Intended for healthcare professionals

Practice 10-Minute Consultation

Forefoot pain

BMJ 2020; 371 doi: (Published 09 October 2020) Cite this as: BMJ 2020;371:m3704
  1. T Pelly, core surgical trainee1,
  2. T Holme, specialty registrar in trauma and orthopaedics2,
  3. MA Tahir, general practitioner3,
  4. K Kunasingam, consultant trauma and orthopaedic surgeon4
  1. 1Kingston Hospital, London, UK
  2. 2St George’s Hospital, London, UK
  3. 3Barlby Surgery, London, UK
  4. 4Croydon University Hospital, London, UK
  1. Correspondence to T Pelly

What you need to know

  • Tenderness on palpation of the metatarsal spaces with a positive Mulder’s test suggests Morton’s neuroma

  • A key diagnostic test for plantar plate tears is the drawer test

  • Suspect sesamoiditis in patients with pain on resisted plantarflexion of the first metatarsophalangeal joint, and request sesamoid specific radiography views

A 46 year old woman presents with forefoot pain and a burning sensation between her third and fourth toes that is particularly severe when wearing shoes with high heels.

Pain of the forefoot, including the toes and metatarsophalangeal joints, is a common presenting complaint in general practice.1 Forefoot pain can affect two main anatomical areas: either first metatarsal and phalanges (hallux), or the lesser metatarsals and phalanges. The site of pain, along with other clinical features, can help to establish the cause of forefoot pain in a primary care consultation, and guide initial management.

What you should cover

Symptoms of the various causes of forefoot pain may initially appear similar, but on careful questioning possible diagnoses can usually be teased apart. Forefoot pain often restricts the person’s activity, which may have secondary effects on their health and wellbeing. Clinical features of forefoot pain are summarised in table 1. Systemic conditions including gout and rheumatoid and septic arthritis are important differentials, but beyond the scope of this article.

View this table:
Table 1

Features of forefoot pain

Where is the pain?

Primary metatarsalgia presents with pain on the plantar aspect of the foot under one or more metatarsal heads. Hallux valgus, rigidus, and sesamoiditis affect the first metatarsal head (fig 1). Plantar plate damage often presents with pain at the second metatarsal head.12 Morton’s neuroma is typically identified in the third and fourth metatarsals.

Fig 1

Typical sites of forefoot pain

What does the pain feel like?

People with pain from …

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