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Dorsal foot pain in overweight Karate player

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Dec 29, 2009.

  1. David Smith

    David Smith Well-Known Member

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    As you were so quick and if your still looking in:
    I have a friend coming in to see me who has a dorsal foot pain that radiated to the big toe. She is extremely overweight and does karate so sits in a kneeling position frequently and also kicks things a lot. The pain is worse when wearing high heel shoes, is painful walking or any activity and when resting and can be elicited by dorsiflexion and plantarflexion and longitudinal compression of the 2nd and 3rd metatarsal and direct compression just proximal to the base of 2nd 3rd metatarsals.
    I suspected a combination of compression syndrome and involvement of the deep peroneal nerve. Saw here last night at a martial arts function and the relevant joints did not appear to have any swelling or osseous changes that might have occured due to direct trauma. What do you think?

    Cheers Dave
  2. Dave:

    It is probably a compression neuropathy of the deep peroneal nerve. When examining for possible nerve involvement, using a light tapping of your finger [I like to use my forefinger or middle finger] over the course of the potentially involved nerve, from proximal to distal, will help you determine whether the nerve is involved or not. If the symptoms are caused by injury to the joint or tendon or bone or ligament, then this light tapping will not cause pain or parasthesias. If the injury is to the nerve, this manual tapping procedure will cause either a sensation of pins and needles, or "numbness" or pain along the distal distribution of the nerve. In the case of the deep peroneal nerve, this will be between the dorsal hallux and 2nd digit and in the dorsal 1st intermetatarsal space area. If pain is produced, then this would be considered a "positive Tinel's sign".

    I would suggest the patient quit kicking, quit sitting on her feet and quit wearing any shoes with snug uppers over the deep peroneal nerve for a few weeks, along with twice daily, 20 minutes per session, icing therapy. If she want to continue to kick, then have her purchase a padded foot guard for her martial arts kicking activities.

    Hope this helps.
  3. efuller

    efuller MVP

    Another thing to consider, in addition to the neuritis, is a subluxed cuneiform. I would have never believed that this condition had existed if I had not had this myself. Radiation to the toe makes the neuritis more likely. The cuneiform subluxation hurts worse when the weight of bed sheets plantar flex the rays. It took several tries at manipulation of my cuneiform before the symptoms stayed away.


  4. Admin2

    Admin2 Administrator Staff Member

    Related threads:
    Other threads tagged with martial arts
  5. pebbles

    pebbles Member


    I have never posted before but thought I might jump in with a treatment option for this condition.

    Trigger points in the peroneal longus and EDL can possibly cause peroneal nerve compression as it courses under these muscles.

    Also trigger points in the Tib Ant, EDL or EHL may cause the pain pattern you describe. Deactivation of any points in the anterior or lateral compartment may help.

    Happy New Year
  6. David Smith

    David Smith Well-Known Member

    All good advise that I will pass on Kevin

    Happy New Year Dave:drinks
  7. NeedingMassage

    NeedingMassage Active Member

    Hi chaps,
    don't you think she needs to address the cause of her problems i.e. "...extremely overweight..." and then you can start treating any symptoms (if they still exist when the cause is resolved).
  8. Assuming a diagnosis of a "compression neuropathy of the deep peroneal nerve" what is the pathological pathway whereby obesity "causes" this condition?
  9. NeedingMassage

    NeedingMassage Active Member

    Without a positive Tinels, why assume? Kneeling with feet plantarflexed under buttocks compresses a dorsal foot into the mat/floor. As body weight increases, so the compression of nerve increases.
    Last edited: Jan 4, 2010
  10. The lack of a positive diagnosis hasn't stopped you making assumptions has it now?

