My funky foot part two; a holding pattern

In April, I outlined my experience to that point, with my left foot. At that time, after several months of annoying and somewhat perplexing symptoms, I expected that by now, I’d have more of a solution – perhaps a surgery or something – to report. Sadly that’s not really the case. I can report some progress, though, small as it may be …

A recap

So that you don’t need to click the link above, should you be interested in such things, my situation thus far in a few simple bullet points:

  • I began experiencing toe tingles and weird symptoms in the summer of 2011, which progressed to downright painful toe jolts.
  • It took two attempts at a podiatrist to find one I could trust by early spring 2012.
  • I was diagnosed with one neuroma between toes 3 and 4, with a slightly less clear problem between toe 1 and 2.
  • I had begun sclerosing alcohol injections, in an attempt to decrease/kill the toe symptoms.

Since spring

I guess you have to celebrate any successes you have with a situation like this, so I’m somewhat happy to report that the sclerosing injections were a minor success. Seven treatments were able to kill the intense jolting that was occurring while running and uncomfortable tingling that was occurring pretty much any time I stepped hard through the ball of my foot. This would include, but was not limited to, running, going up or down stairs and any kind of jumping and landing. So, as of the beginning of June, at least something had gone right.

I never was able to pinpoint a cause of, nor get any useful medical opinion on a nerve tingling/numbness I’d often get emanating from the arch of my foot and running up the medial side of my big toe. With reduced running I don’t get that much right now, but even more inexplicably, I’m left with a very tiny numb spot at the medial tip of my big toe that can temporarily get bigger with excessive running. It seems to be the result of compressing a nerve, and there is a type of neuroma – the name of which escapes me at the moment – that is specific to this area.

Additionally, what had originally felt like perhaps up to three separate issues in my foot have become somewhat clearer in that I now have two very distinct zones with lumps – the original 3rd interspace (foot lingo for between the 3rd and 4th toes) and the 1st interspace (foot lingo for between the 1st and 2nd toes). Since the initial symptoms had been partially resolved, a few appointments with my podiatrist over July and August were focused on better understanding these lump symptoms that remained, operating under the assumption that one is a neuroma, and the other may be a combination of a few things, and trying to determine if they could be treated with custom orthotics or would benefit from surgery.

Finally, with the jolts and intense tingles a thing of the past, I’ve been able to cycle unimpeded (as my Ride2Survive in June will attest to) and have resumed a moderate level of running. I say moderate because I’ve only pushed it to about 13k as my longest run and been wildly up and down in my volumes. I’ve stayed away from intense hills or speedwork and when my weekly mileage starts inching much above about 25k, it’s accompanied by more foot discomfort, as my lumps become more noticeable and achey overall. While I never revisited trail running this past year because of these distance and volume related issues, I’ve begun to think trails might be a better option because of the variety and the generally slower paces and power hikes trail running necessitates.

Diagnosis gaps abound

As I wrote in part one, my podiatrist suspects that my slightly longer 2nd toe, and my propensity for rolling my left foot inward (overpronation) may have caused some general metatarsalgia (a very broad condition that essentially means irritated toe), but I’ve had a long 2nd toe all my life, so why a sudden problem in the past two years after running for the better part of 20 years? Plus, the symptom is not directly related to the 2nd metatarsal head and bone, which would be the case if I was suffering from metatarsalgia of the 2nd toe. I’ve largely discounted this theory.

sesamoiditis imageNonetheless, I have indeterminate lumpy discomfort around my big toe, which may be caused by a long toe bone, my foot rolling inward, a neuroma – or some combination of these things. Since x-rays can’t show soft tissue problems, I had an ultrasound of my entire forefoot in July, which was also largely inconclusive. And then, an additional wrinkle – since the 1st interspace is a very uncommon place for a neuroma, metatarsalgia seems unlikely and, since my lump sensation is almost tucked right down beside/underneath the big toe, my podiatrist became suspicious that it may actually be sesamoiditis. Sesamoids are two small pea-sized bones (picture left or above, depending on how you’re viewing this) that sit underneath the big toe bone and act as pullies for the tendon that runs from there along the bottom of the foot. If the tendon was inflamed, it would fit with some other sensations I’ve had on the underside of my foot (other nerve/tingles running along the arch and almost a tight/thick feeling along this area). This theory seems to make more sense, but the exact area of the lump doesn’t really correspond to the positioning of the inner sesamoid bone.

It’s at this point I’ve begun to think I need to get a second opinion. My current podiatrist recommended in August that I should get an MRI to try to determine whether I was dealing with sesamoiditis, but in most research I’ve done and other medical advice I’ve received, you’d use a bone scan if anything to diagnose this. Plus, with what ended up a 7 month wait (currently booked for January, but presently at risk due to health sector job action), wouldn’t the weird symptoms have made him consider an MRI much earlier in my then year-long odyssey? Plus, from what I’ve also read of sesamoiditis, unless the bones are actually fractured, treatment is really limited to conservative options. Ice the area until the symptoms reduce and orthotics to both cushion the area and off-load pressure. With this such a long-term condition, icing inflammation isn’t appropriate (though I do sometimes do so after a run) and I’m already playing with a number of orthotic things which I detail below.

