Case Histories: Metatarsal Pain from Crossfit (Using a Biomechanical Approach)

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  Richard Blake KRM team

  12/26/23, 11:09 PM

   

  Patient: Metatarsal Pain from Crossfit Workouts

  
  
  

       History and Chief Complaint This next patient loves to work out. Mainly does CrossFit, but walks everywhere (does not own a car) and runs 20 miles a week. About 3 months ago, the right front of her foot became very painful. She would describe the pain as 8 out of 10 at its worst, and a mixture of sharp pain, burning, and numbness at times. The chief complaint is a possible fracture in her foot due to the level of pain. Since the pain came on, her only activities include non-weight bearing, like spinning classes and swimming (fortunate to have access to the community pool). Prior to the onset of pain, both her Crossfit and running workouts had increased, but she felt no problem while working out. In fact, her pain presented after 3 days of rest due to a deadline at work. She presently had pain in her right foot getting out of bed in the morning. It felt okay most of the day in good shoes, but could not walk barefoot. As the day went on, her foot pain got worse, and she never had back pain on questioning. 

   

  Question #1: What are the two main causes of 8-10 pain levels in a non-surgical patient?

   

       Gait Evaluation was not impressive with a fairly stable foot. Perhaps the right (involved) foot was slightly more pronated than the left. However, there was limb dominance to the right side and left arm swing further from the body than the right. The right hip (beltline) was higher than the left, and seemed to jerk upward on heel contact more than the left (Hip Hike). The patient also had lumbar lordosis with normal knee rotations. 

   

  Question #2: An obvious Limb Length Discrepancy will be found here. Which side would you predict to be the long side?

   

       Physical Examination of the injured area showed no swelling. There had been no treatment other than rest due to a lot of work. She had iced her foot once or twice but felt that made her hurt worse. She pointed to the 3rd and 4th metatarsals as the painful area, and she did have a positive Mulder’s sign for Morton’s Neuroma. However, all of the 4 interspaces hurt some on palpation, not just the 3rd interspace. When I asked if the pain was worse on the top or the bottom of her foot, she said both hurt but probably the bottom slightly worse. She however had negative straight leg tests for sciatica on both sides. Her achilles tendons were tight symmetrically (around 5 degrees from normal gastrocnemius only).

   

  Question #3: What is the difference between palpable pain in only one intermetatarsal space versus palpable pain in 4 intermetatarsal spaces?

   

       Cursory Biomechanical Examination  and Asymmetry Noted The local biomechanics showed a slight forefoot valgus deformity on a pes cavus foot type. RCSP on both sides was 1-2 degrees inverted. Limb Length testing revealed over ¼ inch long right leg. No muscle weakness was noted on either side, in fact the patient seemed very strong. 

   

  Question #4: When a patient presents with nerve symptoms, my #1 priority is to evaluate for limb length discrepancy because I do not want to miss that possible connection to nerve hypersensitivity. Explain the most simple reason that the spine is compromised in a limb length discrepancy. 

   

       Tentative Working Diagnosis was L5/S1 nerve radiculopathy causing right foot pain. 

   

  Question #5: The key to this diagnosis is that all 4 intermetatarsal spaces hurt, not just the one with Morton's neuroma, and you have a limb length discrepancy notorious for irritating the nerves coming off the spine. What lumbar disc is involved with the plantar middle of the foot?

   

       Common Differential Diagnosis (2ndary Working Diagnosis) Morton’s Neuroma pain 3rd and possibly 2nd Interspaces

   

  Question #6: Since intermetatarsal nerves can cause radiating pain, a solo nerve can be involved only. What can be done to help in this diagnosis?

   

       Occam’s Razor and Rule of 3 The simple solution for nerve pain is to take the stress off of the nerve. Metatarsal pads placed just proximal to the weight bearing surface are normally ideal. However, the Rule of 3 teaches us to look deeper into 3 causes of this nerve pain. Treatment #1 are lifts to level the spine. Treatment #2 is actually a low back evaluation due to the high back stresses of CrossFit. Treatment #3 could be many things including: achilles stretching to decrease the stress on the metatarsals, forefoot valgus support within an orthotic device to stabilize this foot, and shoes with less heel elevation (like zero drop shoes) to decrease impact stress on the back. 

   

  Question #7: I love these rules because they get me focused immediately on the cause(s) of the presenting pain. What does cause reversal do for long term prevention?

   

       What Phase of Rehabilitation? Patients like this make it initially hard to decide if they are in the Immobilization Phase 1 or the Re-Strengthening Phase 2. With symptoms like this, you are really not sure as a podiatrist how soon to call in the back specialist. She seems so far away from Phase 3 Return to Activity that I emotionally placed her in Phase 1. My phase 1 thoughts are very protective, very diagnostic, and very conservative. 

   

  Question #8: What key component of Phase 1 rehabilitation should not be done with a nerve problem?

   

       Should We Image? The lack of foot signs (swelling, ecchymosis, or erythema) works against the idea of ordering x rays. If we think it could be a neuroma, then an MRI should be done if the patient is not responding to the conservative treatment. Remember, in most cases of foot pain that involves nerves, nerve conduction studies are negative (I look at it as the nerve is hyper-excitable but not damaged).

