This is pain felt in the ball of the foot associated with abnormal biomechanics. The abnormal biomechanics can result from other deformities (hallux valgus or flat feet as an example), relatively long 2nd or 3rd metatarsal bones or tight calf musculature.
Patients typically describe the pain as ‘walking on marbles or pebbles’, and sometimes an ‘electric-shock’ to the toes.
Modification of footwear can provide initial relief, with thicker padded soles, metatarsal pads or offloading orthotics.
If non-operative management fails to resolve the symptoms, surgical options depend on the underlying cause. If a high arch is present (Pes Cavus) or there is loss of arch (Pes Planus) then surgical options may include breaking bones (osteotomies) or fusing joints within the foot and re-aligning the foot to improve weight distribution. Similarly, if the 2nd and 3rd metatarsals are long, these may be broken (osteotomy) and shortened. Management of hallux valgus and rigidus can be found here (link to appropriate section on website).
If the primary problem is from tightness of the calf musculature, these muscles may need releasing to help offload the ball of the foot. I do this with a gastrocnemius release from the medial side of the calf, midway down the lower leg.
As with any surgery there are potential risks. This will be discussed in more detail during the consultation, however common complications are stiffness, swelling, nerve injury, infection, under correction and over correction of positions.
In cases of tendon transfer and osteotomy or fusion procedures, your leg will be placed in a below-knee cast for 2 weeks, at which stage a wound check will be performed and a complete below-knee cast applied for a further 4 weeks. For this initial 6 weeks no weight-bearing will be allowed, and crutches will be supplied for support. Elevation, above the heart level, as much as possible, is important. After 6 weeks, a walking boot will be applied, and weight-bearing will be permitted in the boot for 6 weeks and physiotherapy instigated.
If surgery to help with tightness of the calf musculature is performed, your leg will be in bandaging and a surgical boot will be provided to allow you to weight-bear whilst protecting the wound. You will be provided with crutches for support. Elevation, as much as possible, is important in the first few weeks. The bandaging will come down at 2 weeks and dressings changed. Referral for physiotherapy to help with stretching exercises will start from this stage and you will expect to come out of the boot soon.
With regards to return to work, it is dependent on the amount of weightbearing required. If the work is sedentary and you can keep the foot elevated, then return before 2 weeks is satisfactory. Otherwise, return to work should be expected after 2-4 weeks for calf muscle release and after 12 weeks for osteotomy and fusion procedures.