Hello fellow runners!
I've noticed a few members asking questions about forefoot pain located near the 2nd and 3rd metatarsophalangeal (MTP) joints, so I decided to write this blog to provide some helpful information.
Forefoot pain is a common complaint among runners, and it can significantly impact your performance and enjoyment of the sport. As a physiotherapist with a passion for running, I want to share some insights and tips to help you prevent and better manage forefoot pain. Whether you're a seasoned marathoner or a weekend jogger, this guide is for you.
The Role of Training Load in Running Injuries
One of the more critical, but often overlooked factors in the development of running injuries, including forefoot pain, is training load. It is tempting to seek out other more cut-and-dry treatments that can be implemented without having to change other aspects of your running routine. For example, it would be great if there was a single exercise that would solve the problem or a special treatment that could be done to fix everything in one fell swoop. The promise of a quick fix is easy to market, but before considering any of these options, the first port of call should be a review of your training load parameters and being open to the idea that a full recovery might be dependent on a good number of weeks of reduced training load:
Intensity (Speed of Running): In the 4-6 weeks leading up to the onset of your foot pain, have you significantly changed the intensity of your running? Perhaps you have been going harder to get your minutes per km down to a certain goal? Or maybe you’ve started a bunch of speed sessions that you previously haven’t done a lot of. Or maybe you’ve changed your running course, and your new routes involve a lot more hill work?
Duration (Distance): Have you had any sudden increases in overall mileage? If you’re training for a marathon or half marathon, it might be that your foot pain is related to the increases in distances you’ve been clocking up. Sometimes, even if you stick with a training program with graded increases in kilometres, it might just be that the rate of increase in distance is too much for the adaptive potential of your particular feet.
Frequency (Intervals Within a Training Session and Number of Sessions per Week): Have you increased the number of running sessions you are doing per week? Or have you increased the number of intervals within a given training session? Maybe you’ve gone from being an occasional, once-per-week jogger to running five to six times per week? This sort of rate of increase in running frequency carries a risk of injury because your joint structures and soft tissues aren’t adapted to the demands, and there is not enough time between sessions for recovery.
What if Your Training Loads Have Been Well Monitored and Progressed, but You Still Have an Injury?
It’s not uncommon for runners to present to our clinic with a complaint of foot pain (or knee pain, hip pain, back pain…), and for them to express frustration that they thought they had done the right thing by following a training program that was designed to assist runners in building up gradually. I can certainly understand the frustration. For myself, I have had to take a break from running for six weeks to look after a peroneal tendon irritation that I can only attribute to my attempts to improve my time for my usual 10km training route. I thought I had done a good job building up my efforts gradually, but over a few weeks I developed pain that became progressively worse.
In these scenarios, it’s important to understand that there is no recipe that applies equally across a whole population of runners. The truth is that, as a group of professionals (trainers, physios, sports doctors, coaches, etc.), we suck at predicting injuries in athletes. The best we can say is that events that lead to an injury and the number of factors at play are super complex.
So there really is no foolproof option for injury prevention. The best we can do (in terms of controlling training loads) is to err on the side of caution. And be okay with the idea that some of our performance goals need to be balanced out against the potential for injury.
Elite versus Weekend Warrior Training
With that in mind, it's important to distinguish between exercise programming designed to maximize performance and programming intended to avoid injury and keep you consistently participating in regular running. While it can be tempting to adopt elite training programs in an attempt to boost performance, for most of us, sticking with a program that has longer-term performance goals and less rapid progressions in training parameters is more beneficial. This approach minimizes the risk of injury and ensures sustainable improvement.
Forefoot Pain at the 2nd and 3rd Metatarsal Heads
If you're experiencing pain specifically near the head of the 2nd and 3rd metatarsal heads, it is likely to be one of three conditions:
Stress Fracture of the Metatarsal: Repetitive stress and overuse can lead to small cracks in the metatarsal bones, resulting in pain and swelling that worsen with activity and improve with rest.
Pathology within the MTP Joint: Various issues can arise in the metatarsophalangeal (MTP) joints, including:
Plantar Plate Injuries: Damage to the ligament that supports the base of the toes can cause pain and instability.
Joint Capsule Sprain: Overstretching or tearing the joint capsule can lead to inflammation and pain.
Degenerative Pathology: Conditions like osteoarthritis can cause joint pain and stiffness.
Freiberg Disease: In adolescent populations, particularly females, a condition known as osteochondritis can develop in the joint surfaces of the MTP joints. This condition, known as Freiberg disease, leads to joint pain and limited motion due to the death of bone tissue.
Morton's Neuroma: This condition involves the thickening of tissue around one of the nerves leading to your toes, causing sharp, burning pain in the ball of your foot. You might also feel stinging or numbness in the toes.
Tips for Managing Forefoot Pain
While managing your training load is crucial, there are additional tips to help manage forefoot pain. Remember, all of these tips are likely to be limited in effect if your training load is not balanced:
Footwear: Invest in running shoes that offer good cushioning, arch support, and a wide toe box. Avoid high heels and shoes with pointed toes in your everyday life.
Strengthening Exercises: Strengthening the muscles in your feet and lower legs can improve foot mechanics and reduce pain. Exercises like toe curls, calf raises, and arch lifts can be beneficial.
Stretching: Regularly stretch your calves, Achilles tendon, and plantar fascia to maintain flexibility and reduce strain on your forefoot.
Running Mechanics: There is no such thing as a perfect technique to aspire to, but it’s worth assessing your patterns to see if there is scope for some running technique adjustment.
Seek Professional Help: If the pain persists despite self-care measures, consult a physiotherapist for a thorough assessment and personalized treatment plan.
When to See a Physiotherapist
Persistent or severe forefoot pain should not be ignored. We can help clarify the likely driver(s) of your pain and develop a comprehensive treatment plan tailored to your needs and goals. Treatment may include manual therapy, specific exercises, and advice on footwear and orthotics. Above all, though, treatment is built around an assessment of your training load parameters and the construction of a plan to reduce your training load just enough so that your injury can heal, but not so much that you have to miss out on running any more than is necessary.
At our clinic, we specialize in treating running injuries and helping runners get back on track. If you’re struggling with forefoot pain or any other running-related issue, don’t hesitate to reach out. Let’s work together to keep you running pain-free and enjoying every step.
Stay healthy and happy running!