Case Study: Metatarsal Pain in a Runner | KevinRoot Medical

Case Study: Metatarsal Pain in a Runner

  • Case Study: Metatarsal Pain in a Runner



    (Answers in Red at the End)

    History and Chief Complaint

    • A 52 year old runner presents with metatarsal pain both feet 
    • He could not say that one side was worse
    • He had been wearing a traditional 14 mm heel drop shoe when the pain started
    • He decided to wear the Altra Olympis instead which was zero drop on recommendation of the running store after the symptoms developed
    • Even though his symptoms did not improve with this switch, he was able to continue to run 20-25 miles per week without limping
    • The pain never got over level 5 pain on a scale from 0-10 (and he never had pain walking)
    • He never felt any swelling or saw any bruising or redness
    • Describes the pain as sore not nerve like
    • Before coming into the office, he also cut his running down to 15 miles a week and bought some blue Superfeet inserts (which seemed to help some)

    Question #1: What are your initial thoughts on changes to his running?

    Gait Evaluation

    • Moderate to severe pronation walking
    • He was more stable running and he was a forefoot striker

    Question #2: What are the 3 types of running strike patterns?

    Question #3: How does each strike pattern influence metatarsal pain and orthotic corrections?

    Physical Examination

    • No swelling, ecchymosis or erythema
    • Mild soreness only 3rd metatarsal head right 
    • Full range of motion metatarsal phalangeal joints except slight limitation 1st MPJ
    • Laxity on lachman's testing 2nd through 4th MPJs but no pain on both sides
    • Flexible 2-5 hammertoes both sides
    • Calluses sub 2nd and 5th metatarsal heads bilateral


    Question #4: What is the normal positioning of MPJ while performing the Lachman test, and what is the Bouche provocation version?


    Cursory Biomechanical Examination  and Asymmetry Noted

    • RCSP 5-7 degrees everted bilateral
    • Forefoot Varus 7-10 degrees bilateral
    • Functional Hallux Limitus with metatarsus primus elevatus bilateral
    • 4-5 degrees Tibial Varum bilateral
    • Tight Achilles tendons bilateral


    Question #5: With a metatarsus primus elevatus, what metatarsal tends to take an overload situation? How may this change when dealing with tibial varum also?


    Question #6: Remember the mantra: Metatarsal Pain Look for Achilles Tightness. How may that apply here? 


    Question #7: With these biomechanics, was switching from a Brooks Beast to the Altra Olympis a good idea?


    Tentative Working Diagnosis 

    • Metatarsalgia due to Forefoot Running


    Question #8: What is Occam’s Razor with Metatarsal Pain?


    Common Differential Diagnosis (2ndary Working Diagnosis)

    • Metatarsal stress reaction secondary to running stress (running produces many subtle bone injuries that we always have to be aware of)


    Question #9: Why is the history and physical exam not telling us that this is a stress fracture?


    Occam’s Razor and Rule of 3

    • The simplest solution is to pad the metatarsals and off weight the most affected one
    • The Rule of 3 looks for causes we can correct that can cause stress in the metatarsals: tight achilles to stretch out, pronation tendencies to correct, and a metatarsus primus elevatus to support


    Question #10: In a forefoot varus deformity, the foot lands inverted at the metatarsal region and pronates to attempt to bring the 1st metatarsal in contact with the ground. What is an orthotic forefoot modification perfect for this foot?


    What Phase of Rehabilitation?

    • Re-strengthening mainly, but a trial of 3 every other day 2 mile runs were done producing no pain
    • This trial meant the runner could run within a 0-2 pain scale, so immediately placed in Return to Activity Phase (when runners can run some)


    Question #11: Return to Activity Phase is highlighted by Cross Training and Gradual but progressive activity gains in the sport they have not been able to do. This runner was running 5 times a week at 5 miles each. What are some modifications to this that may be safer?


    Should We Image?

    • Yes, because some metatarsal stress fractures involve the plantar cortex and the examination is very soft (not definite)


    Question #12: No stress fracture was noted on x-ray. However, the third metatarsal was longer than the 2nd. Why could this be a reason for more 3rd metatarsal pain?


    First Decision: How to Reduce Pain 0-2

    • Done by simply reducing the mileage from 5/day to 2/day


    Second Decision: Inflammation Concerns

    • None obvious, but the patient was advised to do contrast bathing 1-2 times a day for deep swelling.


