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Thursday, January 25, 2018

Metatarsal Pain: Email Advice

Dr. Blake,

I hope this message finds you well. Thanks for the blog--it’s a great resource, I've been learning a lot from it, and I appreciate your therapeutic approach.

The short version: pain in the area of the right foot MTP joints on the underside of the foot, associated with activity, pretty well under control for now but worried about increasing activity levels in general and hills in particular.

The long version: healthy, active, 25yo male, lifted regularly, walked lots, went for backpacking trips with a heavy pack with no trouble for years, worked part-time in a commercial kitchen, etc. Tried to take up boxing in the summer of 2016, got some small but stubborn tibial stress fractures from skipping rope on concrete, took a lot of time off but gradually resumed activity (lifting, walking, dancing) with no trouble. Incurred some very small fractures in the left metatarsals in a motorcycle accident in March 2017, healed fully, resumed activity. A little pain in the left foot from time to time, but nothing that worried me.

After a couple of brisk hikes in late June/early July, I noticed some unusual pain in about the 3rd-5th MTP joints of the right foot, on the underside of the foot. Not tender to the touch, but a kind of dull throbbing on and off throughout the day. I thought it might be just part of the adaptation process--it had been a while since I had done any serious walking, what with coming back from the broken foot. And I had a short-term job that required a fair bit of loaded hiking (forestry), so I pretty much plowed ahead. The foot didn’t get any better, but it didn’t get dramatically worse, either; I was in stout, supportive boots (albeit possibly too narrow and with too high a heel, see below) during the day, and I noticed some pain when I took them off at night, but nothing crippling.

Still, I figured some time off would do me good, so after the job wrapped up in September I stayed away from running and hiking for a couple of months. The foot calmed down but wasn’t quite back to normal after six weeks off. Pain during everyday life was essentially zero, but eccentric calf raises with the forefoot on a block caused a lot more pain in the right forefoot than I would normally expect, so I saw a primary care doctor who ordered x-rays (attached--let me know if the attachment doesn't work) and referred me to a podiatrist.

The podiatrist diagnosed hallux limitus in the right foot--there was a lot of talk about “degenerative,” “never gets better”, “have you tried swimming, it’s great cardio,” etc. I didn’t care for the sound of this, not wanting to go back to working at a desk, and the podiatrist didn’t strike me as the most competent. So I sought a second opinion from a local AAPSM/ACFAS guy who had a fair bit of running experience (former D1 distance runner). I also began a walking/jogging progression, very conservatively, while avoiding anything I knew aggravated the foot. In particular, I noticed that time on the stairmill and on a steeply inclined treadmill seemed to cause pain out of proportion to impact, and forefoot striking when I ran also made things noticeably worse.

The second podiatrist said that hallux ROM was fine, he didn’t see any swelling, no tenderness to the touch, and encouraged me to experiment with shoes and over-the-counter orthotics and running surfaces and to stop walking around the house barefoot. He didn’t see anything unusual or alarming about my gait, and noted that my feet were a bit flat but not necessarily in need of an orthotic. His diagnosis was “metatarsalgia, like a bruise--not a stress fracture”. This was in about the first week of December.
Dr Blake's comment: This is why I love the AAPSM. Right or wrong, good overall approach. Sounds like nerve to me, and I am glad you had no Hallux limitus. Did he check your achilles for tightness? This is a big reason why patients get metatarsalgia. You work on the 3 causes of pain: mechanical, inflammatory and neuropathic. Mechanical is dropping the heel height, stretch the Achilles tendon, and Hapad longitudinal Metatarsal Arch Pad Small just behind the soreness. Inflammatory with icing or warm water soaks (have to see what feels better). Neuropathic with pain-free massage, Neuro-Eze gel, Neural Flossing three times a day. These at least for what we know now. 

I ended up in the Altra Olympus, very happy with them for walking and running, and somewhat happy with Altra’s desert boots for casual wear. (I tried Hokas, but even their wide sizes were a touch narrow in the forefoot for me.). A felt metatarsal pad on the stock insole (for both feet) also helped a good deal. I found that easy running on grass with a heel strike and a high cadence didn’t seem to make things any worse, and got a pair of cushioned flip-flops for walking around the house.
Dr. Blake's comment: You are doing everything right. For those that do not know Altra shoes, they are all zero drop, meaning no heel lift to put pressure on the front of your foot. I love the big Hapads to spread the force. You may have to thin out. The small size is usually perfect. 

