predispose to forefoot pain. As an example, some forms of artificial turf are associated with higher great toe injury rates among both soccer and American football players [5,6].

                               
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jul 31, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Dunn JE, Link CL, Felson DT, et al. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004; 159:491.
  2. Menz HB, Tiedemann A, Kwan MM, et al. Foot pain in community-dwelling older people: an evaluation of the Manchester Foot Pain and Disability Index. Rheumatology (Oxford) 2006; 45:863.
  3. Castillo-López JM, Vargas-Macías A, Domínguez-Maldonado G, et al. Metatarsal pain and plantar hyperkeratosis in the forefeet of female professional flamenco dancers. Med Probl Perform Art 2014; 29:193.
  4. Moran DS, Evans R, Arbel Y, et al. Physical and psychological stressors linked with stress fractures in recruit training. Scand J Med Sci Sports 2013; 23:443.
  5. George E, Harris AH, Dragoo JL, Hunt KJ. Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system. Foot Ankle Int 2014; 35:108.
  6. Hotfiel T, Carl HD, Jendrissek A, et al. [Turf toe injury--extension sprain of the first metatarsophalangeal joint]. Sportverletz Sportschaden 2014; 28:139.
  7. Brooks F, Hariharan K. The rheumatoid forefoot. Curr Rev Musculoskelet Med 2013; 6:320.
  8. Trivedi B, Marshall M, Belcher J, Roddy E. A systematic review of radiographic definitions of foot osteoarthritis in population-based studies. Osteoarthritis Cartilage 2010; 18:1027.
  9. Roddy E, Thomas MJ, Marshall M, et al. The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot. Ann Rheum Dis 2015; 74:156.
  10. Galica AM, Hagedorn TJ, Dufour AB, et al. Hallux valgus and plantar pressure loading: the Framingham foot study. J Foot Ankle Res 2013; 6:42.
  11. Hopson MM, McPoil TG, Cornwall MW. Motion of the first metatarsophalangeal joint. Reliability and validity of four measurement techniques. J Am Podiatr Med Assoc 1995; 85:198.
  12. Nawoczenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait. J Bone Joint Surg Am 1999; 81:370.
  13. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24:731.
  14. Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc 2002; 92:102.
  15. Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am 2003; 85-A:2072.
  16. Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus. Foot Ankle Int 2016; 37:457.
  17. Espinosa N, Brodsky JW, Maceira E. Metatarsalgia. J Am Acad Orthop Surg 2010; 18:474.
  18. DiPreta JA. Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. Med Clin North Am 2014; 98:233.
  19. Schuh R, Seegmueller J, Wanivenhaus AH, et al. Comparison of plantar-pressure distribution and clinical impact of anatomically shaped sandals, off-the-shelf sandals and normal walking shoes in patients with central metatarsalgia. Int Orthop 2014; 38:2281.
  20. Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskelet Disord 2006; 7:95.
  21. Chang BC, Liu DH, Chang JL, et al. Plantar pressure analysis of accommodative insole in older people with metatarsalgia. Gait Posture 2014; 39:449.
  22. Locke RK. Morton's neuroma. J Am Podiatr Med Assoc 1993; 83:108.
  23. Fazal MA, Khan I, Thomas C. Ultrasonography and magnetic resonance imaging in the diagnosis of Morton's neuroma. J Am Podiatr Med Assoc 2012; 102:184.
  24. Pastides P, El-Sallakh S, Charalambides C. Morton's neuroma: A clinical versus radiological diagnosis. Foot Ankle Surg 2012; 18:22.
  25. Sharp RJ, Wade CM, Hennessy MS, Saxby TS. The role of MRI and ultrasound imaging in Morton's neuroma and the effect of size of lesion on symptoms. J Bone Joint Surg Br 2003; 85:999.
  26. Studler U, Mengiardi B, Bode B, et al. Fibrosis and adventitious bursae in plantar fat pad of forefoot: MR imaging findings in asymptomatic volunteers and MR imaging-histologic comparison. Radiology 2008; 246:863.
  27. Bencardino J, Rosenberg ZS, Beltran J, et al. Morton's neuroma: is it always symptomatic? AJR Am J Roentgenol 2000; 175:649.
  28. Jannink M, van Dijk H, Ijzerman M, et al. Effectiveness of custom-made orthopaedic shoes in the reduction of foot pain and pressure in patients with degenerative disorders of the foot. Foot Ankle Int 2006; 27:974.
  29. Hsi WL, Kang JH, Lee XX. Optimum position of metatarsal pad in metatarsalgia for pressure relief. Am J Phys Med Rehabil 2005; 84:514.
  30. Jackson L, Binning J, Potter J. Plantar pressures in rheumatoid arthritis using prefabricated metatarsal padding. J Am Podiatr Med Assoc 2004; 94:239.
  31. Chang AH, Abu-Faraj ZU, Harris GF, et al. Multistep measurement of plantar pressure alterations using metatarsal pads. Foot Ankle Int 1994; 15:654.
  32. Holmes GB Jr, Timmerman L. A quantitative assessment of the effect of metatarsal pads on plantar pressures. Foot Ankle 1990; 11:141.
