3rd Metatarsal Capsulitis: Email Advice

Hello there,

I tried to send this message via the link on your blog but it seem to get stalled so I have no idea if you will have received this message.

I am a very active person so my feet do get a good workout (ballet, hiking, fieldwork research in mountains etc.). Quite suddenly (no warning), I had intense pain in the ball of my foot (pain when walking) and went to doctor right away. My regular doctor did not seem overly worried about it although I did have an x ray that showed nothing wrong. I had no referral at this stage. I knew something needed to heal so I stopped my regular activities, kept off the foot as much as possible, and wore flat shoes. Within a few weeks, I began to walk almost pain-free in flat shoes - just a minor sensation when stepping.

Dr Blake's comment: Excellent job immediately acting on the problem. X rays are notorious for false negatives. 

Things continued to improve. About a month afterwards, I felt almost no pain (just an awareness of that part of foot but not really pain) at regular walking in regular flat shoes or barefoot at home, so I thought I was getting somewhere in healing. But things reached a standstill for many more weeks (same awareness of foot, but I was hesitant to re-attempt anything more active than walking lest I create a setback). So I went back to doctor to get a referral to a podiatrist. He diagnosed "capsulitis" and said something about ligament tears around the 3rd metatarsal joint. No further screening, but I have a referral to get orthotics and some type of shoe (I was rushed out of there as he must have been behind schedule, so I have no idea if these are orthotic shoes for regular use or a special shoe for healing period). It did hurt when he pushed hard on that joint, but walking is almost pain-free - same mild awareness of that area of foot.

Dr Blake's comment: When you do activities that vigorously involve the ball of your foot, capsulitis or the 2nd and 3rd joints are common, along with sesamoid injuries under the big toe joint, and nerve pain from trauma to the superficial nerves. Look into getting small longitudinal medial arch Hapads and Budin splints. I have ample information on the blog on purchasing and positioning. Email me again if you have questions. Also with capsulitis you need to be doing metatarsal doming 3 times a day (pain free) and icing for 10 minutes 2-3 times per day. 

Questions:

(1) Anyhow, given that I am at about 9 weeks after the pain started and there has been improvement (even if slow), what should I do next (other than the orthotics and possible shoe etc that was prescribed)? I am headed in the right direction but not ready to resume activity yet. Perhaps physiotherapy, and more vigilant icing 3x a day (no one ever told me to do this)? Do I need some type of stabilizing boot or not if I don't feel noticeable pain in regular flat shoes?

Dr Blake's comment: Yes, icing, and no special boot other than the orthotics. Make sure that the orthotic devices really protect the area when you go up on the ball of the foot. If the orthotics have an irritative met pad, have it removed and use the budin splint with the orthotic instead. I love PT for this. You go 2 times weekly and they can act help you increase activity. You are leaving the Immobilization Phase of Rehabilitation and entering the Restrengthening and Return to Activity Phases. 

(2) What do you think of the healing progress so far? Given what I've read, these injuries are slow to heal so maybe the healing time for my issue is normal and on track. How does one gauge when one can resume a bit more activity?

Dr Blake's comment: Everything sounds fine and on track. You should be congratulated for acting on it quickly. Once you get the orthotics and splints, gradually increase walking but do not emphasize a pushoff. The PT will help. You can do mat exercises for ballet, but wait at least until your ballet shoes are padded with metatarsal pads before you start floor exercises. Do you have someone to help you with ballet slippers? 

Any advice would be appreciated as this podiatrist did not seem inclined to sit down and talk to me about a thorough game-plan for how to proceed. And given how important my activities are to me, I want to do the right things. 

Thank you,