Midfoot Pain

author : AMSSM
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Member Question

It's been about a month since I finished an Ironman race (2nd in 3 years, took a break in between).  Since just about when taper started, and on nearly every run since, I've been having pain in my midfoot.

Pain only comes up when I roll over a spot on the ball of my foot (I'm pretty sure it's right between the 3rd / 4th metatarsal).  It feels like something (maybe a tendon?) rolls over a bone and I get a brief, shot of pain locally and then it goes away.  No lingering effect, no numbness/tingling, no burning, no pain in the toes.  

The pain is enough that I run flatfooted until it goes away which is usually ~5-10 minutes into the run.  I think it's only in the AM's that it hurts, which is when I do all my workouts.  

I can activate the pain when rolling my foot forward from heel / toe, but also if I go side to side when on the balls of my feet -- when I'm running, walking or just standing.  While sitting, I can't seem to push on a spot to activate the pain, it feels like I need the "roll" to make it hurt.  Also if it helps, I find that when I spread my toes the pain comes more frequently, if that makes sense.  

Any ideas what might be going on?  Tips or suggestions?   

Answer by Kimberly Fisher, DO, MBA
Member AMSSM 

Based on your symptoms, my first thought was that you have fibrosis or scar formation in the space between the metatarsals or long bones in your feet. This can also be a neuroma, which is scar tissue that involves the nerves that travel between the foot bones.  This is sometimes called a Morton’s Neuroma that most commonly affects the third web space. This condition is due to trauma causing bruising, swelling, and inflammation leading to scar tissue development in the region either from a direct blow or repetitive trauma to the foot. Presenting symptoms are pain worsened by pressure on the affected area that may have associated pain or numbness into the toes if there is nerve involvement. Symptoms are exacerbated with running or narrow shoes. Symptoms improve when shoes are removed and pressure is relieved. Squeezing the forefoot while palpating the involved interspace may cause pain and the presence of a clicking sensation is known as Mulder’s sign.

It is important to understand the anatomy of this region in order to understand how this condition develops and affects your current health. The ball of the foot, or forefoot, is made up of the joints between the metatarsal heads and the proximal phalanges. Metatarsals are the long bones within the foot. The phalanges are the short bones that make up each individual digit or toe. There are two phalanges in each digit, one proximal and one distal. The toes are numbered from one thru five starting with the big toe (1) through the little toe (5). When standing, our body weight is distributed from the heel to the ball of the foot with pressure on the metatarsal heads. All five metatarsal heads should bear an equal amount of weight. The space between each metatarsal is called the inter-metatarsal space. These spaces contain inter-digital nerves, vessels, muscles, and bursa (a fluid filled cavity that provides cushion and shock absorption). With proper foot function and anatomy the forefoot load is absorbed and ambulation is pain free. When there is trauma to the forefoot, even chronic low-level injury, inflammation develops leading to fibrosis or scar formation.

Inter-digital neuromas commonly affect women more than men. Narrow shoes and high heels can exacerbate symptoms. Over-pronation has been associated with neuroma formation. If the 2nd metatarsal head is shorter than the 3rd metatarsal head, one is at increased risk for development of a neuroma due to unbalanced weight bearing in the forefoot. Careful palpation for localized boney tenderness is helpful in ruling out stress fractures or osteochondritis. Joint line tenderness and swelling should be would indicate synovitis or inflammation within the joint space. 

MRI or ultrasound tests are diagnostic of inter-digital neuromas, however, given the excess expense of these studies and lack of acuity of disease, conservative measures should be tried first. Initial conservative treatment involves avoiding the offending activity and utilizing orthotics. Try switching to a shoe with more shock absorption and broader toe. A metatarsal pad can be placed proximal to the symptomatic area, meaning behind the ball of the foot towards the heel. Studies have proven pain relief can be achieved by simple offloading with orthotics.  You can consider orthotics for both feet to keep your gait balanced.

Cases that fail to respond to theses conservative measure after three months may benefit from injection therapy by a physician. This entails injection of local anesthetic (0.5mL 1% Lidocaine) and glucocorticoid (20mg Methyl-prednisone) to reduce inflammation. The recommended approach for this procedure is from the top of the foot as this has shown fewer observed complications and faster returns to normal activities. If after 9-12 months your symptoms continue, the final line of treatment is surgical removal, which boasts success rates of 80-90% and rarely recurs.

I hope this provides insight and direction that can help with your training. Cheers to your health.

Kimberly Fisher, DO, MBA

The Ohio State University

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date: July 31, 2013

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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