Dr. Allen, I have had pain in 2nd inter-digital space/metatarsal head for almost two years now. I have bunions outside both my little toes and currently run in Altra shoes to accommodate the space needed. The pain ebbs and flows as I decrease/increase my mileage. Currently I can run around 6 miles before it starts to hurt. I started to forefoot run a few years ago, which seems to have created the problem. As I have transitioned to a midfoot strike, and a less flexible shoe model, the pain outside of running has decreased. However, I would like it to go away completely. Two podiatrists and two osteopaths have given me no diagnosis other than to sell me an orthotic. No one can tell me why or how it will help so I have not spent the money on it yet. My question is, how should I proceed? My plan is to go back to the last DO I saw and ask for an MRI. Can you advise? I live in Tulsa, OK so making the trip to CA isn’t really an option. Thanks!

Dear Tulsa,

It is unfortunate that you have not received a proper diagnosis and treatment strategy.  2-foot doctors and 2 osteopaths and no diagnosis or treatment plan is unacceptable but seems to be more and more common.

This is not that hard.  The word diagnosis means “to know”.  Here is what we know.  You have pain in your foot around the 2-3rd metatarsal interspace and metatarsal heads that gets worse with running…. especially as the mileage increases.  There are only so many things this can be.  For example, you obviously do not have tennis elbow!  Let’s narrow it down to the foot and other conditions you don’t have.  You don’t have a fracture, plantar fasciitis, heel spur, 1st metatarsal pain/bunion.  Let’s see what you might have based on your description.  Here they are in order of probability.  Probability is determined based on your history, location of the pain and when it gets worse.

Plantar Plate tear/sprainThis commonly occurs in the running population and most often affects the 2nd metatarsal-phalangeal joint or 2nd MTP.  Microtears occur over time due to poor mechanics, trauma, repetitive microtrauma due to the repetitive loading associated with long distance running.  Doctors often miss this diagnosis due to being unfamiliar with it and dismiss it as “metatarsalgia” which simply means pain in the metatarsal region.  This is not a legitimate diagnosis.  There are effective and conservative treatment options for this condition.

Morton’s Neuroma. This is an inflamed nerve that occurs in the metatarsal interspace(s) most often affecting the 2nd and 3rd MTP.  Wide shoes seem to help as not as much “squeezing” occurs on the metatarsal bones which in turn lessens pressure on the nerve.  This condition is often confused by doctors with plantar plate tears and results in the wrong treatment plan such as a cortisone injection into the area.  It is painful, and cortisone can damage the plantar plate ligament.  There are effective and conservative treatment options for this condition.

Capsulitis. The joint capsule surrounding the MTP joints can also suffer micro tearing resulting in inflammation.  For all purposes capsulitis should be treated in the same way as a plantar plate tear.