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Saturday, June 1, 2019

Chronic Metatarsal Pain: Email Advice

hello dr Blake,
I am writing all the way from Italy and was wondering whether you could be so kind as to help shed some light on a foot problem I've been struggling with for the past 5 years. I hope you enjoy puzzles! I'm 33 years old, male, 6' 4'', 165 pounds. 

5 years ago I suffered a minor injury which caused capsulitis on my 1st MTP joint (right foot). Eventually the capsulitis resolved, but at the same time I gradually started to experience additional discomfort on the same foot for reasons which in hindsight seem to be attributable to increased weight/pressure on the affected foot when walking. For example, the metatarsal pad of the orthotics I had been prescribed to treat the capsulitis after a few months started to be painful (whereas with my left foot I could barely feel it), and after I switched to a pair without the met pads (April 2016), the discomfort shifted to other areas of my forefoot (sometimes lateral, sometimes medial, and always when pushing off). Sometimes I had the unpleasant sensation of 'feeling' my metatarsals when walking. Fed up with the orthotics, I tried to go back to walking without them as I had always done for 30 years. After a few days of walking pain-free I thought the condition had finally resolved and everything was back to normal, but shortly after the old symptoms came back. 
     So I went to see a podiatrist (January 2018), who said that my discomfort was due to unilateral over pronation and that I needed semi-rigid orthotics. The new orthotics worked very well for a couple of days, but then again symptoms-wise I was back to square one, with modest improvement. The podiatrist then made me a rigid pair of orthotics, but again, very little changed. Since he couldn't see any structural faults he came to the conclusion that the problem was muscle-related, more specifically my right calf was weak. This was maybe due to the original injury, since the capsulitis made it painful to push off as usual and so probably I started to use my calf muscles less and less. Nowadays I can rise on my toes on a single leg but I find it much easier with the other limb. I signed up at the gym, carried out a 4-month program with a fitness instructor (nothing specific for my problem though), experienced some improvements but very discontinuous, and finally went to see a physiotherapist (March 2019).
     The PT noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, an overactive tibialis anterior, and something about my latissimus dorsi which on that side was working harder than normal to maintain balance. I did 5 sessions where they manipulated mainly my pelvis and trunk, the reasoning was that all of those imbalances were affecting my foot, and not vice versa. On some days I noticed a definite improvement, but again, a bit discontinuous, so eventually they referred me to a podiatrist they knew in order to rule out intrinsic foot problems (April 2019, i.e. this week). 
Dr. Blake's comment: First of all, I am sorry I am late answering. You are not overweight and I am not sure that their is any association with the original capsulitis. All of your symptoms could be related to your unilateral pronation. If you look at your two orthotics, are they asymmetrical, with more support to the unilateral pronation side. 
     The podiatrist noticed a number of things apart from the unilateral over
pronation (ligamentous laxity, not much forefoot fat pad, big toe tends to make little contact), but the main thing seemed to be that the affected leg is 0.4" longer).  Thus, I would need a new pair of orthotics that took all of these things into account. I have no qualms about that, and I am willing to believe that 0.4" could go a long way to adding weight on my leg and foot and contributing to the problem. The affected leg is probably a bit longer, my fitness instructor once filmed me while walking on a treadmill and it clearly showed that the affected leg tended to circumduct (is that a verb?), and the anatomical leg length discrepancy may be compounded by a functional one.
Dr. Blake's comment: Yes, the long leg tends to be the more pronated, and 11 mm is a lot. I tend to try to separate the orthotic therapy and the lift therapy. So, I would gradually over one month build you up under the short side. When the patient is more pronated on the long side, correcting that aspect will make that side even higher, so you may need up to 1/2 inch. 

