2nd Metatarsal Pain: Email Advice

Hi Dr Blake

I am a 37 yr old female of average size and weight - on the thin side actually- presented with foot pain predominately to the first and second digit as well as the metatarsal-phalangeal region.

Dr Blake's comment: What type of pain are we talking about? How does it affect your function, day to day and athletics?

Tried the walking boot for one month without relief. Second opinion doctor ordered mri which showed 2cm bursitis in that region as well as inflammation of the second toe joint.

 I am an active mother but not a runner or extensive athlete. Possibly ill fitting shoes at times. Had a cortisone injection 4 days ago. Have had some nerve pain in the first and second toe but not terrible post injection, but I am not having total relief from the foot pain. 

Dr Blake's comment: It can take 2-3 weeks, if long acting cortisone was used, to see the overall effect. 

Still it is there as before but slightly reduced. The initial injury pain began 4 months ago. Took oral steroid first and antibiotic - now injection. 

Dr Blake's comment: Do you have the option of physical therapy? Have they tried met pads, Budin splints, accommodative padding, toe crests, etc to check its effect on the pain syndrome? 

Mother recently diagnosed RA however negative bloodwork but positive on clinical presentation. Should I be concerned of an impending RA diagnosis for myself ? Should I be having full relief from the injection and if so why am I not ?

Dr Blake's comment: If you see my post on cortisone shots, it can take 2 to 3 shots to check the effectiveness. It is easy to get several arthritis lab screens done, which I would do in your case. 
Sincerely

http://www.drblakeshealingsole.com/2010/05/cortisone-shots-thought-process-behind.html

2nd Metatarsal Pain: Email Advice

Hi....

I found you via you tube where I was searching for 2nd metatarsal stuff.  I have a very sore left foot.  Just the 2nd toe/metatarsal area.  I had prior bunion surgery about 7-8 years ago.  It was done by an orthopedic doctor.  I have went to see his partner this time (who specializes in feet/ankles).  He recommended metatarsal pads.  They did not help.  My foot has gotten progressively worse (feels like I'm walking on a painful rock).  I am wearing an orthopedic shoe.  I recently saw him again and he said it is a "functional" foot issue and I need surgery.  

I'm only 50 (lol) and I don't want a pin sticking out of my foot for 4-6 weeks.  My 2nd toe isn't a hammertoe, but it doesn't rest on the ground like my other toes.

Do you have any other suggestions?  Aside from surgery???

Thanks,

Dr Blake's comment: 

     Thanks for your email. Here is the section from a book I am writing on 2nd metatarsal joint pain. Hope it will help you. Rich

4. Capsulitis/Plantar Plate Injury of the 2nd/3rd Metatarsal Phalangeal Joint

    Whereas the pain from metatarsalgia tends to be very generalized, capsulitis with or without plantar plate tears tends to be very localized to the bottom of one of the joints. Below is an example of an accommodative pad being applied to a pre-existing orthotic device in an attempt to float or off weight the area.

Accommodative Padding for  3rd Metatarsal Pain

   

 The top 10 initial treatments for capsulitis/plantar plate injuries are:

1. Ice Pack for 15 minutes 3 times per day on the bottom of the foot, and change the last icing to contrast bathing as the symptoms improve each evening.
2. Avoid barefoot and active push off or going up onto the ball of the foot
3. Purchase Budin Splints, small longitudinal medial arch Hapads, and small metatarsal Hapads to experiment with immobilizing and off weighting the sore area.
4. Mark the sore area with lipstick, transfer to the shoe padding, and try to accommodate the sore area. You can purchase 1/8th inch adhesive felt from Moore Medical to achieve this well.
5. Analyze your shoes to see which types feel the best and stick with these. Stiffer the better is a general rule but may not apply to you.
6. Experiment with buddy taping the most involved toe to the toe next to it (not to the first toe however), or do a version of spica taping for those two toes to restrict dorsiflexion.
7. Use activity modification principles to keep fit. Ride a bike with the pedal on the heel or arch. Use an elliptical without raising the heel off or using any elevation. Swim without pushing off the wall or walking in the shallow end of the pool.
8. Purchase an Anklizer removable boot if symptoms are not controlled in shoe gear.
9. If the injury was traumatic, like with a fall, or if there is a marked amount of swelling, or an inability to bear weight, seek advice on getting an MRI and baseline x rays.
10. If the toe involved has moved to a different position, it is the sign of a displaced fracture or torn ligament, and you should immediately seek advice of a podiatrist or orthopedist.

