If you are a runner and you start having pain in the ball of your foot, you might be worried that you have a stress fracture. So you have a couple of choices.
One option is to go see your local orthopedist or sports medicine podiatrist. The second option is to stop running and see if the pain gets better.
If you’re listening to this podcast right now you are likely not very interested in option number two. After all, most runners want to run. So you might try to figure out a third option such as trying to treat the problem yourself.
Although I believe it is truly possible and reasonable for most runners to figure out the problem and attempt to address it themselves, this episode is going to discuss what happens when you actually go to a doctor with pain in the ball of your foot and you are diagnosed with a condition called “metatarsalgia.”
Although not all runners get diagnosed with this condition it’s important to understand this common diagnosis because the way it relates to patient-physician interactions may help you know what you should expect, or even demand from your doctor, if you are a runner and you’re told you have a condition that is caused by running.
The first thing you have to understand is that when you go to the doctor you have a problem. There’s something wrong with your foot. It hurts. And before you can fix the problem you have to put a name on it.
The name a doctor puts on the condition is called a diagnosis. The diagnosis should match a finite set of signs and symptoms. And if the diagnosis is correct then there should be a finite number of solutions. The solution that the doctor recommends it’s called the treatment plan.
So if you have a correct diagnosis then you can get the correct treatment and you can get better and get back to running. Simple enough, right?
The problem is runners are often given a diagnosis that is either incorrect or insufficient to really help the runner get back on track. Metatarsalgia is a great example of this scenario.
Although most medical terms and diagnosis names are long and complicated, most are actually all fairly simple descriptions. Many of them are based in Latin, but they are really merely descriptive in most cases. When coming up with the medical term or name for a diagnosis there is actually a formula to create those terms. The most common diagnosis formula specifies a body followed but the problem affecting that body part.
For example let’s look at the diagnosis term “laryngitis.” The larynx is your voice box. So the first part of this term is pointing out that the problem is with the larynx or voice box. The second part of the term “-itis” refers to inflammation of that body part.
Anytime you here a medial word ending in the suffix “-itis”’ it is referring to a condition of inflammation affecting that specific body part. But inflammation of course is not the only problem. If you hear a medical word ending in “-algia,” that refers to pain affecting that body part.
When you hear the term metatarsalgia you should expect this is a description of a painful condition. The painful body part is one of the metatarsal bones in the foot. There are actually five metatarsals in your foot. So the doctor says you have metatarsal and the doctor is trying to tell you if you have pain in the ball of your foot.
But wait a second. Didn’t you already know you had pain in the ball the foot before you even went to the doctor? You knew that when you were running. I mean seriously this doesn’t make any sense to me. You go to the doctor pay your co-pay fill out a bunch of paperwork and at the top line underneath your name where the doctor asks you to write down the problem you write, “I have pain in the ball of the foot when I run.”
If you then suffer the obligatory series of weights before you actually see the doctor and the doctor pushes around on your foot and tells you have metatarsalgia, the doctor is using a long expensive word to tell you basically “you have pain in the ball of the foot when you run,” is that helpful?
Of course not! But it does sound like a fancy word.
Metatarsalgia is an extremely common diagnosis used by sports medicine podiatrists and orthopedists to describe a whole set of conditions that can cause pain in the ball of the foot. But you have to understand which condition is causing the pain. To make this clear, let’s look at another analogy. Let’s say you have a headache. You go to see your doctor and your doctor says you need to see a neurologist because you have a headache. So you make an appointment with a neurologist. How helpful would it be if the neurologist diagnosed you with a headache?
Not very helpful at all I would imagine. You would likely be thinking, okay what is it, is it a brain tumor? Is it caffeine withdrawals because I just quit drinking coffee? Is it a migraine headache? Is it tension headache? What is actually causing the headache?
So when I see a runner who is frustrated because they are not getting better, the pain in the ball of the foot is just not going away, and they tell me that they were diagnosed with metatarsalgia, I kind of roll my eyes because I realize the patient was diagnosed with a headache in the foot.
