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I had a patient in today, he's 57, a keen runner and cyclist, but running is his main sport. He runs long distances (marathon and ultra marathon). Occupation- Postie, walks long distances every day without issue. Good general health. No meds.
Medical history- L hip pinned in 2005 after breaking it running. He has also had cartilage cleared from both knees around 5 years ago. In 2014 he had surgery to remove a mortons neuroma i/d R 3/4 mets.
c/o Numbness RF digital plantar area (plantar webbing in particular and mostly 3rd toe). He used to be able to run for over 3 hours but now can't manage more than one hour without removing footwear. Removal of footwear and "wiggling" toes eases numbness but after putting footwear back on, numbness returns after 20-30 minutes. Unfortunately I don't have much MSK/bmx equipment in my clinic (mostly a general pod venturing into more sports but it's still a scary area for me so be kind please!) so I couldn't see his gait when running but he says he "thinks" he's a forefoot striker. Numbness is worse when road running and better when off road/cross country. He also c/o "burning" RF plantar, lateral heel extending laterally up side of calcaneum, he feels this when driving and after he stops running.
o/e good ROM joints in foot and ankle. Very tight gastroc/soleus, barely past 90 deg dorsiflexion. Very low supination resistance. He says he never stretches... Pain on specific point on palpation of lateral plantar heel. No pain on calc squeeze test. No mulders click or pain/paraesthesia on palpation of 3/4 met space. Neuro results (monofilament and tuning fork) 'normal'.
He currently has a pair of what look like Freelen insoles with various poron additions of various thicknesses (met dome, plantar MLA pad and very thin kinetic wedge) and a poron top cover which he has had for over a year but says are doing nothing. He got these from NHS pods, whom he is still seeing. He says he felt like the arch support in these was "too much" before he got the MLA pad, something which I just can't figure out but he says the pad helped ease the discomfort.
In my head is nerve compression or entrapment of lateral plantar nerve or possible scar tissue from neuroma op? The burning described at the heel also makes me think nerve compression.
I have given him various calf stretches to do and told him I'd seek further advice from others who know more than me and can teach me and allow me to help him... I'd love to help him out here.
Can anyone give me some pointers? Sorry, this is probably a rubbish write up. Getting back into bmx is a steep learning curve!

 

Could it be something as simple as his running shoes width being too small ????

 

If you think it is neuro, work up neuro and then work backwards to the biomechanics. Think wiring diagrams, or think common neurological complaints in the foot. Is there a single nerve location that could create both symptoms? Tarsal tunnel fits a lot of the parts of the story, but not all. Tarsal tunnel is seen more often with feet with high supination resistance. Check the PT muscle when you do supination resistance, if they help you with the PT muscle, then it will be much easier when compared when they don't help you. Check STJ axis position in the transverse plane. (Kevin Kirby's palpation of location of axis paper.) Or, as Craig said, it could just be the shoes.

 

1st step as Craig said get him to run in wider shoes, if the numbness continues then off to a neurologist for an assessment as it might be coming from as high up as his back.

If it his back then there will need to be some contact with a good Sports physio as there will need to be a look at the proximal muscles systems and a huge amount of core work

 

Thanks very much everyone for your responses. I had suggested wider shoes to him but he wasn't keen. I'll go in stronger with that one now!

 

Just to bear in mind, checking for shoes being too narrow is important, but shoes being too wide or the lacing pattern not holding the foot back can also cause issues. Had this a few times when the foot was sliding forward in the shoe and causing similar compression than if the shoe had been too narrow.

 

Thanks Ian, do you have any recommended lacing patterns to try?

 

Try this for a few ideas to try but assess what he's currently in first- might be nothing to do with it!

https://runrepeat.com/top-10-running-shoe-lacing-techniques