When Pain is Felt Where the Toes Meet the Foot (a.k.a) Metatarsalgia

The following questions was posed to me by a triathlete: “So after the last race (at the end of august) I started feeling some pain on the top of my foot where my foot meets my toes. I tried to run one time after the race and basically had to walk home because I couldn't put any weight on my foot. I couldn't bend my toes and the pain was awful!! I’m in a boot now for 2 weeks.”

Believe it or not, these issues are very common, though perhaps not to the severity of this athlete.

The possibilities of this pain are as follows:

1. metatarsal stress injury or stress fracture

2. low grade compartment syndrome

3. joint sprain or injury

4. acute flare of a Morton’s neuroma

5. referral pain from another source

When the severity is significant enough to not even be able to put weight on the foot, then the stress fracture and compartment syndrome become most likely. Bones can break from acute trauma or from the cumulative stress that eventually builds beyond the bones capacity to withstand. If you are running while it occurs, especially in competition, the body has a way of blocking out the pain until the activity is over. You will always be aware that something isn’t exactly right, but it will always be much more painful once the activity stops. Fractures also tend to cause localized swelling that will persist for days up to a week even without activity. If the pain is much better the next day or within a few days, then the chance of a fracture is minimal, and something else on the list is more probable.

Compartment syndromes occur when the pressure inside some of the smaller compartments of the foot is increased to a point where the nerves and blood vessels become somewhat pinched off. This triggers a pain response that can be exactly like what is described above. It’s very much like acute shin splints, only in the foot. There will often be some swelling in a more broad area, and it typically will be better in a few days if the activity is shut down for a few days.

Joint injuries tend to be more nagging and after the initial injury calms down, you may be left with the sensation of walking on a bunched up sock or a pebble. You may have swelling over the joint and in severe cases, may even see the toe position start to shift over. This is most commonly seen with the second toe (next to the big toe) and it will most commonly shift towards the big toe.

Morton’s neuroma is a thickened nerve between the middle and fourth toe (next to baby toe). You can have pain and swelling in the ball or top of the foot. The usual immediate symptom is burning pain and it is most often relieved by taking the shoe off and getting off the foot. Many people have neuroma’s that have been present for many years and would never know it. They are often incidental findings in an exam and may or may not contribute to a more significant condition.

Lastly, on this brief list, is pain that refers from another source. Often times, runners will experience pain on top of their foot, near or behind where the toes meet the foot, that feels as if the bone is broken. The pain can sometimes be there, sometimes not and usually is only felt intermittently. It is not associated with swelling but can be severe at times. From a treatment standpoint, it is crucial to find out where the pain is coming from, and is most often stemming from sensory nerve that is wrapping around the ankle.

In all of these conditions, we can experience pain that is significant immediately after a run or a race that mimic what happened with this athlete. Typically, if the pain goes away very quickly, it’s something far less serious and doesn’t need to impact your ability to run and train. However, there are reasons why pain occurs, and it’s important to try and understand where it came from to help prevent recurrences and more chronic or significant injuries from happening.