For initial immobilization, anklizer boot with EvenUp on the other side, or a hike and bike shoe, or stiff hiking shoe

Budin Splint typically wrapped over both the 2nd and 3rd toes

Accommodations can be made using lipstick to exactly mark the sore area

Small Longitudinal Medial Arch Hapad for max met pad effect

2nd MPJ Plantar Plate Tear: Email Advice

Hi

I'm a professional Rugby League player in England and have recently ruptured my Plantar Plate Ligament under my 2nd toe. The toe keeps coming out of joint and under the 2nd metatarsal head is very painful. I have 8-10 games left of the season and would like to play in the remaining matches. I can have a local anaesthetic for games but during the week when training i can't. I've tried all sorts of taping trying to keep the toe from coming out of joint and pulled down toward the floor but haven't found a suitable one that allows me to train properly. I wondered if you had any advice on taping techniques or some kind of splint that may help me get through the next few weeks. I'm having orthotics made to offload the pressure on the 2nd met head.

I hope you can help

regards

Dr Blake's comment: Glad to try to help. Please try to find some Budin Splints. You should get the single, double and triple loop ones and experiment. For the Single Loop, you can put the loop over the 2nd only, or over the 2nd and 3rd toes combined. With the double loop, you can try 2nd and 3rd or 2nd and 4th. With the triple loop, you only have 2/3/4 possibility. You can also first try taping the toe down (I found a picture for the first, but you would do 2nd in a similar fashion) and then using the splint.  I also have found adding 1/4 inch adhesive felt over the top of the toe before you put your sock on can help push the toe down when you play (could not find a quick image of that). Many times you also have to put as much metatarsal arch under the 2nd and 3rd metatarsals as possible to lift up the metatarsals while pulling down the toes.I like the small longitudinal medial arch Hapads for this purpose. And then probably, if there is any more room in your shoe, to add a float to accommodate the 2nd metatarsal head at weight bearing.  Hope this makes sense. Rich

Plantar Plate Tear of the 2nd MTP: Email Advice

Hi Dr Blake,

I'm desperate for advice. I'm 17 wks pregnant and after 10 mos of misdiagnosis and on/off pain, I was informally diagnosed with plantar plate tear of 2nd MT. My MD said since the pain has been present for 10 mos, the likelihood of it healing on its own is slim.  The joint is more lax dorsally than the uninvolved side and I have a mild hammer toe deformity. I started wearing a walking boot a week ago, and it provides almost complete pain relief.

I am a physical therapist. Really want to avoid surgery. Does this sound like it could repair itself? Does it sound like a grade 2 or 3 tear?  Will have to wait to get MRI until after pregnancy. Thank you!

Alice (name changed)

Dr Blake's comment:

  Sorry for your problem, and congratulations on the pregnancy. I have 2 wonderful unbelievable boys, and can not image life without them. You have a wonderful journey ahead. They will grow, but you also. Only an MRI will tell us grade 2 or 3, with grade 3 being a complete tear of the plantar plate. Unfortunately, due to your pregnancy, you must wait. The walking boot is now your gold standard. It has proven you can produce a pain free environment for healing. You must use it on and off for 3 months, unless you can find a shoe that gives you just as much pain relief. Consider looking into hike and bike cycling shoes with rigid soles, or hiking boots, or getting a Otto Bock carbon graphite shoe insole and see if it works in your athletic shoes.

But, whatever you are walking in, we must create a pain free environment over the next 3 months to try to create a great healing environment. During that time, you ice pack the area from the bottom 3 times a day for 15-20 minutes. This daily program reduces the inflammation, both the acute (daily), and the chronic (built up over the last 10 months). Begin to experiment with Budin splints to get the right tension and decide if you put over the 2nd toe only or over both the second and third toes. Sometimes, I will use the double Budin splint and place over the 2nd and 4th toes with the two loops. You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints.

    As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads or a custom foot orthotic device to perform that function. The most important thing to do right now, and for the next 3-4 years is daily Metatarsal Doming Exercises. This will strengthen the bottom muscles probably 3 times more than they were, but it is important not to curl the toes. It can take the next 1-2 months just developing the ability to keep the toes straight before you actually dome. 

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). 

https://youtu.be/-v9IrSucQpE

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

http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

Thank you for any insights or recommendations you can share!

Painful 2nd MPJ: Email Advice

Hi Dr. Blake,

I've been reading your blog and was hoping you may be able to offer me some suggestions/advice.  I was diagnosed by my podiatrist ( through Kaiser) that I have capsulitis (2nd Metatarsal).  He also pointed out that I have an unusually long 2nd metatarsal bone and my arch was normal.  I have had 2 cortisone shots.  The first was over a year ago and the 2nd was about 3 months ago.  They both took away the pain on the ball of my foot/toe for about 2-3 months, but the pain is back.  I was trail running about 4 to 5 miles, 5-6 days a week, although I have scaled back to a couple days a week because the days are shorter.  I supplement with a stationary bike.  I also do occasional hikes.  I seem to notice more discomfort/pain following the hikes, maybe due to longer periods on my feet and/or a different stride?

