The patient is a 39 year old male, 6’ 1” tall, 185 pounds, presents with a complaint of pain in the ball of the left and right foot with the left being markedly worse. The problem has been present for 6 months, and has worsened over time. He states that initially ignored the problem hoping it would just go away, then tried changing shoes after reading online about how “Morton’s Neuroma” could be caused by shoes that are too narrow, but the problem persists. The patient is a very active person, runs approximately 25 miles per week at a 9 minute mile pace, regularly does aerobic workouts at the gym, including high intensity interval training, as well as a weekly pick up basketball game. He works as an executive, dressed in business casual attire. He states his condition initially felt like something was in his shoe, or his sock was “bunched up” and eventually progressed to having some swelling behind his second toe, with his second toe starting to become crooked. He also states he is experiencing some burning pain into the toes and numbness in the third toe of the left foot. He has ceased running and basketball for a few weeks, decreased his workouts, but the pain recurs when he attempts to return to his previous activities.
Physical exam findings of the lower extremities includes intact pedal pulses, instantaneous capillary filling time, absent varicosities, all toes are warm to touch. Deep tendon reflexes are equivocal, and Babinski sign is absent bilateral. There is no Tinel sign in the tarsal tunnel bilateral, however a positive Muldar sign is present in the third interspace of both feet. Range of motion of all joints or both lower extremities is within normal limits and muscle strength is good in all groups. Leg length measurement indicates a 5 mm discrepancy , left longer than right, with the hips extended and flexed. No significant deformity is noted with the exception of the second toes being slightly contracted dorsally and medially, left greater than right, however the Lachman test (drawer sign) for the second MTPJ is negative. Walking gait analysis reveals pronation of both feel, with prominent abduction of the feet left greater than right, symmetrical shoulders and hips, symmetrical arm swing,
Weight bearing x-rays of both feet display a slightly elongated second metatarsal, with cortical thickening and deviation of the second MTPJ. There is splaying of the third interspace as well as narrowing of the second interspace. X-rays are otherwise contributory at this time. Preliminary diagnosis of capsulitis of the second toe (predislocation syndrome) and neuroma of the third interspace of both feet was made at this time. Educational literature was given to the patient regarding both conditions, as well as an in-depth discussion regarding the likely etiologies, further diagnostic testing, and treatment options.
An injection consisting of corticosteroid and local anesthetic was recommended and performed into the third interspaces. The patient was instructed in tape splinting the second toes into slight plantar flexion to be maintained during all weight bearing activities. Plantarflexion exercises for the toes were recommended as well as massage techniques for the affected areas. Recommendations for wearing athletic type shoes with a wide toe box and cushioned soles were made, and athletic activities were limited until the symptoms subside. The patient improved over the course of a few weeks, however he reported recurrence of the burning pain in the toes after running for more than 20 minutes. The patient declined more aggressive treatment for the neuromas at this time and upon further consultation it was decided to attempt using functional orthotics to control the biomechanical etiology, prevent further progression of the painful conditions and maintain the patient’s active lifestyle.
Next week, we will discuss an orthotic build that attempts to treat simultaneous and possibly contradictory conditions of the forefoot
