Today on the Doc On The Run Podcast, we’re talking about how a runner can tell tenosynovitis from neuritis in the top of the foot.
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I’ll explain more at the end of the episode. And let’s queue up the theme song and get started with today’s show.
If you’re running and you start getting pain on the top of the foot, it could be lots of different things and it depends on what happened, what you did and what it feels like and then what you do to actually pin down the diagnosis. Now, there are a couple of really common things that I see over and over and we’re just going to talk about those two right now.
So this assumes you don’t have a stress fracture and that you’re convinced you don’t have a stress fracture either because you saw a doctor and they said it’s not a stress fracture or you did some self diagnosis stuff and you’re pretty sure that it’s either the tendon or a nerve on the top of your foot. Well, here’s the thing. You’ve got to think about, how did it start?
The most common way you can tenosynovitis or neuritis on the top of the foot that seems like tenosynovitis is that you’re running and you’ve over tightened the laces on the top of your shoes. I did that myself one time. I was doing the Salt Lake City Marathon, I was training heavily, I wanted the PR and I was really nervous.
At the start of the race, I was tightening my shoe laces and standing around, it felt a little loose, so I basically tightened them again and then I felt like they were too tight so I loosened them. I did this three or four times and I was literally still fiddling with my laces when the gun went off and so I just cranked them down and took off.
About eight miles in, I realized that my left foot, every time it hit the ground, I started to feel it. I knew that it hurt but I was on pace, so I was not going to stop then and I went all the way until about mile 23 or so, before I actually had to walk for a little bit because it hurt so bad. Now unfortunately that, of course, is still three miles from the finish. It was where it was flat and it was completely demoralizing because I should have been able to just cruise all the way into town to the finish line and get my PR and instead I completely destroyed it and blew it entirely by having to walk quite a bit because my foot hurt so much. Now that was tenosynovitis and that was just inflammation of the sheath around the tendons on the top of my foot.
The thing is, if you get that as your problem because you overtighten the laces, if you ice it, it’ll feel a lot better, pretty quickly. If you do something like the contrast bath routine, where you really flush out that inflammation and stop that inflammatory response, it’ll feel a whole lot better. If you’re moving your toes a lot and it hurts, that also suggests it’s tenosynovitis.
But neuritis is a little bit different. So with neuritis, it might feel better while you’re icing it but the nerves really don’t calm down that quickly just from doing something like the contrast bath routine or from icing. So if you’ve applied ice and it feels better while you’re doing it but it really doesn’t make much change, it might be neuritis. Also the way it feels tells you a whole lot about which of those two things it might be.
If it’s a musculoskeletal thing, like a tendon sheath or a tendon injury that’s really inflamed, well, in that case, those musculoskeletal things respond well to treating the inflammatory process, getting rid of the inflammation and they start to improve pretty quickly. Nerve things tend to linger. The nerves kind of get aggravated and they very slowly improve.
If you have slow improvement, more likely it’ll be a nerve, as long as you’re actually treating the inflammation part. Also, if it’s tingling, burning, radiating, if it really shoots up your foot toward your ankle or out toward your toes, way more likely to be a nerve issue. The musculoskeletal thing usually hurt in one spot and when you push in it in that spot, it just hurts right where you’re pushing.
So that’s the first thing. Now, all these things really point to one or the other, whether it’s a nerve injury or a tenosynovitis but the tendons on the top of the foot have a nerve really close to them and the tight laces, over tightening your cycling shoes, particularly really, the ones you crank down with a wire, they can really apply a lot of tension on the top of the foot that compresses the nerve and causes neuritis.
They can also compress the tendons and cause tenosynovitis. So either of those can easily happen. Now, if you’ve tried a bunch of stuff, poking around yourself and thinking about what it really feels like, thinking about how it started, you’ve altered the lacing pattern to take pressure off that area and you’re still thinking, “Well, maybe it’s a nerve thing because it just doesn’t seem to be getting better very quickly.”
One thing you can do is you can take Lidocaine patches that you can get over the counter and you basically cut it into some small squares. You look at your foot, you know where the nerve goes. It’s very easy to find actually and usually it’s around that same spot. But on the top of the foot, it’s this one nerve called the intermediate dorsal cutaneous nerve that causes pain on the top outside of your foot or the deep perineal nerve that happens to cause pain on the inside of your foot.
You look at those spots and figure out where the pain is and then you put one of those patches over there and leave it on for 12 hours during the day, take it off at night and then see how quickly it responds. because one of the treatments for neuritis is for a doctor to actually inject it with local anesthetic, to make it numb, to see if it quiets the nerve.
Well, if you put Lidoderm patches or Lidocaine patches, any patches that have local anesthetic properties in it on the top of the foot and that nerves right under the skin, well, if it quiets the nerve and you start to improve very quickly, then you know, it’s neuritis and not tenosynovitis. Because if you put the patch on and you still move your toes and it really hurts, well, that’s more likely to be a tendon issue because you’re moving the tendons and it’s causing pain. Those are also deeper structures and they don’t get numb or you don’t get relief as quickly from those dermal patches that have local anesthetic in them.
So that’s one of the ways you can tell the difference between neuritis and tenosynovitis on the top of the foot, when you’re a runner.
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