Today on the Doc On The Run Podcast we’re talking about pain in the ball of the foot in runners and why the right diagnosis matter.
One of the most common locations for pain when you are a runner and you get an over-training injury is in the ball of the foot. That is the thick padded area at the base of the toes that you use to push off when you are running.
There are lots of different conditions that can affect runners when you get pain in the ball of the foot, and two of the most common ones are a neuroma where you have irritation of a nerve that runs underneath the bottom of the foot, and then up into the toes. or you can get a condition called capsulitis, which is just inflammation of the joint capsule, and sometimes actually a sprain of a tiny little ligament called the plantar plate ligament in the joint capsule itself.
These both can cause pain. Now, because those things are really close together in terms of where they’re actually located in your foot they can cause very similar symptoms, and the pain is similar.
Now, there are differences of course between those conditions, and not surprisingly the treatment can be different as well.
Today’s episode is basically based on a question that was sent in by Steve, and it was really thoughtful of him to send this question in to us. One of the questions he wanted to know was whether or not the treatment is different in these two conditions. Because obviously if the treatment was the same that would really simplify things. You just do all the stuff that would help both of them, and then you would just get better. We’re gonna talk about that a little today.
The first thing is that some treatments are the same so you have to decrease the mechanical irritation, and the inflammation of those tissues to get them to heal, and in that respect some things will help both of them.
If you do things to decrease the inflammation, if you do things to decrease bending at the toes, like, avoiding exercises that cause excessive bending in the toes, if you use shows that are stiff, and have a curvature under the forefoot that will decrease some tension applied to those structures, then that will help a neuroma and it will also help capsulitis.
There are many treatments that really are different in these two conditions. For example, using pads in your shoes to decrease pressure and irritation of the nerve, or the joint capsule, or the plantar plate ligament that could’ve been injured.
Those pads actually go in different locations. You can use metatarsal pads, and that’s one of the most commonly recommended pads for both of these conditions, but they have to be placed in a slightly different location to be most effective given the specific condition you have.
If you have a neuroma, and you use a standard metatarsal pad, and it’s in the right position for a neuroma it will probably help, but if you have that exact same pad in your shoe, and the edge of it is actually pushing against the plantar plate ligament, or the inflamed joint capsule it will actually make that condition worse.
I usually have runners modify those pads in a way that decreases some irritation of the joint capsule when they have a plantar plate ligament, and they need to decrease some irritation. There are other ways to pad the plantar plate, and protect it better than just using standard metatarsal pads, but the pads have to be in a different location if there is a different condition. That’s one of the big differences.
Anther difference in treatment is that taping can be extremely effective at decreasing tension and motion in the inflamed joint capsule but it won’t really help a neuroma very much. That’s one of those things where if you start taping the toes to try to stabilize them it may help one condition, but not the other.
One of the biggest treatments that doctors do differently based on the condition is regarding injections. There are lots of different things we as physicians can inject into your foot to try to improve any of these conditions.
The most common is probably a cortisone injection. If we inject cortisone around the nerve and you have a neuroma it decreases all the inflammation, and some swelling, and the fibrosis, or scarring that’s starting to happen around the nerve, and that makes it improve.
If you have capsulitis and you really do have just purely inflammation within the joint, and you inject cortisone into the joint it will decrease the inflammation, swelling, and pain within that joint. There are very big differences between these conditions, because first of all if you inject the cortisone into the joint that’s a closed space. It’s like a little sack around the joint.
If you inject cortisone into the joint and you actually have a neuroma it’s not gonna help at all, because the cortisone will not diffuse out of the joint, and decrease the inflammation around the nerve. The same is true in reverse.
If you think you have a neuroma, and you inject the neuroma, but you actually have capsulitis it won’t really help because the cortisone which is supposed to reduce the inflammation will not get into the joint capsule to decrease the inflammation that’s within the joint capsule on the inside of the joint.
That’s the first thing is injecting in different places has different effects, and it makes a big difference if you have one of these conditions versus another.
The types of injections that doctors use also will vary quite a bit. Cortisone can be used in both conditions, but again, it has to be in the right place to be effective. There are a couple of other kind of injections that doctors sometimes do when you have one of these two conditions.
If you have capsulitis, or if you have a plantar plant sprain, or maybe even a small tear in the plantar plate ligament that is affecting the joint capsule then a doctor may want to be a PRP injection, or even a stem cell injection into the joint to try to get it to heal, and that’s sort of the opposite of a cortisone injection. Instead of shutting off the inflammatory process which is supposed to be just the beginning of the healing process if you inject PRP, or a stem cell injection, then you are trying to actually stimulate rapid healing within the joint.
That doesn’t really work I don’t think very effectively for nerves, so I would never do that for a nerve, but if you have a neuroma that you’ve had for a long time, it’s continued to cause pain, and it’s become sort of chronic, and intractable, and you just can’t get it to heal then you could do something called a series of alcohol sclerosing injections, and those alcohol injections basically kill off the nerve so that you don’t have pain anymore.
It’s sort of analogous to doing the surgery but you don’t have an incision, and you don’t have a huge bill like you would get from surgery, but they’re very different things. Alcohol is not gonna help capsulitis, but it can help with neuroma treatment. PRP injections, or stem cell injections, may help capsulitis but won’t really help a neuroma at all.
The bottom line with this is that the amount of time it takes to heal it really hinges on three things when you are a runner. The first thing is you have to have the accurate treatment, and that brings us to the second thing, you can only be doing the accurate treatment if you have an accurate diagnosis.
If you are not really sure whether you have a neuroma, or if you have capsulitis, or some other condition that’s causing pain in the ball of the foot you’ve gotta make sure you’ve got the right diagnosis. That’s why we came up with the Ball of Foot Pain Course to sort of help you understand what I do when I see a patient. I look at them, I’m trying to help somebody get back to running, when I sit in their living room, look at their foot, exactly what I do.
What I push on, how you tell the difference, what signs really point to a neuroma instead of a joint capsule issue like capsulitis or a plantar plate sprain, but you have to have an accurate diagnosis. If you don’t get an accurate diagnosis either on your own or from a physician it’s just unlikely that you are gonna get the accurate treatment.
The third thing is that you have to be aggressively doing the things that help and avoiding the things that slow your recovery. If you are a runner with pain in the ball of the foot you really need to understand what you need to do right now to make sure you get the correct diagnosis. That means seeing someone that specializes in runners, talking to someone who specializes in runners, or doing something like the Ball of the Foot Pain Course that will sorta walk you through that process so you can figure it out.
You’ve gotta know what condition is really causing your pain when you run, and you have pain in the ball of the foot. Once you know which condition is causing your pain you really need to understand what you can do right now to make sure you are doing everything you can do to speed the healing process.
If you are a runner with pain in the ball of the foot you also need to understand what you must stop doing right now to make sure you aren’t slowing the healing process. If you can do those things, if you can make sure you’ve got the right diagnosis, make sure you’ve got the accurate treatment, and then you are aggressively doing all the stuff that will make it heal faster, and avoiding the things that will make it heal slower, then you really can get back to running as quickly as possible.
Aggressively do the things that help and avoid the things that slow your recovery.
Sign up for the Ball Of Foot Pain Course For Runners so you can get back to running.
If you have a question that you would like answered as a future edition the Doc On The Run Podcast, send it to me, and then make sure you join me in the next edition of the Doc On The Run Podcast. Thanks again for listening!