Conway McLean, DPM, Journal columnist

Foot pain is something most of us experience at some point in our lives. Depending on which study is quoted, the vast majority of Americans have discomfort originating from this vital body part, some claiming 9 out of every 10 people do, at some point. Heel pain is likely the most publicized region of the foot capable of producing consistent pain and plantar fasciitis, the most frequent cause, is epidemic. But foot pain is not only easy to ignore, most Americans believe your feet are supposed to hurt.

After heel pain, the next most frequent area of the foot prone to pain is the ball of the foot. This is the weight bearing area at the front of the foot where the metatarsal bones end, meeting with the base of the toe bones. The ball supports the body when the heel raises up, an event occurring with each and every step. The physical stress to the area, over time, is tremendous. Depending on the study, recurrent pain from this part of the body occurs in 30-80% of the population at some point in their lives.

When pain is experienced from the whole ball of the foot and is not localized to a particular metatarsal-toe joint, the term used to describe the condition is metatarsalgia, an ill-defined term simply indicating there is pain from this area. One interesting aspect of metatarsalgia is the multitude of causes and associated factors leading to it.

Metatarsalgia is rarely the result of some injury or accident. It is more common as we age, with women seeming to have a stronger tendency for it. One of the changes occurring with the years is the reduction in flexibility and strength of our soft tissue structures. Also important is the status of the plantar fat pad, the specialized, highly compartmentalized padding which disperses pressure away from the metatarsal heads, the part of the metatarsal bone which is weight bearing.

Thinning of this material, termed plantar fat pad atrophy, occurs in most everyone to some degree, as we age, a process varying greatly. Loss of this padding on the bottom of the foot leads to symptoms for most. The symptoms often are described as being diffuse, experienced as a dull, achy pain. But because the pain is rarely sharp, too many people suffer in silence. They have some level of discomfort on a daily basis, and may be less active as a consequence, but find it a symptom easy to ignore.

Metatarsalgia results from numerous other factors besides thinning of the padding. A multitude of different conditions can lead to its development. One of the most frequently seen is the high arched foot, where less of the bottom surface of the foot is in contact with the ground. This means there is more pressure to the smaller area. Metatarsalgia is often associated with this foot type.

Another important issue is activity levels. Are you pounding the pavement in hard dress shoes or running for miles on concrete? And for the joggers out there, how old are your running shoes? They lose their support and cushioning, both resulting in greater force to the bone and joint structures found at the ball of the foot.

For various reasons, high heeled shoes continued to be valued components of women’s fashion. As should be predictable, the position of the foot in this kind of foot gear lends itself well to greater force to the ball of the foot. A somewhat similar effect occurs when someone’s Achilles is too tight, pulling up on the heel, creating greater pressure to the forefoot. A muscle imbalance is a common clinical finding, which can sometimes lead to the same situation, culminating in the gradual development of metatarsalgia.

The management of metatarsalgia is frequently of the “at-home” variety. The pain drives many of us to seek out new shoes or inserts. Numerous gadgets and pads are of course available. Shoes vary tremendously in their stiffness and support so this approach can sometimes be helpful for those with a milder variety. But since the causes vary so widely, the treatment required to obtain relief will as well.

From a stretching program for a tight Achilles to custom arch supports, all manner of approaches may be beneficial. This is rarely a surgical problem, with conservative measures of some sort generally able to resolve the discomfort. The trick is finding the root of the pain. Most of the time its biomechanical, the complex fashion in which the human body maintains an erect posture as well as ambulating through space. In other words, how do we stand and walk, the intimate details being both complex and multi-faceted.

The human body must endure all manner of trials and travails in its long journey through life. From the dangers of childbirth to navigating our way through the infirmity of old age, problems develop. Damage of various kinds is bound to result. This is especially true of the feet, carrying and supporting the body as they do. The feet are essential to both standing and walking, both critical components of good health, of overall quality of life. It’s a special structure and effective therapies are going to be best provided by a physician specializing in care of that part of the body, like a podiatrist.

Some get relief from metatarsalgia with simple ‘over the counter’ methods, while many suffer in silence, assuming this is how it’s supposed to be. Figuring out why there is pressure to this region, the ball of the foot, is going to lead to the best treatment. But this takes detective work……and an intimate knowledge of the mechanics of the foot and leg.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.