    Question #13: How do you “sell” contrast bathing when there is no swelling, and it does not hurt to walk or run 2 miles?


    Third Decision: Any Nerve Component?

    • None Apparent 


    Fourth Decision: Initial Mechanical Changes

    • Stay at 2 miles for the next 5 workouts (should be every other day)
    • The next 5 workouts advance to 3 miles to see if symptoms come or not
    • Achilles stretching 3 times a day
    • Morton’s extension medial to sore point
    • Varus insert to begin pronation control
    • Experiment between 2 shoes to see which feels better (heeled or flat)


    Question #14: 2 reasons why the heeled shoe may feel better on the metatarsal pain in this runner?


        When you review the mechanical changes listed in Chapter 6 of Book 2 of Practical Biomechanics, you can see your many options. It will be important to decrease stress on the sore area, while the diagnosis is being made. 


         Common Mechanical Changes for

    Metatarsal-Phalangeal Joint Issues (with the common ones in RED)

    1. Budin Splints
    2. Taping of Metatarsal Phalangeal Joint
    1. Buddy Taping
    2. Metatarsal Padding for Support (especially dropped metatarsals)
    1. Physical Therapy for Soft Tissue Mobilization
    1. Forefoot Off Weighting
    2. Rocker Shoes
    3. Stiff Sole Shoes
    4. Bike Shoes with embedded cleats
    5. Cam Walkers
    6. Custom Orthotic Devices with Metatarsal Support
    1. Full Length Custom or OTC Inserts
    2. Metatarsal Doming
    3. Single Leg Balancing and Single Leg Poses in Yoga, Tai Chi, Chi Gong
    1. Avoiding Prolonged Toe Bend Positions

         I am presenting this patient not for this particular running related problem, but he struggled for years and years with this weak spot in his anatomy. Probably 15 years after this presentation, he had surgery to fix a plantar plate tear in the same spot. However, each time he presented with pain, we were able to calm it down and get him back running in the 0-2 pain level. Watching this injury develop probably from Grade 1 Sprain to Grade 2 and eventually Grade 3 was fascinating. Like so many of my patients, he was not compliant with the “rest of his life metatarsal doming” and orthotic wear. He also loves rock climbing and a few of his flares came after a weekend of this activity using his toes to literally hang on for dear life.

    Answers to Above Questions:

    1. You need to get the pain between 0-2 so the patient needs to find out if they can run, and it he can, how much without increasing the pain above 2.
    2. Heel strike, midfoot strike and forefoot strike
    3. Heel strike: Heel strike can be unstable, and therefore the correction should focus on the heel with deep heel cups and varus or valgus cants. Midfoot strike: The correction of the midfoot is where most orthotic devices can reign superior, so they help midfoot strikers the most. Forefoot strike: The orthotic correction has to be at the distal end of the orthotic device and onto the forefoot. The treatment for the metatarsals is right where the correction is and sometimes these conflict with each other.
    4. Normal Lachman test done with the metatarsal and proximal phalanx in neutral, and Bouche maneuver with the digit slightly dorsiflexed.
    5. Met Primus Elevatus overloads the 2nd metatarsal head, and tibial varum can pull the stress laterally onto the 3rd metatarsal
    6. The achilles tightness found in this patient should be stretched 3 times daily to decrease the plantigrade forces on the metatarsals
    7. Yes and No. The zero drop Altra can get the weight more proximally, but with pronation the Brooks is more stable so less shearing forces and less medial overload.
    8. Occam's razor means the simplest solution is usually THE solution. Occam's for metatarsal pain is either padding or off weigthing. 
    9. No swelling or other physical signs that can present in a stress fracture were seen. The symptoms, especially after running and with walking, were too low for a stress fracture. 
    10. Forefoot Varus Extension starting under the metatarsal shafts on the plastic with a relief (punch out) for the 3rd metatarsal head
    11. Cut his running for now to 3 days a week, no days in a row, and cut down to the distance that does not increase symptoms over 2.
    12. The longer the metatarsal, the more plantigrade it is relative to the other metatarsals
    13. When you are treating a patient mechanically, I also like to see the response to inflammatory treatment. One of the most therapeutic and diagnostic treatments for metatarsal pain is contrast bathing each evening. Deep swelling that you physically can not see, can be the cause of a lot of symptoms. 
    14. Heeled shoes may roll you over your foot faster (less time on the metatarsals), and can be more stable (less pronatory shearing stress).

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