Conway McLean, DPM, Journal columnist

What follows is a typical scenario, experienced by many Americans. An ordinary workday, like most others, except towards the end of your shift, a new sensation is experienced. A subtle ache is noted, arising from the ball of one foot. You pass it off as simply bad shoes, but it develops again over the weekend. And walking around the house without shoes is more than uncomfortable. An internet search leads to a long list of possible causes, but no answers.

What is the “ball” of the foot? Definitions vary, but most agree it is that part of the bottom of the foot found between the arch and the toes. From a physical perspective, it is part of the platform for ambulation (aka gait, the act of walking, “putting one foot in front of the other”). As the heel raises up, we roll our weight onto the ball of the foot. But this important body part is prone to a host of problems and diseases.

Pain from this area can be due to a simple problem. Walking in higher heeled shoes leads to greater pressure to the front of the foot and inflammation develops. This is a more common scenario, rather than a single traumatic event, there is the repeated pounding of our typical daily lives. Too many overuse their shoes, leading to a loss of cushioning and support. Or some other condition results in an excess of trauma and pressure to this region. Symptoms, a polite way of referring to pain, eventually occur.

Inflammation, one of the buzzwords of the day, can be an important component of pain from the ball of the foot. But inflammation can develop not because of pressure but tension, which invariably develops when the farther part of this joint (that would be the toe), moves out of position. When a hammertoe develops, this is exactly what happens, and pain on the ball of the foot may ensue.

Feet vary greatly, person to person, as do many facets of humanity. One variable is the positioning of the metatarsal bones (those long bones that end at the ball of the foot) relative to the ground. When one of them is lower than the others, it experiences more pressure. Over the years, chronic callusing of the skin under this lower metatarsal bone can be seen. Individuals with this foot type may not have pain for years, but the extra pounding usually results in pain eventually.

Pain experienced in this area may not be generated by problems from the joints in the ball of the foot. There are other structures there, including small nerves running between the metatarsal bones. Because these delicate structures produce pain signals when pinched or pressured, certain foot types are prone neuromas. This is a term used to describe this pinched nerve in the forefoot. It’s often challenging for the discerning specialist to differentiate between joint and nerve pain. Frequently, both body parts are symptomatic.

Many other causes for discomfort from this region are seen, some of which are not the least bit obvious. A good example would be the forefoot pain when someone has a tight heel cord, technically referred to as the Achilles muscle-tendon complex. Shortening of this muscle-tendon group occurs to many of us, altering body mechanics and function, stressing the back, knees, and shins. The lever concept means that a tight heel cord forces the front of the foot down harder than appropriate. More force means more pressure and, once again, symptoms are likely to develop.

Age certainly takes its toll on the human body. The consequences of time are significant, and conditions which cause no pain when we are younger, can lead to symptoms eventually. A perfect example is the specialized padding at the bottom of the ball of the foot. This structure, termed the plantar fat pad, thins over the years in many of us, some more than others. When this thinning process advances sufficiently, the bones and soft tissue structures around these joints will be subjected to excessive forces. This repeated insult, experienced with each step, will typically lead to pain.

Gait is a complex act, despite the fact we don’t think about it, even when performing it. When the heel comes up off the ground just prior to pushing off with the ball of the foot and the toes, most of your body weight is placed on this region. If one of the metatarsal bones is longer than the others, a common variation, it is going to get much more of the pressure at this point in the gait cycle. As you may have guessed at this point, extra pressure means pain.

Pain experienced behind the second toe may be due to structural damage, often a tearing of the plantar plate. This is a thick, fibrous structure to which certain ligaments, tendons, and others attach. It is a vital anchoring point for various soft tissues, even bone. The plantar plate stabilizes the toe, helping you push off with your toes when walking. An injury to this plate, whether due to a single traumatic event or from repeated but more subtle insult, invariably causes both pain and often deformity, as a tear in the plate can allow the toe to drift subtly to one side. Various secondary problems can develop after this has occurred.

The anatomy of this region of the body is surprisingly complex, as is the mechanical functioning of the ball of the foot. It should be obvious this is a critically important body part since walking is so vital to health, well-being, and quality of life. Pain from the ball of the foot has numerous possible causes, and determining the specific reason sometimes takes a physician specializing in the biomechanics of the foot, ankle, and leg.

If pain is experienced from this area and it doesn’t resolve with simpler home measures, there may be a real problem, a structural and potentially chronic condition. And don’t think you can just live with it: chronic pain when weight bearing too often leads to changes elsewhere, especially in our gait, but also in lessened activity levels and reduced cardio-vascular health. Consequently, symptoms from the ball of the foot can affect your overall well-being. Don’t live with foot pain: get treatment so you can get going!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at drcmclean@outlook.com.