    Here's a quick thought experiment, lets say we know for sure that this is an entrapment neuropathy. Let's clone our patient so we have two of them, lets allow one of them to keep adopting this sitting posture and stop the other one from doing it. Which one is likely to still get the problem? SO is obesity the "cause" of the problem or is it the sitting posture? My money is on the activity not the weight per se.
  11. NeedingMassage

    NeedingMassage Active Member

    Conversely, take your two, keep them kneeling as they do but have one lose weight - my money is on the problem resolving in the lighter version while the other continues to suffer.
    Or perhaps we have them both stop sitting and both lose weight for an immediate and also longer term improvement.
    Now, if only we had a 'real' person to test these assumptions on. Hang on, isn't there an overweight, kneeling, heel wearing karate practitioner around here somewhere.....
  12. Taking your logic that obesity is the cause of this problem, everyone who was obese would have this problem. Why don't they? Because they don't all adopt this posture. Viz. it's the posture that's the problem.

    Furthermore, lets say this lady weighs 14 stone, which for her height is classed as obese. I weigh 14 stone, which for my height is not. I can sit in this position and not get this problem, while she, evidently cannot. What is the difference in compressive forces due to body mass between the two of us?
  13. NeedingMassage

    NeedingMassage Active Member

    She's obese, sits on foot, foot hurts.
    You're not obese, sits on foot, foot doesn't hurt.
    Difference = Obesity

    Odds on that obese people sitting on their feet this way may will develop this problem. Probability reduces if they lose weight.

    To quote Kevin A. Kirby, DPM 11/25/09 Podiatry-Arena Pearls of wisdom
    "It is incomprehensible to me that a podiatrist would not want to devote their practice careers toward better understanding the biomechanics of the foot and lower extremity for the benefit of their patients when, in fact, the foot is the only part of the body to be regularly subjected to external forces that are possibly orders of magnitude greater than the body weight of the individual."

    Thus to dramatically increase the weight of the person subjects the foot of the person to even greater loading, whether they sit on them, stand on them, walk on them.
    Answer = lose weight (client responsibility).

    p.s. - How tall are you?
  14. You can quote my good friend Kevin all you like, and as he and others will tell you, I have devoted my career toward better understanding of biomechanics. That's why I understand that if two people are the same weight in static sitting the GRF will be the same magnitude. Hint: force = mass*acceleration. I'm 6' 3'' BTW.

    I'll answer my own question for you, the reason all obese people don't suffer with entrapment neuropathy, is that they don't all sit in this position, wear this type of shoe etc.. Viz.......

    Why have I seen several patients with this condition who were not obese?

    I suspect we've reached the end of this discussion.
  15. NeedingMassage

    NeedingMassage Active Member

    My point is that pressure = force / area (the contact point of her foot is likely to be less than yours so the pressure at that point would therefore be greater) - nonetheless, I agree our discussion is concluded but I am keen to follow Dave's progress / findings for this case study.
    Last edited: Jan 6, 2010
  16. David Smith

    David Smith Well-Known Member

    She's in on Friday for an assessment (in clinic rather than at pub) She's had 10 days of rest and icing so there may be an improvement, watch this space.

    Cheers Dave
  17. dgroberts

    dgroberts Active Member

    Oh, and you don't "play" Karate.

    If you used that term to anyone who do it seriously they'd probably kick you in the chops! :)
  18. David Smith

    David Smith Well-Known Member


    Saw this girl last Friday. She had rested and iced as advised and the neuro pain radiating to the hallux seemed to be reduced i.e no referring of pain. No Tinels sign. Also no pain on dorsiflexion of 2nd 3rd met cuneiform joints. Only pain on plantarflexion of 3rd and lateral deflection of whole midfoot joint. Still very tender then. Pain on direct dorsal palpation reduced but also very painful from plantar direct palpation.

    Cuboid felt slightly subluxed, but the foot is fat and difficult to tell, however manip of cuboid gave satisfactory sound and feel of clicking back into place. Mobilised ankle joints, which were equinus. Made SA felt cuboid pad 5mm and laterally posted valgus forefoot with 5mm felt pad. Continue ice and rest and review 2 weeks.

    Regards Dave
  19. NeedingMassage

    NeedingMassage Active Member

    Hi there David,
    How is your friend getting along with her problem?

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