My funky foot part one; symptoms and diagnosis

As I’ve told friends and people I ride and run with about the foot issues which are severely impacting me at present, I often get puzzled looks at the terms metatarsalgia and neuroma. I felt that, as opposed to lengthy explanations over and over, I’d just capture all that stuff in a journal post. I thought it might be kind of interesting to capture my whole foot experience over time, so I’ve decided that this will be the first of two or three posts. There’s also the possibility that someone will find this of use if they are experiencing their own weird symptoms.

History

I began experiencing what I would call minor tingles in the third and fourth toes of my left foot in the late summer of 2011, appearing only an hour or so into runs. At the time I thought nothing of it and figured it would disappear over time. As opposed to disappearing, by the fall of 2011 the tingles slowly turned into what I would call minor nerve jolts. While not painful, they became fairly uncomfortable and began appearing earlier in my runs, sometimes requiring me to stop and massage or crack my toes. By Christmas it was clear I was dealing with a condition that would require treatment and I began looking for a podiatrist in early 2012.

neuroma illustration
A neuroma is a swollen nerve between toe bones – image courtesy ACFAS

Earlier in 2011 I had committed to being the Sunday morning Dunbar Clinic Coordinator for the SportMedBC InTraining program. I felt this would ensure I kept my weekend running volume lower to accommodate more time on the bike as I trained for Ride2Survive, even if I decided to do a few extra miles after the clinic. This seems positively serendipitous to me now that I ended up having foot problems that affected my running. By the time the clinic began in mid-January the symptoms were still something I could run through. Quickly fast-forward 13 weeks to the end of the clinic and I was embarrassed to be a bit of a running gimp while leading 50+ people to 10k race success, but I digress. I’d been doing some research on my own, and was pretty sure I was dealing with a neuroma, even though I’d never heard of the condition before.

As I was a week or two into the clinic near the end of January, I began to notice two things – the initial neuroma symptoms had plateaued and were not becoming worse, however, I was also developing similar but distinct new symptoms centered around my 2nd toe and big toe. In truth, it’s almost like I had three separate but eerily similar things happening on my left foot. I was experiencing nerve issues in both the 2nd and 3rd interspace between toes now and some intermittent nerve sensations that ran up the inner, medial side of my big toe.

Around the same time, I was referred to my first podiatrist by an acquaintance. Without belaboring things too much, this first specialist was nothing short of a disaster. My initial consultation wasn’t bad and he diagnosed me as severely over-pronating with my left foot. I knew I’d had a tendency to roll in, but not to the extent that it was clear I do, and have for some time. This probably goes a long way to explaining the presence of a neuroma and past conditions including a sports hernia and torn meniscus. The following quote is from an explanation that is one of the clearest I’ve seen:

The cause of Morton’s neuroma is most frequently overpronation. This is where the foot rolls inwards and the arch collapses as you walk or run. This allows the metatarsals to be overly mobile, resulting in compression of the nerve.

However, from that point on I unfortunately ended up wasting several weeks of valuable diagnosis and treatment time. He was expensive (particularly compared to my current podiatrist) and poorly prepared. I’d never heard an articulated game plan for treatment and, while he confirmed that he suspected a neuroma at the site of my original symptoms, he seemed a bit stumped by the two newer (and by now more intense) symptoms. It took him over a month to get any kind of imaging done and had me testing various taping and off-the-shelf orthotics, advising me remotely by email and/or phone. Unfortunately, he was also hard to reach and it could be close to a week to get any kind of a response. I should add that the email was his idea. My second visit included more taping talk and a cortisone injection which did nothing. On the third visit he wanted me to pick up a sclerosing agent at the pharmacy, tried to cancel my appointment ten minutes before the time, forgot to have the order ready and gave me the wrong name for the clinic … well, you get the idea. We were done, thanks.

I went to my family doctor to get another referral. By some pretty strange coincidence, his referral was to the doctor who shared an office with the first doctor. What are the chances? I did a little secondary research on this guy, asking some other people who’d been referred to him and sleuthing online. Given my first experience and what I found out about the second podiatrist (not an option, I’m afraid), I decided to start from scratch with my own primary research and seek out professionals who focus on athletes. Enter Dr. Roy Mathews. He is well-reviewed online and I received two pretty glowing references from people who have seen him. It’s very early, but I’m fairly impressed. His initial consultation, while half an hour shorter than the first doctor’s, was also much more efficient and 1/3 of the price. I came out of the first consultation with a new x-ray request, a test taping for a run and a plan of attack. What I liked the most is that he spent time explaining the anatomy of the foot and why things often behave in a certain way.

Diagnosis and beginning treatment

After reviewing the x-rays, the big thing of note was how much longer my 2nd metatarsal is on that foot. He suspects I do, in fact, have a neuroma in the original spot and have developed metatarsalgia of the 2nd toe due to its length generating extra pressure on the metatarsal head. The Mayo clinic would seem to agree:

A high arch can put extra pressure on the metatarsals. So can having a second toe that’s longer than the big toe, which causes more weight than normal to be shifted to the second metatarsal head … a neuroma is a growth of fibrous tissue around a nerve usually occurs between the third and fourth metatarsal heads. It causes symptoms that are similar to metatarsalgia and can also contribute to metatarsal stress.

metatarsalgia
The bigger symptom I am dealing with – courtesy The Mayo Clinic

Not only can over-pronators be at much higher risk for each of these conditions, but they can go hand-in-hand because their root cause is often the same. As such, and given how much conservative treatment has been tried, Dr. Mathews has suggested surgery might be in order, a wedge osteotomy to be precise, to shorten and reduce pressure on the 2nd metatarsal. If the neuroma is not symptom-free by that point, he would perform a neurectomy at the same time. 4-6 weeks in a boot and crutches, another 4 weeks to be walking and probably 3 months until I’m running and cycling again. I haven’t embraced this at all yet, as I expect every option to be explored before anyone cuts a wedge in my toe bone and inserts a headless screw. We have also spoken about the possibility of ligament release surgery – a procedure with low risk and recovery in as little as 3 weeks. As you can see it’s all up in the air.

While two neuromas on the same foot at the same time is uncommon, it’s not beyond the realm of possibility. We’ve already begun a series of 4-7 sclerosing alcohol injections 7-10 days apart to treat the original neuroma. For reference, a sclerosing injection is an alcohol dilute and anaesthetic preparation which kills the affected nerve tissue and gets rid of the symptoms, avoiding more invasive treatments. After only one treatment, I’m happy to say that I think there’s a bit of improvement. I am still aware of the small lump but cannot produce any nerve jolt to the toes no matter how hard I roll it. The injection also seemed to have a temporary effect on the larger knot associated with my 2nd toe, so I am going to see if we can approach both of these with the same sclerosing treatment and see if there is any effect.

There is no guarantee that the sclerosing treatment will work and I should know after three more injections. There is also a good chance that the suspected metatarsalgia is just that and won’t be affected at all by the sclerosing treatment. At the end of the day, once the ride is done at the end of June, I may have a choice to make. For now, I can do my ride training and have, with the strong recommendation of Dr. Mathews, decided to abstain from running, as painful as that is (both figuratively and literally). Over the next couple months I’m hoping we can continue to experiment with conservative methods to alleviate the metatarsalgia symptoms and that the injections work on the neuroma. I expect my next update will come around the end of June, and I know what I’m in for.

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