  33. Wu KK. Morton's interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg 1996; 35:112.
  34. Rasmussen MR, Kitaoka HB, Patzer GL. Nonoperative treatment of plantar interdigital neuroma with a single corticosteroid injection. Clin Orthop Relat Res 1996; :188.
  35. Thomson CE, Beggs I, Martin DJ, et al. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. J Bone Joint Surg Am 2013; 95:790.
  36. Mahadevan D, Attwal M, Bhatt R, Bhatia M. Corticosteroid injection for Morton's neuroma with or without ultrasound guidance: a randomised controlled trial. Bone Joint J 2016; 98-B:498.
  37. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int 2008; 29:483.
  38. Sofka CM, Adler RS, Ciavarra GA, Pavlov H. Ultrasound-guided interdigital neuroma injections: short-term clinical outcomes after a single percutaneous injection--preliminary results. HSS J 2007; 3:44.
  39. Hassouna H, Singh D, Taylor H, Johnson S. Ultrasound guided steroid injection in the treatment of interdigital neuralgia. Acta Orthop Belg 2007; 73:224.
  40. Chuter GS, Chua YP, Connell DA, Blackney MC. Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton's) neuroma. Skeletal Radiol 2013; 42:107.
  41. Musson RE, Sawhney JS, Lamb L, et al. Ultrasound guided alcohol ablation of Morton's neuroma. Foot Ankle Int 2012; 33:196.
  42. Hughes RJ, Ali K, Jones H, et al. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol 2007; 188:1535.
  43. Gauthier G. Thomas Morton's disease: a nerve entrapment syndrome. A new surgical technique. Clin Orthop Relat Res 1979; :90.
  44. Dereymaeker G, Schroven I, Steenwerckx A, Stuer P. Results of excision of the interdigital nerve in the treatment of Morton's metatarsalgia. Acta Orthop Belg 1996; 62:22.
  45. Pace A, Scammell B, Dhar S. The outcome of Morton's neurectomy in the treatment of metatarsalgia. Int Orthop 2010; 34:511.
  46. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma. Cochrane Database Syst Rev 2004; :CD003118.
  47. Bucknall V, Rutherford D, MacDonald D, et al. Outcomes following excision of Morton's interdigital neuroma: a prospective study. Bone Joint J 2016; 98-B:1376.
  48. Nashi M, Venkatachalam AK, Muddu BN. Surgery of Morton's neuroma: dorsal or plantar approach? J R Coll Surg Edinb 1997; 42:36.
  49. Cohen BE, Nicholson CW. Bunionette deformity. J Am Acad Orthop Surg 2007; 15:300.
  50. Ajis A, Koti M, Maffulli N. Tailor's bunion: a review. J Foot Ankle Surg 2005; 44:236.
  51. Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser toe deformities. J Am Acad Orthop Surg 2011; 19:505.
  52. Hannan MT, Menz HB, Jordan JM, et al. High heritability of hallux valgus and lesser toe deformities in adult men and women. Arthritis Care Res (Hoboken) 2013; 65:1515.
  53. Bus SA, Maas M, Michels RP, Levi M. Role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetic neuropathy may not be as straightforward as widely believed. Diabetes Care 2009; 32:1063.
  54. Glasoe WM, Coughlin MJ. A critical analysis of Dudley Morton's concept of disordered foot function. J Foot Ankle Surg 2006; 45:147.
  55. Morton DJ. Metatarsus atavicus: the identification of a distinct type of foot disorder. J Bone Joint Surg Am 1927; 9:531.
  56. Lee KB, Park HW, Chung JY, et al. Comparison of the outcomes of distraction osteogenesis for first and fourth brachymetatarsia. J Bone Joint Surg Am 2010; 92:2709.
  57. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health 2010; 2:487.
  58. Yammine K. The sesamoids of the feet in humans: a systematic review and meta-analysis. Anat Sci Int 2015; 90:144.
  59. Ozkoç G, Akpinar S, Ozalay M, et al. Hallucal sesamoid osteonecrosis: an overlooked cause of forefoot pain. J Am Podiatr Med Assoc 2005; 95:277.
  60. Kose IC, Hizal M, Bulut EG, et al. Bilateral fused os intermetatarseum presenting as dorsal foot pain: a case report. Surg Radiol Anat 2014; 36:503.
  61. Ishii T, Kawabata H, Kuratsu S, et al. Two cases of complete polymetatarsia without polydactyly. Br J Plast Surg 2005; 58:267.
  62. Stewart S, Dalbeth N, Vandal AC, Rome K. The first metatarsophalangeal joint in gout: a systematic review and meta-analysis. BMC Musculoskelet Disord 2016; 17:69.
  63. Balutis E, Pino A. Gout Causing Isolated Sesamoid Destruction Mimicking a Neoplastic Process. Am J Orthop (Belle Mead NJ) 2015; 44:E398.
  64. Dobson M, Alwahab Y, Fazal MA. Interphalangeal joint involvement of the big toe in gout: a rare presentation. J Am Podiatr Med Assoc 2012; 102:256.
  65. Rewhorn MJ, Leung AH, Gillespie A, et al. Incidence of complex regional pain syndrome after foot and ankle surgery. J Foot Ankle Surg 2014; 53:256.
Topic Outline

GRAPHICS