There are several different causes of pain in the balls of foot and runners. Pain is the problem. Pain isn’t the cause of the problem. When runners get pain in the ball the foot the most feared diagnosis is likely a metatarsal stress fracture. But that’s not the only problem that can cause pain in the ball of the foot when you run.
You can also get a Morton’s neuroma. A Morton’s neuroma affects the same area of the foot but it’s completely different structure. A neuroma has nothing to do with the metatarsal bones. When you get a neuroma there is nothing wrong with the metatarsal bones, but instead its inflammation irritation and swelling of a small nerve that runs between the metatarsals bones. But some doctors will still call it metatarsalgia.
Another problem that can affect runners is inflammation of a small ligament at the ball of the foot called the plantar plate. The plantar plate is underneath the head of the metatarsal bone. But again, this is not actually affecting one of the metatarsal bones. Instead the pain is actually caused by a minor sprain of a ligament attaching to one of the metatarsal bones. Yet some doctors will still call it metatarsalgia.
A fourth problem they can affect runners and cause pain in the ball the foot is osteochondritis. This is inflammation and degeneration of the cartilage on the end of the metatarsal bone. And although the cartilage is coding the end of the metatarsal where it bumps up against the toe, it’s technically not a problem with the bone but it’s really more a problem with the cartilage covering the bone. Yet some doctors will still diagnose the condition is metatarsalgia.
One of the reasons doctors label all of these different conditions metatarsalgia is that in the past insurance companies have been likely to pay for the patient’s visit when patient is diagnosed with this painful condition. But again you are going to the doctor to make sure that an insurance company processes your claim correctly. You’re going to the doctor to find out exactly what is wrong so that you can make it improve as quickly as possible and get back to running.
Metatarsal stress fractures heal when you decrease the stress enough to allow them to recover. A Morton’s neuroma will heal if you decrease the mechanical irritation to the nerve and reduce the inflammation so that the nerve stops swelling. A plantar plate sprain will heal if you can decrease the stress applied to the plantar plate by limiting the motion of the affected toe. It will also help it heal if you sufficiently reduce the inflammation. Osteochondritis may heal if you can reduce the motion in the toe and decrease inflammation.
When you hear the treatments for these various conditions you can see that in most cases it will help to reduce the inflammation. It’ll also help if you reduce the stress applied to the injured structure and or reduce the amount of motion in the toe.
Sometimes I ask a runner what the doctor told them to do after the doctor said patient was suffering from metatarsalgia. In some cases the runner will say that the doctor said they would inject the nerve. In that case I know that the doctor actually thought the patient had a neuroma. But another cases, it’s not very clear at all. Sometimes they say, “the doctor told me I just needed to stop running and it would heal.”
In that case it really could’ve been any of those conditions. In some cases the patient is told to ice it and see if it improves. In that case it could also be pretty much any of those conditions. In some cases the patient is told to take some anti-inflammatory medication and see if it improves. In that case it could also be pretty much any of those conditions. In other cases the patients will say they were told they might want to think about wearing a fracture walking boot, if it doesn’t get better after they stop running. A fracture walking but will help most of these things heal (but the time in the boot will cause other problems). So unless I hear a very specific treatment that I know really is directed at one specific structure, I don’t really feel confident that the doctor had a clear idea of the true cause the problem.
If you have a stress fracture you have to direct the treatment at removing the stress. If you have an inflamed nerve you have to direct the treatment to calm down the nerve. At this point I’m sure you get the idea.
The bottom line is that anytime you have a running injury and you go to the doctor you should be very wary of three things.
If you have the right diagnosis and the correct treatment plan you should get better. If you’re not getting better the chances are good that you either have the wrong diagnosis or something is wrong with your treatment plan. In either case, you need to either follow up with your doctor to let her know you’re not getting better or seek a second opinion from someone who specializes in running injuries.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often intially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
But if you are still confused and think you need the help of an expert, a “Virtual Doctor Visit” is the solution. He has been “meeting” with runners all over the world and providing just that sort of clarity through online consultations for years. He can discuss your injury, get the answers you need and explain what you REALLY need to do to keep running and heal as fast as possible.
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