Hapads on top of Orthotic Device with various pads under forefoot to accommodate or cushion

Since then, I’ve been titrating up the jogging, taking it easy and staying on grass, adding 5 minutes here and an extra session there, and I still seem to tolerate it pretty well, so that’s all to the good. I’m down about 5 pounds from 200 in December to 195 now and plan to drop another 5-10 in the coming months, which should also help. I’ve been supplementing D3 and K2 for years and have continued to do so, along with milk, yogurt, and a calcium/magnesium supplement. I've also been lifting and it doesn't seem to cause any pain. Two things have given me cause for concern.

The first was a hike I took on December 26 or 27. About 11 miles round trip with ~3000 feet of elevation gain, a big day out but the sort of thing I would have done without a thought before the motorcycle accident. I was in Asolo TPS 535 boots with Sole orthotics, a combination that had never given me any trouble on backpacking trips and big hikes before forefoot problems started. (Different pair of boots from the ones I had worn over the summer--I hadn’t really worn these for any major hiking since the forefoot problems had started.). By the time we got back to the car, my feet were in quite a lot of pain--both feet, dull throbbing pain pretty much all across the MTP joints, and also some “spiky” pain in the area of the right sesamoids. Outside of the 0-2 range, definitely not the normal soreness I would have expected after an unusually big hike. The pain was probably 90% back to normal and back to normal within a week, where “normal” means “maybe a little sensitive in the right 3rd-5th MTP joints with occasional fleeting mild soreness here and there, but essentially no pain and no discernable pain with everyday activity.”
Dr. Blake's comment: The problem was the new unbroken-into shoe, and a more then what you were used to hiking. It sounds reasonable it should have flared up with the shoe was not flexible enough at that moment allowing more stress to the tissue. Glad it calmed down. 

The second was a few days ago when I tried to stretch my calves by standing on a block with my heel hanging off and letting the heel drop. Felt fine at the time, but about three hours later, I noticed a dull throbbing pain from the right 3rd-5th MTP joints, which came and went periodically for the next 24 hours or so. I’ve been icing for 10 minutes 1-2x/day for the last few days as per your blog--too soon to tell whether it makes a long-term difference, but it sure seems to help acutely. I'm also going to start contrast therapy. Again, the pain was pretty much back to normal (so, a little “sensitive” or “tender” but essentially zero real, consistent pain with everyday activity and jogging on grass) within about three days.
Dr. Blake's comment: This is called placing your foot in a negative heel position and all the weight on the forefoot. Another unusual stress that irritated things. These are benchmarks for what you can and can not do this month. Typically they are not permanent in any way, but you are not ready for that for the next 3 months. Then you can test it again. Were you doing it single leg or double? Less stress with double. 

Anyway, what these two incidents (together with my earlier experiences with the stairmill and inclined treadmill) suggest to me is that even though I can run a bit on the flat, hills may be a problem. But I’d like to work in forestry again this summer, and walking up hills is a pretty central job requirement. And it’s been six months now, including two months more or less completely off--seems like a long time for this not to heal, given the circumstances.
Dr. Blake's comment: Please experiment when you are doing at risk things only either the double loop Budin splint (loops on the 2nd and 4th toes) and a carbon graphite plate under the insert you are wearing. These are only for the times you feel you should have the extra protection. 

So: any recommendations for reintroducing hills? Any suggestions for thinking about how much heel my work boots should have, other than trying various different things and seeing what’s comfortable? (For reference: high heel like what I wore last season, lower heel.). Anything I should be thinking about that I’m not? Anything I shouldn’t be thinking about that I am? Should I worry more, less, or exactly as much as I am that this is the first inkling of a degenerative condition that will lock me into a desk job forever, or at least for next season?
Dr. Blake's comment: Your thought process is wonderful, and we are dealing with some many variables: heel height, stiffness or lack of flexibility more like, tightness of shoe. The tissue is stressed by holding the stretch for a long time, like the negative heel stretch, making it too hard to bend through (like with the new shoe), explosive actions, high impact. Try several shoes and pick the one with some flexibility but some cushion (not weighted heavily on either side). Try to be mindful to reduce stress in your actions, whether that is slower, or gentler, or using your arms more to push you up. Do not favor or something else will go wrong. Ice daily whether you think you need to. Experiment with the plates and Budin splints or hapads, but try to change the environment. Work through times that get sore even if you thought you were getting it right. Healing should occur, even with these ups and downs. Good luck Rich

I think that’s about everything I wanted to ask, together with all the relevant information. If there’s anything else that would help you give an informed answer, feel free to ask. Thanks for reading, and thank you for your time.


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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.