Today on the Doc On The Run podcast we’re talking about pain in the ball of the foot in runners caused by a condition called “osteochondritis.”
If you are a runner and you have pain in the ball of the foot there are really only a few conditions that could be causing the trouble. This episode will be the third of a three part series that explains all of the things you need to think about if you’re a runner seeking treatment for any of these problems. Previously we talked about pain in the ball of the foot caused by plantar plate sprains and neuromas. Today, I’m going to explain a little bit about another condition which is in a similar location in the ball of the foot and can also cause pain in runners.
The condition we’re going to talk about is called Osteochondritis. The name sounds fancy but “osteo-” means bone and “-chondral” means cartilage and “-itis” means inflammation. Osteochondritis technically means inflammation of the bone cartilage surface in a joint. In terms of runners though, osteochondritis means that you have some damage to the cartilage in one of your joints in your little toes. Usually it’s the base of the second toe right where the second toe meets the ball the foot. If you move it, it’s painful because the cartilage is damaged and the joint is damaged in some way.
There are lots of different causes for osteochondritis. There’s a condition called Freiberg’s which is often happens and starts when you’re teenager doing something like ballet where teenage girls doing a standup on point in ballet class. All of that force on the end of the bone starts to cause damage to the ball the foot. It cracks the bone and the cartilage starts to degenerate. The joint starts to get worse over time as the head of the cartilage and the bone underneath it starts to collapse.
Sometimes this begins when there’s chronic inflammation in the joint and the joint’s been repeatedly damaged. Sometimes it’s the result of a singular trauma event, like when you smash the toe kicking something. If you kick something hard enough, the bone and cartilage in the joint can get damaged. The bone cracks underneath the cartilage and then the bone starts to cave in and the cartilage starts to degenerate. But regardless of what the cause is, if you get this condition you have to do something about it or continues to cause pain.
The pain when you get osteochondritis, it is a little bit different than the other types of pain. For example, doctors tell osteochondritis from other conditions when they ask these questions like when does it hurt, what is it that you’re doing it makes it worse, what does it feel like?
Since its damage to the joint surface, it hurts more when use the joint. Now that sounds silly but it’s true. So if you move the toe joint more and you put force on the toe joint more, it hurts more. So if you’re doing calf raises at the gym, you are doing hill repeats, you’re using an elliptical trainer, you’re doing anything that causes a lot of motion at the toes and at the ball the foot where you’re standing up on the toes, this irritates the joint more and it hurts worse.
A neuroma is a nerve issue whereas osteochondritis is a joint issue. With the neuroma you have pain when you compress the nerve or when you’re irritating the nerve with motion. Some runners will have excess pronation and natural motions in the foot but the excess motion leads to nerve irritation.
The character of the discomfort from a neuroma may be described as burning pain, radiating pain or an aching numbness type sensation…those are all typical of a damage to the nerve. But with osteochondritis, it just hurts in the joint when you move the joint surfaces. With osteochondritis, patients may also say that they noted swelling in the joint. You don’t really get swelling with neuroma.
You can get swelling with a plantar plate sprain on the bottom of the second toe joint. So it’s in a similar location to osteochonritis, but the location of tenderness is different. The plantar plate really hurts just when you press on the plantar plate or if you stress the plantar plate in some way. Osteochondritis hurts more if you compress the joint and then you move the joint.
Doctors tell the difference between these conditions in a number way. The most important aspect is likely the physical exam. We actually created a self-diagnosis course that walks people through this whole process so you can see what exactly the doctors are pushing on, pulling on, manipulating to reproduce your symptoms in a way to suggest you have one of these conditions over another.
But its not just the physical exam that the doctors used to tell the true cause. For example, X-rays can be very helpful. Neuromas do not show up on X-rays but damage to the joint and osteochondritis will show up on an X-ray, particularly in the advanced stages. A plantar plate sprain may not directly show up on an X-ray but it could show up in terms of a slight change in the position of the toe because that plantar plate sprain has weakened the ligament supporting the joint and the toe starts to move in a different direction.
It depends on where you are along this sort of spectrum of trouble when you’re trying to choose what you need to do make it better. In the acute phase, where it’s just become inflamed and you have this whole “-itis” thing happening where you have inflammation in the joint and it’s becoming irritated. The simplest thing of course is to ice it. You can take Anti-Inflammatories like Ibuprofen or Naproxen but really just icing the ball of the foot can be very effective. You can also do contrast bath soaks where you’re submerging the foot completely in cold water then hot water then cold water then hot water and so on in order to really flush out the inflammatory fluid and decrease the blood flow in that area to decrease inflammation.
If it’s in acute inflammatory phase and it’s really the tissue lining the joint that’s causing the pain, anti-inflammatories and applying ice can actually reduce your symptoms quite a lot. But you still have to do other things to try to decrease the stress and irritation of the joint.
One of the keys to decreasing force at the ball of the foot, is to run on flat ground. If you’re running uphill it is more force. If you’re doing lots of hill repeats it is more force. If you happen to like to run on trails through the mountains, well the more the you’re on uphill slopes, the more you’re going to stress the joint, compress the joint and irritate the damaged cartilage and bone within that joint. If you can run on flat ground, that limit the force through the damaged joint.
