Patient with outer foot pains

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Good afternoon,

Patient presents himself with symptoms originally started as bilateral foot burning pains in pinky toes after leg workout and has progressed further into other toes/ball of foot but not big toe or arch. Burning pains continue when active but relieve with rest. Narrow toe box, soft running shoes, walking on carpet increase symptoms vs. hardwood floors relieve symptoms. X-ray and Ultrasound of both feet clear. MRI of back clear also. Flat hard sole shoes help and CorrectToes (toe spacers) relieve symptoms. Puzzled - any help would be very much appreciated thank you!

 

How old is the patient? Any musculoskeletal symptoms proximal to the feet?

 

Hi thanks for the quick reply. Patient is 46 years old. After 2 months bilateral gluteal burning pains hence back MRI was ordered and clear. Guessing gait from foot pains altering hip mobility? EMG also clear except for chronic neurogenic motor units noted in abductor hallucis and extensor digitorum brevis muscles, secondary to footwear. Originally poor dorsiflexion; however, PT stretches increased range but symptoms still persist. Thank you

 

Your patient's neuralgia is a symptom. Treating a symptom is frustrating and ephemeral. You need to isolate the etiology. From what you have written above, it appears you have eliminated all of the most common physiological causes. So possibly it is time to think outside the box.

The bilateral gluteal burning is a red flag! Does the patient suffer from (presently or in the past) any other musculoskeletal pain (back, neck, jaw, etc.)? And if so, how was it treated?

Have you run a gait analysis? If so, what were your findings?

 

One other thought came to mind (which would produce the neuralgia), but which I dismissed, namely transient peripheral ischemia or thrombosis. These episodes are very painful, and you would have flagged it during your initial H&P.

 

No other musculoskeletal pain present at this time. Gait observation normal. Flexible arches noted with tailors bunions bilateral. Tried orthotics for month and reported increased lateral column pain. Thanks again

 

Originally functional popliteal artery entrapment came to mind. Dynamic ultrasound and vascular doctor found no evidence of vascular entrapment. Thanks

 

Tailor bunions can be due to (1) tight, pointed toe shoes, or (2) abnormal (gravity drive) pronation.
Can you send me a video of her gait (10 seconds), without shoes, and preferably on a treadmill?
Even when indicated, Orthotics can exacerbate symptoms, if the wrong type is used.

 

My apologizes I have 2 videos, side and back view barefoot treadmill walking but I can’t figure out how to upload a video? Using an iPhone, do you have an email address I can send to or advise how to send? Thank you

 

Email the videos to: Rothbartsfoot@Yahoo.com

 

I just emailed the videos thanks again appreciate it.

 

Hi Dan,

I have attached two photos extrapolated from the third video your sent:

1. The first photo is the left foot at heel contact. The perpendicular heel strike.
2. The second photo is the left foot at midstance. The foot is pronated when it should be resupinating. This occurs in the presence of abnormal (gravity drive) pronation.

Note - It is not the degree of pronation that makes it abnormal. It is the timing in the gait cycle that makes it abnormal.

Also, Pre heel contact, the left foot demonstrates whipping - externally rotated just before heel contact, rectified immediately at heel contact. Very common in the PMS foot structure.

Dx: mild Primus Metatarsus Supinatus foot deformity (which can cause the neuralgia the patient is experiencing).

Suggested intervention: Proprioceptive insoles specifically made to treat this foot structure. I would dispense the 6mm insoles.









Hope this helps.
Brian

 

Ok thanks. Can you send me more info on the insoles? Guessing 6mm on the medial side? Do I purchase directly from you and if so cost please? If not, any recommendations on vendor? Also, what’s your thoughts on why toe spacers/correct toes and hard sole flat shoes almost eliminate symptoms? Do you believe this is all inter-related causing the glute symptoms? Sorry for writing a book, really value and appreciate your help. Thanks

 

I do not sell the insoles. You can purchase them directly from the manufacturer in Tacoma Washington (https://posturedynamics.com). Do not buy the Prokinetic insoles. IMO, they are junk. Instead purchase the original design, the Ultra Thin Insoles. And yes, the 6mm wedge is underneath the distal part of the medial column (internal cuneiform, 1st metatarsal and hallux).

Before contemplating any type of intervention (e.g., toe spacers, hard sole shoes etc), you need to isolate the etiology of the subjective symptoms. Different foot structures require different approaches. Gluteal symptoms are relatively common with the PMS foot structure.

If you are interested in learning more about this foot structure, I suggest you read The Link Between Foot and Cerebellum. Resolving Chronic Musculoskeletal Pain. It can be downloaded on ResearchGate, here.

Enjoy the read.

Brian

 

Great thanks. I just wanted to say thanks for all your help, you didn’t have to help but you did and it’s greatly appreciated!

Dan

 

That is one of the purposes of this forum. To provide assistance to its' members.

Keep me updated on the progress of this patient.

Brian

 

Hi Brian,

I just received the ultra thin insoles, any words of wisdom on wearing like starting slow, shoe types, etc? Also, should I apply the arch supports that were included? Thank you.

Dan

 

Sorry forgot to include a picture of the insoles just to be sure they are the right ones.

 

The gait video is typical of a Primus Metatarsus Supinatus foot deformity. You do not use arch supports with this type of foot deformity.

Make sure the insoles are 6mm, not 3.5 or 9mm.

Shoes are very important. You cannot build a solid house on quicksand. The insoles will not function in broken down shoes. Have your patient buy new shoes with a firm heel and soles.

Size the insoles to the shoes. Only trim the outside of the insoles. Do not trim any of the medial wedge area.

Have your patient stand on the insoles, without shoes, on a hard floor. Then have your patient place the insoles in the shoes. They should feel the same, as he/she did standing without the shoes. If not, something is wrong with the shoes.

Wear time - one hour the first day, no more. Increase one hour per day as comfort permits. When 8 hours are reached in one day, they can be worn all day long.

Keep me updated on the progress of your patient.

 

Great thanks again. Also, sorry but how long does the patient have to wear the insoles for correction to take place or will they need to rely on them for foreseeable future?

 

That varies. If you object is to just eliminate the gluteal symptoms - short term use may be indicated (several months). However, the insoles are typically so comfortable to wear, your patient may elect to use them long term.

 

Ok thanks sorry last question, how long do you think it will take to reduce the foot burning sensations? Or will both the glute and foot burning subside at the same time? Thank you!

 

Again this varies from patient to patient. But typically several weeks for the foot burning to resolve, and sooner for gluteal inflammation.

 

Hi, today I tried the insoles for about a half hour with the patient and they reported burning pain on lateral portion of feet, 4-5 toes, nothing severe more annoying pressure, is this normal until they get used to? They mainly wore while at standing desk working on laptop so not to much walking. They used in a mostly flat but not zero drop, stiff sole and heal casual shoe. Thanks

 

Yes, that is normal. Have your patient break into the insoles, as tolerance permits. Using them, too much, too soon, can produce unpleasant reactions.

 

Brian, did you not indicate, in a previous thread, that a simple Morton's extension does away with the need for this sort of specificity?