   

  Question #9: If we order an MRI, should we get it with and without contrast dye? 

       First Decision: How to Reduce Pain 0-2 When a patient has pain this intense (7-10 level pain), and no outward signs of swelling, ecchymosis, and erythema, the problem is nerve pain until proven otherwise. You must talk to the patient and decide what they can and can not do to keep the pain in the 0-2 range consistently, and then decide if you still want to experiment with anti-inflammatory or neuropathic treatments discussed below. 

   

  Question #10: Nerves tend not to tolerate prolonged ice. What is a normal amount of icing for nerve pain that is generally okay?

   

       Second Decision: Inflammation Concerns There does not seem to be inflammation in this case, but 5 minutes of icing 3 to 4 times a day is both calming to nerves and slightly anti-inflammatory. 

   

  Question #11: What are your go-to topical medications for nerve pain?

   

       Third Decision: Any Nerve Component? This is an obvious case of nerve pain, and they are always a bit confusing. You would think the patient would have back pain and positive straight leg testing when the examination points to a proximal issue to the foot. The key physical was that the pain was both dorsal and plantar on the foot. This means both the peroneal and tibial nerves are involved. Since these 2 nerves split above the knee, the problem has to have some of its origin above the knee. So, here you start thinking both to treat the local foot nerve issue, but get advice from nerve experts that can deal with the proximal aspect. 

   

  Question #12: I love to work with physiatrists with back pain patients and foot patients with nerve pain. My treatment may prove the most successful, but not always. In this case, at what disc level would an epidural (if used) be injected into?

   

  Fourth Decision: Initial Mechanical Changes First of all, the focus is to take mechanical pressure off of the lower extremity nervous system. Therefore, the initial mechanical changes are geared towards the relieving stress off these peripheral nerves including: stopping CrossFit now and adding it back later as the last activity added, eliminating any tight shoes or socks, eliminating any activity that the patient is bending forward with the spine or having their knee completely straight or having the ankle in a fully dorsiflexed position like a deep squat (all these positions put stress on the sciatica nerve), massaging non painfully 3 times a day the painful areas to an attempt to loosen the foot, and avoiding anything which would make the shoe tighter (many experiment with small metatarsal pads). 

   

  Question #13: What position of the knee puts the most tension/stress on the sciatic nerve?

   

       This particular patient had some lower back asymptomatic bulging discs at L4/L5 and L5/S1, and a chronic history of herniated discs in the neck area (which did not come out in discovery until I got the physiatrist's note). Neural tension can develop from multiple sources and then present at the foot as pain, even in the absence of foot pathology. However, nothing is easy as this patient had small neuromas and bursitis on an MRI seen several months later. The question will always be: Are they even related to this pain? The CrossFit workouts were really the culprit with this patient acute episode, but with some solid PT she was able to go back. 

   

  Question #14: If you are unfamiliar with Crossfit, this is a perfect time to watch a YouTube video. What are 3 probable treatments on the low back started by the physiatrist?

   

       I think it is the perfect time again to review the mechanical treatments commonly used in the treatment of Morton’s Neuroma as we prepare to develop Plans B and C if the patient plateaus. Here is the summary from Chapter 6 in Book 2 of Practical Biomechanics for the Podiatrist. I have placed a star after if used in the example above to demonstrate the thought process at work. 

   

  Common Mechanical Changes for Morton’s Neuroma/Neuritis

  1.  Metatarsal Padding*
  2. Orthotic Devices emphasizing Metatarsal Support
  3. Forefoot Off Weighting 
  4. Soft Tissue Mobilization*
  5. Toe Separators 
  6. Buddy Taping
  7. Neural Flossing*
  8. Metatarsal Doming
  9. Standing Strengthening Exercises
  10. Rocker Shoes
  11. Budin Splints
  12. Sciatic Nerve Advice*

   

  Question #1: Nerve or Fracture Pain

  Question #2: Right Side

  Question #3: Palpable nerve pain one interspace you think neuroma, 3-4 interspaces you think more proximal nerve problem from tarsal tunnel to lower back or even cervical discs.

  Question #4: A tilted base of the spine (called sacral base) due to LLD causes curves in the spine with compression on one side and increased mobility of the other side.

  Question #5: L4/L5. This is the disc between the Lumbar 4th and Lumbar 5th vertebraes. The second letter number combination is where the foot pain is, in this case L5.

  Question #6: Local anesthetic injection into one nerve can be diagnostic as to the total pain is relieved. 

  Question #7: Cause Reversal can fix an individual's weak spots. If the patient can continue with the treatment throughout their lives, they can prevent the issue from recurring. 

  Question #8: Phase 1 is Immobilization. Nerves hate Immobilization and can get more irritable.

  Question #9: For years, MRIs had to be done with and without contrasts for Morton's neuromas. Many radiologists have abandoned that practice now. 

  Question #10: 5 minutes

  Question #11: OTC Neuro-Eze or Neuro-One creams

  Question #12: L3/L4 for the middle metatarsals and toes

  Question #13: Fully straight or hyper-extended

  Question #14: Physical therapy, epidurals, lifts and other forms of mechanical treatments like back braces

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