     I am willing to accept all of this. What I really can't wrap my mind around (and this is my main question) is this: if it really is a matter of bearing too much weight on the affected foot then why did it become symptomatic only in recent years, after the original injury? If the leg length discrepancy is truly anatomical, shouldn't I have had similar problems before the injury as well? The injury itself was no big deal, I hit a curb with my big toe but no fractures, just the capsulitis. Until 5 years ago I had never had the slightest problem. Could compensatory postural adjustments or lower leg muscle weakening post-injury have played a role in adding further weight to the affected side?
Dr. Blake's comment: Yes, for sure, an injury can cause other stresses to manifest for the first time. I am never sure if it is due to the deconditioning from the injury, or the compensations from the injury, but it happens all the time. I joke to my patients that at least it will stop after the third area begins to hurt (sometimes they get my humor). The long leg does put more stress on that foot for sure, and if you add the tightness that develops in the achilles with injuries, the stress to the injured foot can be quite bad. 

I'm adding a few bits of info which might help:
  • I tend to feel much less discomfort when walking barefoot (Dr. Blake's comment: for sure, shoes for sure add stress across the metatarsals as we try to bend at push off. Only stress fractures and other bruises hurt worse barefoot. This of course could be a clue for you to try very flexible shoes in the forefoot)
  • x-rays and MRI have always come out 'clean' (Dr. Blake's comment: Negative MRIs to me mean nerve injury first until ruled out. Nerve injuries show negative MRIs. Have you had any nerve symptoms like numbness, sharp, tingling, buzzing, electric, etc. It is also a good sign for the future as you do not have early onset arthritis).
  • pedograph analysis showed more pressure on the affected foot when walking, thought barefoot they were even (Dr. Blake's comment: Many times the difference only shows up running as are bodies have a harder time distributing the weight evenly.)
  • I tend to think that I am bearing more weight on the affected foot, but there are no signs of that on my skin (there is a slight degree of 'hallux valgus' though, could that be a sign?) Dr. Blake's comment: Yes, unilateral bunion formation or hammertoe formation is a sign of more stress.
  • as I mentioned before the discomfort I have on my forefoot is quite changeable, most times it's on the head of my 5th metatarsal, sometimes it's bit generalized, other times I don't feel anything on the 5th metatarsal and it's more on the big toe. In any case, it's always during push off. Dr. Blake's comment: The variability is more a stress syndrome than an injury. Change the mechanics, get stronger with single leg balancing and metatarsal doming, and stretch the achilles tendons several times a day. 
  • judging from what I see and from the pedograph analysis the arch of the foot seems fairly normal
I would be really grateful if you could share some thoughts on all of this, I've been through so much and am getting a bit depressed

thank you
Dr. Blake's comment: I hope you are feeling better. Get more flexible, get stronger, get at least 1/4 inch full length lifts and see if you are better with these changes. Rich 

The patient then answered:

hello dr Blake,
thank you very much for answering. I am writing a follow-up email to let you know how I am doing. If you feel to add any ideas or suggestions that I could pass on to the professionals that are looking after me (also in terms of diagnostic tests) I would be even more thankful (I have made a small donation to your blog as a token of gratitude). I don't want to take advantage of your kindness so if I don't receive further communications I will fully understand.
Over the last month and a half I have been wearing the new pair of orthotics (they have a 5 mm heel lift on the shorter leg, so the lift is not full length), my gait has improved as now I find it easier to push-off (last pair of orthotics were rigid and with little padding), while symptoms have also improved a bit but have not resolved. I am still doing physical therapy and next Wednesday I have a check-up with my podiatrist so I hope to clear things up a bit, but in the meantime I have been doing some research on a number of topics and I have come up with some new elements that may be worth mentioning. As my foot is apparently subjected to increased stress, I'm trying to understand what is causing it.
Dr. Blake's comment: Explain to the podiatrist to perhaps experiment with another orthotic device for the short side without the lift attached and with 2 (1/8th inch) full length spenco or other soft material as lifts one full length and one cut at the toes (sulcus length). That will add cushion but not pitch you forward as much onto the metatarsals. If you use soft material as lifts, you typically can go up a mm or 2 due to the compression. 
One of the working hypotheses is that it may be bearing more weight for some reason, but I've noticed this is something that hardly ever pops up in podiatry or PT. I have read several textbooks and at the most they talk about asymmetrical weight distribution foot-wise (i.e. more lateral or medial) and not body-wise (i.e. right leg/left leg).
Dr. Blake's comment: One method of getting some idea of the right to left weight bearing is looking at old inserts, ones that you have worn awhile, to see if one side is broken down more. The other common method is to stand evenly on two bathroom scales that you know are equally calibrated. Try to stand with equal weight in your mind, and have someone else take the measurements of left and right side. As soon as you look down to read the scales, you throw off this technique. It is only one tool, other than more sophisticated force plates/mats, but seems to be helpful. 
 I am wondering whether muscular imbalances in terms of tightness/weakness between the two halves of the body might play a role in how weight is distributed or force is transmitted to the lower extremities but I haven't been able to find any bibliography on the matter. Also studies on LLD and body weight distribution seem conflicting as to which leg bears more weight, so it's all a bit confusing to me. I did another pedobarographic analysis last month which apparently ruled out this asymmetrical weight-bearing hypothesis, as it showed that mean pressure was actually higher on the healthy foot when walking barefoot, but I don't know if such a test is supposed to be conclusive on this matter.
Dr. Blake's comment: I am not aware of any research on this matter, so I apologize. When a patient is bearing more weight on one side because of short leg syndrome, scoliosis, tight hamstrings or calves, weak muscles, etc they create postural instability as they try to compensate. This postural instability can lead to the measurements varying from step to step, with one side greater with one step, and the other side greater with the next step. Or, something like this. The force plate analysis as an office tool makes it difficult unless you do the test multiple times, and a definite pattern emerges. Most researchers feel you must walk over the force plate 10 or more times even to begin to practice the landing. This is actually why in a busy office I have not purchased these, but I understand their help in many situations. 