But I digress …

Are you doing the math? An uncomfortable lump with potentially four causes and no clear treatment yet. I can run, but not nearly as much or as hard as I want (so training for running races is completely out of the question), but I’ve only been able to do even that much in part due to my own experimentation. While the aforementioned injections got rid of the most intense symptoms, I’ve done a few things on my own that have definitely contributed to my being able to cycle and run a little.

Self-treating

Since we haven’t yet arrived at the point where surgery has been decided upon and/or custom orthotics can be designed, I’ve done some experimentation out of necessity. Conservative treatments for neuromas pretty much consist of corticosteroid injections (useless in my case), sclerosing alcohol injections (partially useful in my case), footwear selection and orthotics. There are even fewer options to treat sesamoid problems, if I even have them to begin with.

While the toe tingling and jolts are now a thing of the past, my problem is hardly solved. I’ve got two lumps in my forefoot, which both generally become a bigger problem the longer or more intensely I run. As a result, the activity I most enjoy with clothes on has been altered dramatically, and I needed to do as much as I can to tip the scales back toward the middle. Medical practitioners can help, but as they say, “Physician, heal thyself.” Below then, are the processes I’ve gone through and some of the solutions I’ve arrived at. If you are struggling with symptoms similar to mine, you can probably get at least some measure of relief from one or more of these things.

Orthotics

Arch supports – Going as far back as the fall of 2011, my physio at the time recommended Sole arch supports, as he suspected my biomechanical foot issue (overpronation) was at least partly to blame for other imbalances I’ve experienced for a long time. He’s probably right. Unfortunately, though, if I use an (even remotely rigid or stiff) arch support for any length of time I begin to develop aching arches and will also typically irritate the big toe’s medial tingling and numbness. We’re not talking small aches either. Cringe-inducing, walk and run ending, “my foot needs a masseuse” arch aches. For some time in 2011 and earlier this year, I valiantly tried a wide variety of levels of support, all to no avail. I just can’t tolerate them and function properly. A further complication is that I really don’t overpronate on my right side, so when using arch supports on both feet as one should, my right leg very quickly develops IT (iliotibial) band pain, since I’m effectively rolling that foot out too far.

One other arch support issue I should mention … proponents of barefoot and minimalist footwear are steadfastly against artificial arch support. Their logic suggests that it’s better to wear more natural footwear and let your arch muscles re-gain some strength. While I don’t fully subscribe to the barefoot/minimal mindset, I do think there’s some valuable information to use (read about my use of toe separators a little further along). There are exercises you can do, including simply being mindful about your stride and rolling out to a more neutral position when you walk and run.

Metatarsal pads – This is a pretty standard tool in the war against forefoot pain and something both podiatrists I’ve seen so far recommended. There are literally a ton of variations on the shelves of sports-med and medical supply stores. Plus, you can easily make your own. Essentially, a small, flexible moderately thick pad is used to lift the middle of the foot and create a small space between the metatarsal heads and the shoe insert. It gives you a little space and reduces pressure as your foot rolls through the stepping motion and forefoot push off.

Powersteps and a pair of scissors work best to pad my metatarsalsPodiatrists tend to be very conservative testing metatarsal pads, for good reason. If they are too big or poorly placed, they’ll cause more pain, but if you get the sizing and positioning just right, they can really be a blessing. I’ve also found the material is really important. Podiatrists like to test pads with various thicknesses of felt and then affix them to your foot with taping. That’s great for one day, but re-taping your foot properly is difficult if not impossible, and the felt becomes too thin quickly for re-use. Once you know that the pads work, though, just experiment until you get it right. After many brands and homemade attempts I found the thickness and stiffness of Powersteps just right. I cut them a little so I can use both right or left for my left foot and place them on the underside of my shoe insert. Of all individual things I’ve done, this has made the biggest difference to both running and walking.

Toe separators – These often get no mention from podiatrists, but in my own research, I’ve come to the conclusion that a lifetime of footwear does our feet a lot of damage. I believe if we were raised barefoot or in minimal shoes, we’d have much less foot pain. One of the outcomes of a barefoot life is properly aligned toes, instead of metatarsals that are crunched together (possibly being a cause for conditions such as neuromas). As such, on my own, I’ve tried several different kinds of these. Many spread your toes so far, they are too painful and won’t fit in most shoes.

correct_toes imageI came close with a product called Correct Toes. They are fairly unobtrusive to wear for walking, but despite being more comfortable than some of the larger more painful contraptions, they are still too hard to wear when running. Regardless, they caused the skin on the toes to pinch and rub quite badly for me. Even cutting and playing with them couldn’t make them work, so overall, no solution for anything.

gel-hallux imageOften the simplest solution is the best. I ended up settling on individual soft silicone gel toe separators. They’re really soft, create just enough separation to straighten the toes and reduce pressure between the metatarsals, and they come in two sizes. I use a larger one beside the big toe and two smaller ones, on each foot. Coupling these with a metatarsal pad on my left foot has really helped. I wear both pretty much all the time when in shoes.

