Foot pain is a common problem among older, obese, and active adults who participate in sports that involve running and jumping. An understanding of basic foot anatomy and biomechanics can help guide the exam and diagnose the correct area. Futhermore, your history of foot pain (onset, provocative factors, palliative factors, quality, radiation, site, timing) is very helpful!
What are the most common diagnosis for forefoot pain?
- first metatarsophalangeal (MTP) joint MTP joint bunions (hallux valgus)
- hallux rigidus (degenerative arthritis) - unusual stiffness resulting in limited great toe extension
- turf toe (forced hyperextension of great toe)
- metatarsalgia - plantar surface below the second and third metatarsal (MT) diaphyses
How does hallux valgus affect my foot mechanic?
Joint bunion can be very painful for patients. The chronic rubbing of the bunion along the shoes lining can cause inflamation, pain and reshaping of the joint. Overtime, the pain alters the mechanic of the great toe and, ultimately, disturb the kinetic chain of the foot, knee and hip. It is not uncommon to find hallux rigidus along with hallux valgus. Normally, the extension of the great toe pulls the plantar fascia tight and stabilizes the foot. Stability of the foot is needed in order to generate the powerful push off force. Hence, weakness in the toe will force other area above to compensate for the inflexibility.
The foot will naturally supinate (heel turn inward) to avoid the pain and place strain on the 2nd and 3rd metatarsals resulting in fractures. The foot supination will decrease the knee's ability to fully extend and introduce new knee strain. Inability of knee extension will decrease hip extension. Ultimately, the body kinetic chain has been altered and produces less power per step.
What do I need to do?
Discussion with your physician is a healthy, vital step in your diagnosis and treatment. Imaging may be necessary to rule out acute fractures that may not be initially apparent. Modified orthotics may be neccesary. Stretching exercises for hallux rigidus. Cheilectomy (removes bone spurs on the top surface of the big toe joint bones) may be needed for some patients to restore function and alleviate long term pain.
Dr. David Carfagno is a Board Certified Internist and Sports Physician, who trained at the Cleveland Clinic Foundation
Tri-Quoc Pham M.A. is ACSM Certified Personal Trainer and a 4th year medical student at Arizona College of Osteopathic Medicine
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Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24:731.