You mentioned in your reply to check for neurological signs, and this is something I didn't include in my first email. I do think there is something going on in that regard as well. One sign involves the dorsal aspect of the big toe, so I don't know if it's related to the general problem (forefoot plantar discomfort) but nonetheless it's worth mentioning. Sometimes I feel a mild burning sensation coursing along the big toe which is (sometimes, not every time) elicited if I move my leg after a period of inactivity when seated or lying down, and on sitting down after a walk.
Dr. Blake's comment: This is classic L4 nerve root irritation.

Or, also, when I'm doing sit-ups with my leg fully extended. What makes me think it's neurological is the fact that this burning sensation is sometimes elicited by stimulating the anal area (e.g. when I wipe after going to the bathroom), a very distant area that is directly connected to the foot only by means of nerves. I know that the deep peroneal nerve innervates the first web space and that it can get irritated when sitting with your legs crossed (something I used to do), but that doesn't match 100% my symptom in terms of location, as it's more dorsal 1st toe rather than 1st web space, and the peroneal/sciatic nerve is more 'buttock' than 'anus'. This burning sensation started post-injury, and I definitely remember that a few years ago sometimes I felt it coursing down my medial calf, on the side. Might it be that some nerve got irritated/damaged with the injury (big toe stubbed against a sidewalk) or consequent capsulitis? I know also that overpronation can cause tarsal tunnel syndrome but in that case symptoms involve the arch/ankle (not my case).
Dr. Blake's comment: This is up to a neurologist to put together, but sounds very neurological. The dorsal of the foot is irritated by tying your shoes too tight or above the knee problem like tight hamstrings, piriformis, or low back, not the tarsal tunnel. 
On the other hand though it's puzzling because other than the burning feeling I've never experienced the classic neurological telltale signs, i.e. tingling/numbness/electrical sensation, and it's something which is elicited with specific motions, and never at rest or at night.

All of this dorsal-big-toe-burning-symptom, though, as I said may not have much to do with the general problem, but I have come to think that there might a neurological component in the plantar aspect as well. Might it be that some plantar nerves are being compressed/being put under stress for some reason, and that weight-bearing pressure is 'felt' much more than usual? On the other hand, as I said before, the telltale signs of neuropathy are absent, and even on forceful palpation the sensitivity of my foot appears normal, so to my layman eyes it appears more a matter of stressed soft tissue than nerves.
Dr. Blake's comment: You have some minor nerve problem, and nerve problems cause a hyper-sensitivity that can make something hurt more at the foot. This is called "Double Crush". Definitely worth to check out, and right now deal with them separately. I hope I have helped and thank you for the donation. Rich

Again, thank you very much for your reply and for any further help you can provide


Antonio

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.