Prevention and Treatment of Forefoot Injuries

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The extensor tendons to the foot come from the small muscles in the front of the leg. The two main extensor muscles are the extensor hallucis longus and the extensor digitorum muscle. The tendons from these muscles cross the front of the ankle and pass across the top of the foot and attach into the big toe and lesser toes. When you walk, your body uses the tendons to pull the foot upward and work with Achilles tendon and calf muscles to pull the boot back down toward the ground. Extensor tendinitis occurs when these tendons at the front of the ankle become overstressed and inflamed. The most common factors that cause extensor tendinitis are tightness of your shoes or laces, over exertion during exercise and falling of the foot arch. You can see if you have extensor tendinitis by flexing your foot downwards and have someone provide resistance to the top of your toes and pull the toes upward against the pressure provided. Any pain felt along the top of your foot or along the tendon, is most likely extensor tendinitis. Treatments can include calf muscle stretching and oral anti-inflammatory medications, or surgery if severe. Long term treatment and prevention will be by using custom made orthotics.
Morton’s neuromas are confined to the top of the foot and are generally benign or non cancerous growths of nerve tissue. They are most commonly found between the third and fourth toes. The condition may occur as a result of irritation, injury or repetitive stress. It involves a thickening of a tissue around one of the digital nerves to the toes, causing sharp or burning pain, stinging or numbness at the ball of the foot. Common symptoms include: radiating pain from the ball of the foot to the toes, tingling of the toes, or sudden shooting pain in the forefoot. A full examination by your podiatrist before beginning training program or participation in sports or activities, along with their recommendation of proper shoes, proper stretching and a comprehensive warm up routine is by far the best course of action to prevent occurrence of Morton’s neuroma. This can be confirmed by Mulder’s sign at the interspaces of the toes. Initial treatment may include over the counter anti- inflammatory medications to reduce pain and swelling, massaging the painful area 3 times daily with ice, and changing footwear to avoid irritation, and arch supports to help reduce pressure to the nerves, reducing activities and injecting corticosteroids to reduce inflammation and pain. Should the condition persist, surgery may be recommended to remove the neuroma.

Another condition in the forefoot is capsulitis, also known as plantar plate strain, or metatarsal overload syndrome. When two bones come together they form a joint and are surrounded by capsular ligaments keeping the bones lined up for proper function. Any activity which require constant and excessive bending of the toes will cause the ligaments to overstretch, become inflamed leading to pain. Your podiatrist will be able to properly diagnose this condition and recommend these treatment options: NSAID’s, stretching, padding or orthotics.
A stress fracture is an overuse injury, it occurs when muscles become fatigued or overloaded and cannot absorb the stress and shock of repeated impact. Fatigued muscles transfer that stress to the nearby bone and the result is a small fracture of the bone. Other factors that can cause this is by wearing improper shoes, decreased bone density and being a female. Rest is the best treatment, and if it is not taken, larger and more persistent stress fractures can develop and re-injury is more likely decreasing the likelihood of healing properly. To prevent stress fractures, you need to progress slowly in any sport or physical activity, eat a balanced diet with calcium rich foods. If you feel pain or swelling, stop activity and rest for a few days. If pain persists, see your local podiatrist.

Sesamoids are bones embedded in a tendon, shaped liked a pea located at the ball of the foot. You could have acute fracture caused by trauma which produce immediate pain and swelling at the side of the break. A chronic fracture is a stress fracture caused by repetitive stress or overuse. Sesamoiditis, is chronic inflammation of the sesamoid bones and tendons in that area caused by increased pressure. This is often associated with dull, long standing pain beneath the big toe joint that comes and goes. This can be due to the shoes or certain activities.
An injury to the soft tissue surrounding the big toe joint is known as Turf Toe. Usually occurring while the big toe joint is extended beyond its normal range and typically accompanied by a “pop” at the time of the injury causing sharp pain and swelling, turf toe affects the entire joint and limits the function of the toe.

In diagnosing a sesamoid or turf toe, your podiatrist will examine the foot, focusing on the big toe joint. Depending on the type and severity of your injury, some non-surgical treatment includes: padding, strapping, immobilization, NSAID’s, physical therapy, steroid injections and using an orthotic device. Surgery is generally reserved for severe injuries that fail to respond to non-surgical treatment over a long period of time. Your podiatric surgeon will determine the type of procedure that is best for your individual need.
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