Dr Blake's comment: Definitely, stride and foot placement can be very variable for different sports/activities. For example, many of my patients are surprised when they can run long distances, but can not walk one street block without pain. Of course, there are also many variables in the terrain with hiking and trail running. Sometimes, runners/hikers can walk up but not down, or soft surface is okay, and rocky terrain not. 

I have also tested different orthotics along with metatarsal pads.  I'm not sure if any of this is helping, although the metatarsal pads may be helping a bit and seem to make the most sense.

Budin Splint with Met Pad for a Painful 2nd MPJ

Combination of 2 different Hapads to off weight sore area

Longitudinal Metatarsal Small Hapad to off weight sore metatarsal

Example of various combinations of pads needed to alleviate pain

With a painful 2nd MPJ, you can get relief with the Budin splint over the 2nd toe, over the 3rd toe, or over the 2nd and 3rd toes combined. Experimentation needed. Start with light tension. 

Dr Blake's comment: Definitely metatarsal pads are a direct help by off weighting. Daily ice massage for 5 minutes 3 times is helpful. Try to purchase some single loop Budin splints to immobilize the 2 and/or 2/3 Metatarsal Joints. Also try to off weight the sore area with 1/8th inch adhesive felt you can purchase from www.mooremedical.com.

After doing some more of my own research, I have read up on taping.  The last couple of days I have taped my 2nd toe down by putting tape on the bottom of my foot and wrapping around the 2nd toe which holds it down.  The other taping technique that I read was to tape my 2nd toe to my 3rd toe in order to stabilize.  Do you feel that I should be doing either of these, or possibly both of these taping methods at the same time?  I haven't tried running with the tape yet, but was next.

Dr Blake's comment: The Budin Splint would do just that when looping over the 2nd and 3rd toes combined. When running with the budin splint, it typically has to be a little looser than just walking around. I do have patients who prefer tape to budin splints. 

I have also noticed that my 2nd toe seems to be drifting towards my big toe.  I'm not sure if that is do to inflammation.  I noticed this before I had the last cortisone shot as well, but it appeared to go away after the shot.

Dr Blake's comment: Usually the injury you are describing is a version of a plantar plate tear to the base of the joint. The tear is never directly centered, so if it involves the part of the ligament closest to the big toe, the toe will drift towards the 3rd toe and vice versa. The toe typically moves upward and a hammertoe develops. 

I have actually seen 2 podiatrists through Kaiser and have received completely different advice from both.  One of them actually supplied me with heel pads, anti-inflammatory pills, and suggested using the insoles that came with my shoes and not using orthotics.  In all of my own research, I haven't seen heel pads as a recommended approach.

Dr Blake's comment: I agree, heel lifts and even orthotics can be in the wrong direction if they transfer weight into the forefoot (the injured area). Here is one of my videos on hammertoes explaining met pads, met doming, and stretches to be done.

Help?!  Any advice/recommendation is appreciated.

Regards,

Bill (name changed)

2nd Metatarsal Help: Email Advice

Hi Dr Blake

     I am a 52 year old male and have been a practicing martial artist for 40 years. Over the past two years I have had a number of problems with my feet after suffering from Gout (hopefully now under control with diet modification) and having had hallux rigidus in my left big toe for as long as I can remember. 

     Of late the biggest problem has been with the second metatarsal on both feet which has made me question whether I would be able to continue my martial arts practice (which combines bare foot and shoe covered activity). After months of despair I came across your YouTube film on Spica taping and have today, with both feet taped, walked without pain for the first time In ages.

I wanted to say thank you for posting the film as it has given me great hope. One question I was unsure of was how long I could keep the tape on for? In the film your assistant said it would last a couple of days and that's fine I just wondered if there is a need to have a 'tape free' period on a regular basis?

Dr Blake's comment: The taping should be used when needed only after you have had 2 weeks of pain relief. Golden Rule of Foot: Tape or Brace for 2 weeks longer than you think you need to if the tape/brace provided a pain free or pain reduced environment. If you have been out of pain for 2 weeks, begin to experiment when you need it and when not. It usually is quite evident with increase pain during or just after an activity. With taping for the 2nd toe/metatarsal area, you should be icing 3 times per day for 10 minutes. A reusuable ice pack on the bottom of your foot while you multi-task is great. Consider some form of metatarsal support like the Hapads commonly demonstrated on my blog. Good luck and I am glad you are getting some good relief. 

Once again my sincere thanks for your help.

Take care.