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Forefoot pain in a runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by t5christie, Nov 23, 2009.

  1. t5christie

    t5christie Member

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    Just wondering if anybody has some advice and experience with patients like the one I saw last week in our student clinic:

    Middle aged man who's a keen middle distance runner stated that he has been experiencing generalised forefoot pain after running 15km of a half marathon. He stated that this pain "radiates" to his lesser digits. Otherwise he is asymptomatic.

    * Cavus foot type (RCSP: 2 degrees inverted both feet, high medial longitudinal arch, prominent hammer toes lesser digits).
    * Neutral forefoot to rearfoot position: slight forefoot valgus to both feet (sorry i know i should have measured this angle).
    * ankle ROM, STJ ROM, MTJ ROM within normal limits. 1st MPJ ROM slightly hypermobile.
    * muscle testing was within normal limits.
    * Supination resistance test: easy
    * Windlass test activation was normal
    * Lunge testing was within normal limits

    Gait: observable tibial varum, prolonged lateral weightbearing gait and delayed midstance MTJ pronation.

    For this presenting pathology my conclusion was that this patient was experiencing exercise induced neuralgia type pain due to prominent hammer toe deformity and lateral weightbearing gait. I couldn't come up with a specific diagnosis:wacko:

    Following assessment I was a bit baffled as to what would be the most appropriate treatment option. As he was symptomatic only after prolonged running my advice was to purchase appropriate running shoes for his activity (eg: general cushioning shoes such as an Oasics Nimbus or Brooks Glycerin).

    Should I have prescribed an orthotic for this patient? Has anyone seen patients like mine who have responded to orthoses therapy? My thinking as far as orthoses therapy was to try and keep the patient's feet in their RCSP using a mid-foot customised orthoses, a possible offloading addition like a metatarsal dome proximal to the 2nd-3rd metatarsal heads of both feet; and a low bulk grind for flexibility to the orthoses during running.

    If anyone has any advice I would appreciate it.

    Regards Tom.
  2. David Singleton

    David Singleton Active Member

    Having just been at boot camp, its fresh in my mind that Craig mentioned that when he used the cross trainer using low gear axis, he could bring on neuralgia type symptoms. This might fit with the symptoms coming on towards the end of the run, as he fatigues he switches to low gear axis! Might be wrong but just a thought! If this sounds right, then lateral column support is indicated.
    Regards Dave
  3. efuller

    efuller MVP

    Some cavus feet bear no weight on their styloid. So, all the weight bearing is on the heel and forefoot and none on the midfoot. Pressure = force / area. The weight bearing area is reduced so there is increased pressure on the remaining ares of contact. Most OTC inserts won't have enough heigth under lateral column to touch the high lateral arch. Custom may be needed to better distribute the forces under the foot. Look at the wear pattern in the shoes to see if there is any pressure under the lateral column.


  4. Craig Payne

    Craig Payne Moderator

    Fatigue affects function.
  5. Even though I don't think this condition has been previouisly described within the medical literature, this condition is not uncommon and is caused by too much force on the plantar forefoot over too little a surface area over too long of a time. I call this condition Transient Plantar Forefoot Compression Neuropathy (TPFCN) and seems to occur fairly frequently in people who use elliptical trainers and may also occur in cyclists. I have seen it also fairly frequently in non-athletes with cavus feet but will more commonly occur when people with cavus feet do sports activities.

    TPFCN is likely caused by compression of the plantar intermetatarsal nerves which induces a "pins and needles" type of sensation in much the same way that excessive compression in the tarsal tunnel or carpal tunnel can cause their respective syndromes. Since the intermetatarsal nerves are much smaller, the symptoms are relieved fairly rapidly once the pressure is taken off the intermetatarsal nerves. Treatment with a custom foot orthosis or over-the-counter orthosis designed with a thicker anterior edge than normal (i.e. anterior edge full thickness or "internal metatarsal bar modification") along with slight heel lifts and regular gastroc-soleus stretching exercises generally relieves the pain completely within 4 weeks.

    Hope this helps.

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