Shoes

Pretty much any podiatrist or treatment recommendation you’ll read will suggest wearing shoes with stiff forefoots. Some mention big ugly rocker shoes. While I could never bring myself to wear those, once I’d tested walking in a shoe with little to no flex in the forefoot I was hooked. If I wasn’t dealing with these symptoms, I’d have a strong preference for flexible, minimal shoes. However, the reality is that at present, I need to reduce my forefoot flexion through push-off – for walking and running.

hoka_stinson shoeI tackled running shoes first and found that, in general, there aren’t a lot of road running shoes with really stiff forefoots, let alone ones with wide toe boxes (to avoid compressing the toes together and to allow for toe separators). After a lot of looking around, I narrowed things down to the Mizuno Wave Prophecy and Hoka One Ones. Without doubt, the Hoka’s have the stiffest forefoot I’ve ever seen – they simply don’t flex. And, despite an extremely thick but very light sole, they also have reasonably minimal drop. As I wanted something I could run road and a little trail in, I opted for the Stinsons. It’s a different feeling to running when you have almost no flex in the forefoot, but I managed to adjust fairly quickly. A stiff forefoot makes little difference to shorties of 5k and under, but the longer I go the more valuable the reduced forefoot flex becomes to keeping my symptoms at bay. However, I’ve found the excessive cushioning not really to my liking and they’re so thick that I tend to drag the rear outsole, creating non-typical wear patterns for me. Their width makes them stable in spite of their height, but they just don’t feel right on my feet. I’ve still got some miles in them, but while I use those up, the search is on for a stiff forefoot, with a little more minimal/normal shoe profile.

patagonia_scree_shield imageI also wanted to find a ‘go-to’ walking shoe and looked extensively without much luck. Then, I happened upon some Patagonia Scree Shield hikers at MEC. Test wearing them, I could tell they’d be great for my lumpy forefoot as the toe box is virtually inflexible through the push off, with a wide roomy toe box for my toes to roam free. I wear them almost daily and they’re very comfortable.

columbia_peak_freak imageAs I said, this year I’ve stayed away from the trails. Up until about a month ago, the only off-road kicks I had were Salomon Speed Cross trail racing shoes. They’re awesome, but probably have some of the biggest forefoot flex I’ve ever seen, coupled with a pretty tight toe box – not really the best combo for me. I still bang around in them from time to time, but they aren’t ideal for my situation. A few weeks ago I just happened to stumble upon some Columbia Peak Freaks (at Winners of all places, when I wasn’t really looking) and found them to have great forefoot stiffness. They’re super lightweight and have a wide toe box. Ideal all around. They were also cheap, so I assumed I was just buying a pair of hikers that I could bang around in. When I got them home and researched them, I found out I’d paid less than half their MSRP and they get solid reviews as a combo approach shoe and trail runner. They’re also rated as nearly waterproof, and a five hour day in the rain a couple weeks ago verifies this.

Summary and looking forward

Dealing with the kind of condition I have is challenging. It has drastically altered my lifestyle and requires a level of patience to get to some kind of end-game that’s not natural for me. I’ve managed to get to a place where my symptoms are almost non-existent for walking and fairly manageable for cycling and short running – probably about as good as I can make things until I have the results of my MRI, and an idea of next steps after another appointment with my podiatrist (and perhaps a second opinion to be safe) sometime around the end of January. I am aware that the MRI may not shed much light on my situation and could very well get cancelled, at which point a custom orthotic could be as good as it gets. As such, I have found a few simple things that seem to have helped a fair bit, to keep me at least doing some running. If you’re in a similar boat to me, and assuming you’re seeing a specialist who knows the foot, of all the recommendations you’ll hear and read out there, my suggested combo is:

  • eschew rigid arch supports in favour of shoes that more gently correct your biomechanical problems, while being more mindful about your stride
  • ensuring you get the placement and size correct, metatarsal pads can really help reduce the pressure on your forefoot and toes
  • consider gentle toe alignment correction, but be sure what you use can be comfortably worn walking and running
  • absolutely move to shoes with more rigid forefoots and wider toe boxes

Beyond what the injections and my own adjustments have done for me to this point, it’s now a waiting game. I intend to keep working at easing my mileage and intensity up over the next few months, and still harbour a hope to get back to even the half marathon and/or 25k enduro trail distance. I’ll consider it a major success if I do. In fact, until a recent hamstring pull sidelined me for a few weeks, I was doing just that and feeling as good as I have in the past year. I’m prepared for whatever an MRI and another podiatrist appointment or two in the new year may indicate. Everything from neuroma excision surgery to only a custom orthotic is possible. It’s also possible that by continuing my own conservative treatment that, over time, the symptoms will continue to lessen and that this might also allow me to gradually run more.

Whatever the case, I expect I’ll have a final installment of this story perhaps by the spring.

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