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.

Tenosynovitis/synovitis. The flexor tendon(s) on the bottom of your foot and the synovial sheath surrounding them can suffer micro tearing and become inflamed.  Tendons will heal more easily than ligaments so if rested properly with a little conservative treatment this can be easily overcome.

Metatarsal Bone Marrow Edema.  Running causes repetitive impacts with the ground…. about 1500-2000 times per mile!  This can result in internal bone bruising to the metatarsals.  The marrow can swell causing pressure on the metatarsal bones and pain.  This is most often confused with stress fractures.  If rested properly with a little conservative treatment this can be easily overcome.

Now let’s look at what treatment options are available to you that are effective.

Plantar Plate Sprains

Metatarsal Rocker bottom shoes or rocker bottom walking boot.  This will offload the metatarsal area and decrease pain.  Decreasing pain is important because if you decrease pain you are decreasing stress on the area.

Proper placement of a metatarsal pad.  Pads come in varying sizes, densities and thicknesses.  It must be placed properly AND be comfortable AND be effective. If it does not meet all these criteria then it is either the wrong size, shape, thickness or density and can be harmful by stressing the area.

PRP injection.  Can be used to stimulate the healing response in hard to repair ligaments.  PRP is not magic and the injury must be rested and rehabilitated properly following the injection.  Ligaments are slow to heal and can take as long as 3-6 months for resolution.

Rehabilitation.  I prefer to use the Alter Gravity Treadmill to slowly return patients to painless walking then running.  The AlterG allows for us to make a patient weight less which in turn results in less stress on the plantar plate.  It takes advantage of a scientific principle called Wolfe’s Law.  This law explains that if we slowly stress tissue (ligament in this case) and give it time to repair and adapt it will.

Now let’s look at what not to do.

Cortisone Injection.  While it may reduce pain and swelling it may also result in long term damage to the ligament resulting in rupture and then surgery.

Massage.  Light massage may be ok to stimulate blood flow but heavy deep massage that is painful will cause more damage.

Physical therapy.  Do you really want or need to have someone watch you grab a towel with your toes?  While light exercise of the toes can stimulate circulation to the ligament save your time and money and do it at home on your own.

Custom orthotics.  Can be effective is a properly placed metatarsal pad is included in their design.  Often it either is not or a metatarsal pad that is too thick, too dense or uncomfortable is used making the orthotic unwearable and therefore useless.

If you are experiencing foot pain and not receiving help I may be able too. I can help either by phone consultation or a visit to our San Diego Clinic.  Mail me at info@sdri.net to get help now or call 858-268-8525