Ball of Foot Pain: Email Advice

Dear Dr. Blake,
I have had a severe foot pain for many years that I cannot understand. The pain is located on the bottom of my foot, in between the first and second toe area, next to the joint of the big toe.  Can you look at my xray image and tell me if you see anything that might be causing it?  I'm concerned that a piece of bone has broken off of my large toe, underneath, and it isn't being detected because the x-ray is taken from the top, as best as I can tell.  Also, can you explain what the white circle on the right of the big toe in the xray is?
I'm sending the other view in the next email.

Thank you very much for your help.

Dear Margaret (name changed), 

     There are 2 very obvious possibilities, and probable a dozen of other ones. Pain between the first and second joints can be caused by the big toe sliding off of the joint laterally (towards the second) which is happening with you. I placed the pointer on the part of the base of the toe that is actually off the joint. You can see where the normal part of the first metatarsal head ends (the white strong part). You have a 2 mm subluxation of the toe on the metatarsal. If I placed your knee cap 2 mm out of its normal groove with the femur and had you move your knee, it would start to hurt very badly. You can check the blog on how to tape the big toe medially (bunion taping with kinesiotape or 3M Nexcare tape). Tape the toe over for a week and also use a medium gel toe separator (found in bunion posts) and see if you can see any relief. I do not see any bone spurs or chips. 

     The second reason is that the 2nd toe is subluxing toward the 1st toe. This happens alot with long 2nd metatarsals. See how the second toe sits on the 2nd metatarsal, and compare to how the 3rd toe sits on the third metatarsal. The 3rd joint is straighter, the 2nd toe looks like (and is) leaning over to the first toe. This again can give you pain in that area. Tape the 2nd toe to the 3rd and 4th for a week with 1 inch tape. See if that eases some of the intensity.

     I am very impressed on how white the 2nd toe is, but it could be just my copy. Whiteness on bone means stress. The second metatarsal should be whiter than the 2nd toe, since it handles more weight bearing. In your case, the toe is whiter than the metatarsal. Something is rotten in Denmark. 

     Another common structure in that area is the deep peroneal nerve. It can get irritated by the above mechanical problems, or other causes of stress like over pronation and some weight bearing repetitive stress like high heels or elliptical. The nerve can actually be irritated at your back around discs L4L5. Is the quality of your symptoms nervy--burning, tingling, electrical, buzzing, etc? 

     Since you have had severe pain, have you been able to get an MRI? That would probably help us immensely. Any other clues you can email me I will attach later to this post. Everyone is curious at helping you. I hope this helps some.  Rich At least tell me what helps the pain temporarily and what definitely bothers it. Thanks

Dear Dr. Blake, 

Thank you very much for your post. I will try to tape them the way that you suggested to see if that helps.

This all started when I was rear-ended on the interstate about 6 years ago by a 4 x 4 truck, about a 4000 lb truck, going about 75 mph.  I was going about 55 mph. The truck had a crash bar on the front, so it jettisoned my car forward, my car being only 1800 lb. In response to realizing the truck was about to hit us, I braced for the impact and floored the gas pedal to the floor. The last thing I remember was it felt like I stepped on a marshmallow, before I momentarily lost consciousness. I came to in time to get back up on the steering wheel, and get the car to the side of the road. I had no memory of what happened during the brief moment I lost consciousness.  No help arrived the scene for over an hour and half, and by then I was somewhat cognizant, and did not realize the extent of my injury, so I did not go to the ER.  Bad mistake. 

The next day my right foot really hurt, but I could not put the full weight on it because my pelvic area hurt so bad. A doctor told me later that I had smashed my knee in the dash. Right around the time we were starting to deal with the foot pain, I lost my insurance, so it went untreated for a long time. To avoid the pain at the ball of my foot, I have learned to curl my toes up when I walk to keep weight off that area. 

In these x-rays, I see a piece of bone, it looks like, near the little toe, in between the 4 and 5th toes area. I can feel it sometimes, its like something sharp is in my foot, cutting it. And when I look at the big toe, it looks like a fracture sideways. 

I am curious as to what is that white circle by the big toe on the xray on the right of the big toe, is that just where the xray overexposes?  I saw that on other foot xray's I saw on the internet.  One doctor told me a long time ago when I said "Thank God, I didn't break my foot"' and he commented "But you did" but he never went into any explanation of where it was broken. Can you tell?  Is it possible for a piece of broken bone to be behind the big toe on the xray, and it can't be seen?  I can tell from all the xrays I've looked at on the internet, that reading xrays is really an art that requires a lot of skill and experience.

Thank you.

Margaret,
     Wow!! You were very lucky! The white circle is called a sesamoid bone and it is normal. You could have injured it or the ligaments under the big toe joint in your accident. Look up a condition called Turf Toe to get an idea. There are a myriad on structures that could be injured and give you these symptoms. The X-ray below is called a Plantar Axial. You should get that, and an MRI, or at least the plantar axial. It will show if any structures under the big toe joint are injured. Here is an example.