Hello again. Hopefully part 1 was helpful, let’s roll on to part 2. This will not cover every cause of pain in the ball of the foot, however I will aim to cover the most common problems presented to me in the clinic. As always if you are experiencing pain, my advice is to seek professional medical advice.

Right, let’s get stuck in straight away.

Plantar Plate Injury
First of all, you are most probably thinking what is the plantar plate. The plantar plate is the ligament type structure that connects the metatarsal to the phalanx (toe bone). It is actually an extension of the plantar fascia.

Permission given by K Kirby. Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 107-108

The diagram above shows the plantar plate, coming from the plantar fascia. It shows that as the plantar fascia tightens, it pulls on the plantar plate, causing the toes to move downwards. The plantar plate helps prevent the toes from hammering (curling upwards). So as you can see it is an important structure.

A plantar plate injury will typically present as a chronic pain, with no history of trauma. Pain is typically located at the at the toe joint and be described as an ache, however there may well be a burning, stabbing or sharp pain. There may be some swelling, however this is not always present. Most injuries I see in clinic are chronic injuries, however it is possible to get an acute tear / rupture, for this there will be swelling.

Walking bare foot and any activity that involves bending the toe upwards will increase the pain, as will activities such as walking up and down stairs, jumping, running. Forefoot running is likely to aggravate the pain along with barefoot style footwear. The 2nd toe is most commonly affected; however it is possible for any toe to be affected.

This usually involves trying to limit dorsi flexion (bending upwards), this can be achieved with the use of stiff soled shoes, taping as shown below.


The use of orthoses (insoles) to off load.

Normally I recommend, period of 6 weeks of no barefoot walking, using stiff soles shoes and keeping the toe taped, with replacing running with swimming or cycling, however every case is different.

Stress Fractures
Is a stress/overuse injury to a bone and is common in long distance runners, and is more common in females, however it can occur in males, especially if there is a poor diet and low Vitamin D.

A stress fracture has no particular history of trauma. It will present with a dull ache and pain can be present at night, there will be tenderness on palpation at the stress fracture site. There may be some swelling. There will be pain on running and possibly walking, which will continue for multiple days after sport. Normally there has been a sudden increase in mileage or intensity on running. A stress fracture will not show on x-ray for at least 2 weeks, however x-rays can be helpful in running out other problems, MRI is the scan of choice for stress fractures.

This depends on the person, location and severity of the stress fracture. Treatment can be a period of relative rest, so running, however you can continue to swim and walk. It may mean a period in a special boot, called an air cast walker, nicked name the ‘Beckham’ boot, after David Beckham was in one following a metatarsal injury. Some stress fractures require surgery if an area with poor blood supply.

Muscle/Tendon Strain
There are many muscles and tendons in the foot, some start within the foot (intrinsic) some start out side the foot (extrinsic)

Most muscle/tendon injuries are an over use injury/training error. This tends to present with a burning pain and will follow the path of the muscle affected and will be aggravated by activation of the muscle. Tendons may not hurt too much when using, however will be stiff the morning after use. There may be some minor swelling present. These should not be injured, as the earlier treatment is sought, the quicker you tend to get back to running.

Initial treatment is the same as all new tendon injuries: Forget RICE, we now call the POLICE

Protection: Protect the injured tendon by not putting weight through it.
Off Load: Old thinking was to rest, however latest research suggests off loading the  effected area is more effective than complete rest.
Ice: 10 minute on and 10 minute off cycles (never put bare ice on your skin).
Compression: Compression the injured area, something like a tube grip can help.
Elevation: This will help to reduce the swelling.

The key then is the strengthen the muscle or tendon again, so it can tolerate the load and also reduce the load through the muscle/tendon with footwear, running advice, training advice, orthoses, taping etc.

Turf Toe
Is an injury of the 1st metatarsophalangeal joint capsule and the surrounding ligaments. This can range from a small tear of the joint capsule to a full tear and even dislocation of the 1st metatarsophalangeal joint and is graded 1-3.The injury is usually from excessive dorsi-flexion of the 1st metatarsophalangeal joint and will be painful on dorsi-flexion of the joint. Palpation of the sesamoids which are 2 small bones located under the 1st metatarsophalangeal joint will usually not be painful. Dorsi-flexing the 1st metatarsophalangeal joint to the end range of motion tends to be painful. So any sports where excessive dorsi-flexion of the 1st metatarsophalangeal joint occurs leaves you prone to this, including dancing, football, sprinting, the list could go on.

The Sesamoids are 2 small bones under the 1st MTPJ (big toe joint). A sesamoid is effectively a floating bone, the largest sesamoid in the body is the knee cap. People with a high arched foot or a big toe that sits lower down than the rest of the toes are prone to this problem, I have also seen an increase of this problem in runners who have made a sudden change to a minimalist shoe.

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You can see above, my big toe, sitting lower than the rest, technically called a plantar flexed 1st ray.

The pain can be described as burning. There may be some small amount of swelling. Palpation of the sesamoids will be painful and running will increase the pain. The pain will settle at rest, if the pain continues in the night and for many days, we need to think about a possible fracture of the sesamoids. The tricky part is that naturally 10% of people have a bi-partite and tri-partite sesamoid, meaning the sesamoid is naturally in 2 or 3 pieces from birth. An x-ray with the correct view and possible MRI or CT scan will help tell the difference between a fracture and a bi-partite sesamoid.

The aim is to off load the sesamoids, this can be done with, a change in footwear Footwear, rocker soled / stiff soled, resting from running using periods of cycling or swimming. Orthoses can be helpful with a cut out under a sesamoids and pad across the rest of the forefoot to off load. Sometimes the use of an air cast walker (Beckham boot) is needed to get the pain to settle. Steroids injections can be used, however not into a fractured sesamoid.