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Sunday, February 24, 2013

Ball of the Foot Pain: Email Advice

Hi Dr. Blake,

I found your blog on the internet, and was hoping you could shed some light on my rather longstanding foot problem.

Two years ago, after running a bit on the treadmill (no more than 2 miles at a stretch) the ball of my foot starting really hurting.  X rays and an MRI did not show any breaks or stress fracture, and 3 subsequesnt podiatrists diagnosed plantar fasciitis.
Dr Blake's comment: Pain in the ball of the foot is so rarely plantar fasciitis, but you may have a rare case. Normally plantar fasciitis presents with heel pain, and sometimes arch pain, but rarely ball of the foot pain. There is just no tension on the plantar fascia in this area. 

 I tried many treatments for  this including the strassburg sock, a night splint, icing, stretching, even custom orthotics.  The pain would get a bit better, but not go away. The pain seemed to be concentrated just at the base of my big toe, slightly toward the inside of the foot.
Dr Blake's comment: When you try a lot of treatments, try to stick with those that give some, if any, relief, and eliminate those that do not help at all. You may have to go back and add something you have already tried for the next week and see if you are some better. Try one new treatment every week over the next month. Treating plantar fasciitis, or another foot injury, somethings requires 5-6 treatments working in unison all at once. But, who wants to waste time on treatments that either do not help, or possibly aggravate the situation. 

Convinced there was somthing else going on (I never thought I had plantar fasciitis) I went to a physiatrist  (M.D.) specializing in sports injuries and rehabilitation.  He seems to feel the problem is an inflammation of my flexor hallicus brevis muscle and surrounding tissue casused by a weak or compromised hip.  (My gait puts too much pressure coming down on that big toe area.)  So I'm supposed to do hip exercises (which I am doing) and gradually some foot strengthening exercises as well.
He also suggested that instead of orthotics, which were only protecting my arch and doing nothing to protect my forefoot, I needed to wear something that prevented my toe from bending backward too far.  So I'm wearing this sort of half sole steel plate under the existing insole of my asics.  I think these plates are designed for turf toe injuries.  (Initially the injury was only on the left foot, but last year it came on my right foot as well.)
Dr Blake's comments: So, sounds more like Hallux Limitus/Rigidus, or sesamoidits, problems. The orthotic devices for ball of the foot pain must have a lot of work getting the right amount of off weighting, stiffness, and cushion. And the shoes you wear them in, or if you use a plate, must be analyzed and experimented with. It can take alot of work, as you can tell from some of my Hallux Rigidus patients. Definitely sounds like there is movement in the right direction. 

Things seem to be getting better, but very gradually.  My foot doesn't hurt as much while walking.  I can pull my big toes backward without significant pain.  It is only when my big toe is pulled back and there is presssure on it that I get this sharp, stabbing pain down my toe and into my arch.  So, squatting is a problem, I can't stand on my toes, or when walking, I can't really push off too much.  While walking, I try to roll my foot forward instead of pushing off with my toes. Needless to say, I can't walk as fast as I used to.  This injury has been very frustrating to me because I am a very active 52 year old woman.  I can do the stationary bike, but I still can't walk very fast, or do many of the yoga poses I used to do.
Dr Blake's comment: I am assuming that the working diagnosis now is FHB tendinitis. Tendon injuries can be inflammation, a partial tear, or a complete tear. This is an MRI differential, so I recommend getting another one. After the MRI, you will know if it is safe to do PT, aggressive foot strengthening, etc. The MRI will tell us if we have a permanent injury, for you will see if any structures look worse than 2 years ago. 
I think I should start doing the contrast baths.  If it's just inflammation, won't it heal in time?  Is there anything else you might suggest I try?  I feel as if I am getting closer to figuring this thing out, but it seems the pattern is that it gets better for a while, then the slightest thing can aggravate it.  It was doing well last week until, while walking the dog, I mistakenly hurried down the hill with him so he could do his business in the right spot!  Then it took almost a week to be able to walk the way I did before that happened.
Dr Blake's comment: So, assuming that you have found that limiting the toe motion helps you, the three obvious additions without further info are: learn to spica tape (see my videos on the 2 versions), get one of the rocker bottom but stable shoes, like the New Balance 926, and have your orthotics modifed for more rigidity across the metatarsals (some form of extension under the metatarsal heads. You also need to be doing 3 to 5 minutes of foot exercises that do not hurt, like met doming, single leg balancing, etc. I have videos on all of these. It will take you a year from now to get your injured foot very strong, so that you can get back to all your activities. 
Your blog contains some great information, and it is so kind of you to try to help as many people as possible and encourage questions from readers.  I know it's difficult to diagnose problems and suggest treatments without seeing a patient, but I hope I've given you enough information to at least give you a sense of what is going on with me.  Basically, I can't put full weight on my big toe while it is flexed upward.  Can you see a time frame for me to be back to normal?
Dr Blake's comment: You may just have some neural tension in the deep peroneal nerve. This, of course, would be missed on an MRI, and give you some neurological symptoms of numbness, tingling, sharp, burning, etc. Ask the physiatrist if this is a possiblity. Good luck and I hope this helps some. Rich
Thank you for any insight, and may God Bless you.
Leslie (in Virginia)  (name changed)

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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.