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Tuesday, September 29, 2015

2nd Metatarsal Pain: Email Advice

Hi Dr. Blake!

I'm so glad I stumbled upon your blog today and that you're taking
questions! I have what's been "officially diagnosed" as bursitis on
the top of my left foot at the second metatarsal head and am hoping
you can shed some light on treatment for this aside from
ultrasound-guided cortisone injection.

The backstory:

In July 2014 I suddenly developed pain btw the 2nd & 3rd metatarsals
on my left foot near the toes. I don't recall injuring my foot but I
had been wearing some "barefoot" sandals a lot and having some issues
with my foot sliding around in them, which caused a lot "gripping" of
the toes. (I had already spent many years "barefooting" without issue
in Vibram Five Fingers at this point, but had moved from TX to PA
about 8 months prior and spent a lot of time in slippers/shoes because
of the cold, so simply wearing a minimalist shoe was not the issue.)

My chiropractor did regular ART on my foot over several months but
there was no improvement, so he tried Graston. A few weeks after he
started trying Graston on my foot, in Oct 2014, the pain moved from
the inter-metatarsal area to the joint at the head of the 2nd
metatarsal. The pain became more severe, and by Thanksgiving 2014 I
was unable to walk.

X-rays were negative but MRI in early December 2014 showed a stress
reaction at the head of the second metatarsal as well as inflamed
bursa. I was put into a fracture boot and spent 4 months in it
full-time. I spent another 2.5 months transitioning out of the
fracture boot into running shoes. By June 2015 I was full-time in
running shoes, but still in pain.

Dr Blake's comment: So, my first question revolves around levels of pain from the initial injury to the fracture boot to the running shoes. As you transition, it is okay to keep the pain between 0-2 levels, but not allow greater than 2. 

MRI in June 2015 showed that the bone was 98% healed but there is
still bursitis at the head of the second metatarsal. Orthopedist
recommended ultrasound-guided cortisone injection to address it, which
I haven't done yet.
Dr Blake's comment: I agree with your resistance to cortisone as the bone was still healing. PTs can use transdermal (non injectable) cortisone to shrink the bursitis. The procedure is called Iontophoresis and you typically go 5 times in a 10 to max 14 day period. 

At the beginning of Sept 2015 I began to see a podiatrist for therapy
twice per week. He places the 2nd & 3rd toes in traction for 10 min,
followed by 10-15 min of electrical stimulation, and then tapes the
foot to support & relieve pain. The tape is kept on for a couple days
each time. I've been for this treatment 6 times over 4 weeks and have
experienced some improvement, but he tapes my foot differently every
time and the more recent times it hasn't been as helpful or has even
increased my pain.
Dr Blake's comment: It is more the traction and electrical stim that is helping the symptoms. 

His theory is that my issues stem from my feet being structurally
unsound and that if he figures out how to tape my foot to relieve pain
then I can get orthotics that will essentially do what the tape does
and then I'll be fine.
Dr Blake's comment: I have never been able to minick the support tape does to an insert. They are too different in approaches. However, if you were getting relief from just tape, you can be assured that this has a partial mechanical treatment. 

Side note about my feet: they are very, very flat. I had severe
bunions (& bunionettes) from childhood, which were surgically removed
16 years ago at age 21. Both my 1st & 5th metatarsals were broken in
both feet. The bunionectomies were Austin and the podiatrist says they
effectively shortened my 1st metatarsal, making the 2nd one too long
and setting me up for this bursitis issue. It's also worth noting that
on my other foot (the right foot) the bunion has been slowly starting
to come back over the last 3 years, and my big toe is drifting towards
the other toes. It bothers me because I have tightness in the arch and
between my 1st & 2nd toes, but it's not painful.
Dr Blake's comment: Flat feet in general place too much pressure on the 2nd metatarsal. If you add shortening bunion procedures, you have the perfect storm of getting a problem with the second toe or metatarsal. The secret to your rehabilitation is to design off weight bearing pads to float the 2nd met head, at least to give it less pressure. Have you tried simply marking the sore area with lipstick, transfering that spot to your shoe insert, cutting out that spot and perhaps even another layer. Then, adding a Hapad support just behind it (close to the arch).

So what do you think? Orthotics? Cortisone shot? Anything else I can
do/consider? I'm very frustrated because I haven't been able to walk
properly in over a year and am experiencing all kinds of other
hip/back issues now as a result. I'm only 37 and really want to be
active again!
Dr Blake's comment: I would work mainly on the mechanics as mentioned above. I would also get some Budin splints for some shoes. I would ice pack twice daily for 20 minutes. I would get the PT. Then, send some comments to this post. Hope this helps. Rich

Thank you for any insights or recommendations you can share!

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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.