Foot Nerve Pain: Where does it come from?

Hi Dr. Blake,

I have enjoyed reading your blog and felt inclined to send in a question regarding my foot pain.

Background:

I developed a lot of pain right under my big toe in my left foot (not in the ball of the foot, but the underside of the toe itself) about a year and a half ago. The pain had first started cropping up with rock climbing and got progressively worse over time. I got a cortisone shot from a podiatrist that did not help at all and I could barely walk (was in a boot/using a knee scooter) for several months. I ended up having 2 more cortisone shots in that toe over the course of the next year (the 2nd two shots did help, they were from a different doctor than the first time and spaced 4 months apart). I had improved to the point that I was able to do my day to day activities, but still could only walk for about 10 minutes at a time without causing a flare up of pain. 

Dr. Blake's comment: Do you know what he was injecting? Ligament, joint, nerve?

At the one year mark, my right big toe started experiencing the same symptoms and the bulk of the pain simply switched over to my right foot. My left toe stopped bothering me and my right toe became the problem.

Dr. Blake's comment: The only explanation was a nerve problem from your back. The position of your toe in rock climbing put to much tension on the local nerve. This same nerve, typically originating from L3/L4 or L4/L5 nerve roots in the back, was painful due to double crush. This means the nerve is being irritated at the foot and back combined. A slight change in your spine would make the symptoms jump to the other foot. That can could be from limping or protecting for a year, or a primary back problem. 

I limped around and tried to manage it with anti-inflamatories for 3 months before deciding to get a cortisone shot in my right big toe. As soon as I got the shot, I had a TON of pain in the ball of my foot closer to my 3rd and 4th toes (probably an inch below the base of my toes). The doctor I was seeing at the time diagnosed it as a morton's neuroma.

Dr. Blake's comment: Cortisone is for inflammation, which many times there is none. Cortisone if injected into the nerve, a superhighway in your foot and leg, can cause pain in many nerves. Morton's neuromas take many years to develop. 

The big toe pain either went away from the cortisone shot or was masked temporarily, and this new pain in the ball of my foot became the main problem. It pretty much made it so that I could not walk for more than 1-2 minutes here and there to get around my house. It also became painful to drive. I felt some relief by using a metatarsal pad to offload the area, but was still in pain. After 2 months, the big toe pain started returning and it would just depend on the day what would hurt more, the toe or the ball of my foot. My guess is that whatever help the cortisone was giving had worn off. 

Dr. Blake's comment: Yes, but cortisone is not a predictable way of helping nerve pain, so please limit. 

I began seeing a new doctor who ordered an MRI. The MRI showed a "stress reaction" in my big toe, but did not show much for the ball of the foot problem. My new doctor advised me to take a vitamin D supplement and to immobilize the toe for a month in a walking boot. After the month was up, my big toe felt a lot better, but I still had pain in the ball of my foot. 

Dr. Blake's comment: It is hard to know if the boot helped the stress reaction, or just not moving the toe helped you not to irritate the nerve. Did you ever have an MRI of the left? 

The new doctor diagnosed it as "metatarsalgia". He said it was possible that it could be a neuroma, but it was unclear from my symptoms. He gave me a steroid injection from the top of my foot down in the 3rd-4th webspace. This definitely helped and the ball of my foot feel much better. HOWEVER, I now have a similar pain in the ball of my left foot (sort of below 3rd and 4th toe or 4th-5th...hard to pinpoint). I again am unsure if this new pain is metatarsalgia, morton's neuroma or something else. It is worse some days than others. Offloading with a metatarsal pad helps. My doctor has prescribed 6-8 weeks of physical therapy so I am planning to try that next. 

Dr. Blake's comment: You are making me a little dizzy!! LOL Only irritable nerves behave like this. Has your back or any other part of your spine, up to your neck, been an issue in the past? 

My questions for you are: 

What advice do you have to finally kick this pain? I feel like I'm playing a game of whack a mole....when one problem improves another one always seems to pop up!

Dr. Blake's comment: The problem with this is probably not finding the true source of the nerve issues. All of the pain would have to be primarily from the low back or higher. That would make the foot nerves sensitive, and as you favor one problem you then set off the other side. At least, this is the most common cause. I do like the "mole game" analogy. Research in your area PTs that are in the national neurologic physical therapy association as these peripheral nerves are not so mysterious to them. I am glad the cortisone is calming things down locally. 

Do you think my ball of foot pain is morton's neuroma? 

Dr. Blake's comment: No! You can have morton's neuromas that have never bothered you, and normally never will, unless something like this happens. Morton's neuroma has a surgical side that I would avoid thinking about. Typically, it is merely a local neuritis that the cortisone great for. So, I would call this neuritis over neuroma from now on. Yes, I am opinionated!!

Nerve problems present 1/3 of the time as pain (you, unfortunately). 1/3 of the time as a mixture of pain and numbness. And, 1/3 of the time as numbness with funny feels of transient burning, bugs crawling around, tingling, vibration. The more pain involved, the more treatment, even though these scenarios present with the same pathology. Sad!

What do you think is the best way to heal the ball of foot pain that I have described?

Dr. Blake's comment: So, I would use 5 minute ice soaks, if tolerated, several times daily. I would get a pair of Hoka One One shoes or other stiff shoes that your toes do not bend alot. I would have the advice of a PT and Physiatrist about your back and peripheral nerve sensations. If someone agrees that you trust, then trying to calm the nerves down with topical medications like Neuro Eze, Lidoderm patches, TENS units, oral medications. Sometimes we are icing the back, and using warm water soaks for the foot. Find what predictably helps some, and stick with it for 3-6 months to slow down this roller coaster. The met pads seem to help for one so that should be part of your treatment. Come up with 5-7 times over the next month that have some positive affect. I hope this helps some. Rich 

Thanks so much!