Given that propelling a bicycle requires the transfer of power from the legs through the feet to the pedals, it is not uncommon for a cyclist to experience pain, numbness and/or tingling in the forefoot area. A common cause of forefoot symptoms in cyclists is an inter-digital injury called Morton's neuroma.
The nerve that innervates the foot originates from the inner aspect of the ankle and passes under the mid-foot. This nerve subdivides into a number of branches, which extend toward the toes between each of the MTP joints of the toe (knuckles of the foot). The nerve splits to innervate each side of each toe. Repeated compression of the forefoot (either from pressure from underneath the foot or from the sides of the foot) can cause irritation and inflammation of the nerve at the branch point between the MTP joints.
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Nerve irritation and inflammation results in typical symptoms of pain, often localized between the affected MTP joint. There can also be an associated feeling of radiation of pain, numbness and tingling into the web-space and toes of the affected nerve. Once the symptoms develop during a bicycle ride, they can progressively worsen to the point that one must stop cycling. Squeezing the foot from the sides, wearing narrow foot wear or high-heeled shoes, running, jumping, and even prolonged walking often also bring on one's symptoms.
The diagnosis of a Morton's neuroma is usually made after clinical symptoms and physical examination findings have been considered. Sometimes, a diagnostic ultrasound or MRI can be used to aid in the diagnosis of a neuroma.
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The treatment of a Morton's neuroma is used to reduce the pressure in the forefoot and calm the inflammation around the nerve. Ways to reduce the pressure in the forefoot include:
1. Adjusting the forward-backward position of the shoe relative to pedal axle.
2. Adjusting the side-to-side position of the cleat on the shoe.
3. Selecting large size pedals and/or shoe cleats.
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4. Selecting cycling shoes with a wider toe box or adjustable strap tension in the forefoot area.
5. Adding a metatarsal pad or bar on the top of shoe insole. The position of the pad should be placed behind the MTP joints (Ideally, this should be done with the guidance of a qualified orthotist to ensure proper placement of the pad).
6. Tilting the inner forefoot with a shim that is placed under or on top the shoe insole.
You can also reduce nerve inflammation by taking oral or applying topical anti-inflammatory medications such as Ibuprofen.
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If symptoms persist despite taking the above measures, a corticosteroid injection of the neuroma could be considered. If corticosteroid injections fail or stop working after several have been attempted, surgical excision of the neuroma (neurotomy) could also be considered for treatment. This usually results in some permanent numbness of the affected toes, but not paralysis.
Other possible causes of forefoot pain in cyclists include large toe MTP joint bunions (hallux valgus), osteoarthritis, hammer toes and metatarsal stress fractures. A medical physician should be consulted to ensure proper diagnosis and management of severe foot pain from cycling.
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