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I have a relatively fit 40 something male who complains of burning in his feet with increased activity. He plays tennis and enjoys walking and finds that after a period of approximately 20 minutes he is set upon by a bout of significant burning in the area of his metatarsal heads.

If he stops at the 20 minute mark he can generally continue again in a short period of time. If he pushes through the pain and finishes whatever it is that he is doing, he finds that his feet are painful for the rest of the day and sometimes into the next day. The pain is greater and comes on earlier with tennis, and I have put this down to the increased shearing forces on the met head area that comes with the twisting and turning required to play the sport.

In gait he is apropulsive with clinical indications of a FnHL. There is some instability (laterally) and as a result a clawing of the toes and collapse of his transverse arch. His rearfoot biomechanics seem relatively "normal" with his STJ never pronating or supinating to either extreme.

He has seen a podiatrist before and received some custom devices. When standing on the devices his FnHL reduces with much less force required to initiate the windlass mechanism and his lateral instability is reduced.

I attempted to re-establish the transverse arch and offload the area using a met dome with no improvement. Pressure relief padding also did not help with the discomfort. The client stated that he did understand what we were trying to do and it did feel better walking around, however there was no notable difference during tennis.

As a result I am at a little bit of a loss. There is no pain on palpation or at rest. The problem is exercise induced and even with what seem to be suitable devices which alleviate the shearing stresses through the met head area, no improvement is seen. Am I missing something? If so what should I be looking for? Any suggestions would be greatly appreciated.

I just want to reiterate that there is no medical history (arthritis, diabetes, neuropathy) that points to this problem.

 

I would check FDL and FHL for trigger points, esp in that foot type.
If you dry needle, or know someone who does, needle these muscles and the posterior calf.
I also had great results after the needling with a particular pt with simple padded insoles and stretches.
Cheers

 

I would get him to come in straight after a walk or tennis, when it is burning, to see if you can palpate anything....

 

Angela,

Were the previous devices prescribed for the present problem or has it developed since then? If his lateral instability is only reduced by these devices could they be improved by increasing the lateral effect of the devices?

Is he palpably tender in the arch, ie the fascia or plantar extrinsic musculature?
Adductor Hallucis and FDB both refer pain into the forefoot area you describe and FDL as mentioned by MaHtay.

Cheers
Shane

 

Burning pain. Activity related. Plantar forefoot.

If unresponsive to common mechanical approaches, don't go chasing far out mechanical theories until you have ruled out the most obvious one...tarsal tunnel syndrome or more proximal nerve impingement.

Did you palpate the PT nerve. Tinel's sign? etc.

That would be the most obvious thing to exclude first me thinks.

LL

 

Andrea, you make no mention of ankle joint restriction: is the calf tight; need stretches??

Rebecca

 

And what about an anterior cavus (forefoot plantarflexed relative to the rearfoot). I had a patient in recently with a flexible anterior cavus with forefoot sympotmatology due to heaps of shearing of met heads. Have issued her with orthoses that support under the midfoot and with a 6mm heel raise. My reasoning is that this allows the anterior cavus to exist without the FF always being overloaded (at least until after midstance). Though I expect it is a fine line between that and too high a heel lift and transferring too much force to the forefoot.

Just a thought

 

hi

i am sure you have down this but from what you have written he is only getting pain when playing tennis. Have you checked his footwear and if he is wearing a tennis trainer then maybe check to make sure the orthoses fit is correct and the trainer is not to narrow.

chris

 

Exactly

Most cases of Burning sensations like "hot spots" in metatarsals I see are fit related, usually narrow footwear.

Try this lacing technique:



Will improve volume in toe box

Or wider shoes

 

the only similiar case i had the footwear was too short