If you want to decrease motion in the toes, it can also be very helpful to try to shorten your stride. If you run with a shorter stride, when your foot gets behind you, it’s not as far behind. Your stride length is shorter. With shorter strides, your heel doesn’t come as far up off of the ground. You don’t put as much pressure on the joint surface when you’re pushing off to run. That can really make a big difference if you have osteochondritis. Just shortening the stride may be sufficient to reduce the discomfort and help you continue to run. If you can run with simple interventions and a moderate improvement, you may not have to have the more dramatic interventions that we’ll talk about later.
Another simple thing is to try to do something to decrease the motion in the toes. The simplest thing is stiff shoes. So if you’re wearing shoes that have a curved rocker forefoot under the ball the foot, and it is much stiffer and is less pliable, the rigidity actually decreases some of the motion to the toes and it can help the inflamed joint calm down.
Hoka running shoes are built with an active foot frame. Although Hoka’s are considered to be maximalist shoes and a lot of people think of them as big cushy shoes, that’s really not true at all. They’re really interesting running shoes and because they actually have an active foot frame built into them that has this stiff meta-rocker in the forefoot, these shoes can really decrease the motion through the forefoot. Anything that decrease the motion through the forefoot can make a huge difference for patients who have osteochondritis who are continuing to run.
Another approach is to simply stiffen the shoes by putting something in the footbed of the shoe that just makes the shoe inherently rigid. The rigid prevents the toes from bending. It is relatively simple to trace the shoe insert that goes in the footbed of the running shoe. With that tracing we can then actually have a thin plastic or carbon fiber insert custom made for the shoe that is cut out and trimmed to fit underneath the insert in the shoe.
That plastic or carbon fiber layer ads stiffness and inherent stability to the shoe. If you decrease the motion in joint, you decrease the pain. Although it’s not really a true custom orthotic, the insert does stiffen the shoe enough that it decreases some of the motion throughout the toes and can decrease irritation of these joints that are being damaged in the process of osteochondritis development. That’s a simple thing that can make a big difference to people who are trying to run when they have osteochondritis.
The next thing that doctors recommend is probably custom orthotics. The idea with custom orthotics is that we can manipulate the way the joints and the foot is actually hitting the ground. To make custom orthotics, we make a plaster mold of your foot, make a reproduction of your foot and then build the orthotic device on that reproduction of your foot. If all goes according to plan, the custom orthotics will stabilize the joints of the foot. The custom orthotics can also decrease the pressure under the foot, particularly at that joint that’s been damage withoOsteochondritis. In that case it means that the device is “offloading” or removing pressure from the second metatarsophalangeal joint (MTPJ) which is joint which most often develop this condition.
As I’ve talked about this before, custom orthotics are great for runners if nothing else will work. But I don’t think they’re necessary or essential for most runners. In fact, I think most runners can get better with most conditions, without custom orthotics. But when you truly need a custom device they can be extremely helpful.
Many doctors will also recommend different types of injections for osteochondritis. If all you have is inflammation of the joint then something like a cortisone injection or corticosteroid injection into that joint that can reduce all the inflammation, reduce the swelling and just shut off all that irritation in the joint. That can cause a huge amount of relief.
Now it depends on where are you are, if your joint is in the acute inflammatory phase, these injections are very effective. Unfortunately most patients with acute inflammation don’t go to see doctors. Injured runners often wait and wait and wait, hoping it will get better. And it doesn’t get better. It becomes a chronic problem and it seems like it’s not going away.
Once it seem like it won’t go away, that’s when a lot of runners will finally go to the doctor to seek treatment. If you injected cortisone at that point it’s actually less effective than it is in the very early stages.
Your doctor may offer it to you but there’s risk with cortisone. Because if you inject the joint and you have any little damaged areas to the cartilage where the cartilage is split, cracked, torn, ripped, or damaged in some way, the cartilage may actually weaken and tear more which could make things worse . If you actually cracked the bone underneath the cartilage and the cartilage hurts because you’re trampolining, and the cartilage is just sort of spongy and pushing up and down when you walk and it moves the joint then the corticosteroids can weaken the joint, the cartilage in the joint may actually tear and cause bigger problems.
For these reasons, I’m not necessarily a huge fan of corticosteroid injections for osteochondritis, but there is one circumstance where they work. Let’s say you’ve had a lifelong goal of qualifying for Boston. Then after years of trying you finally get in and you really just want to go do the race. You don’t really care that much, your kind of over running anyway. You just don’t want to do any marathons. You just always wanted to do Boston. Well in that case, if we inject the joint just to calm it down so you can make it through the race, it is very effective.
But you have to realize that there is risk with injecting cortisone. Because cortisone breaks up collagen. The cartilage is just highly organized collagen. For this reason, injecting the joint with corticosteroid can weaken the cartilage and the joint supporting structures. So the injection could in fact address the acute inflammation or the inflammation at that time. But then you might weaken the joint supporting structures enough that you end up with a plantar plate sprain just because you weaken the inside of the joint capsule. That is possible.
It’s not a cure all with corticosteroid injections even though you’ll hear all the time about professional athletes being injected with cortisone who then just continue to play. It’s not always the best approach but it can be right in certain circumstances. Discuss the end goal with your doctor.
The other injections that you’ll hear about are PRP injections which is “platelet rich plasma.” With a PRP injection, we actually draw a small of blood out of your arm, spin it down in a centrifuge and separate the platelets, which basically have all of the factors you need to stimulate wound healing of all different types. So in theory a PRP injections should actually increase the development of stem cells in that area when you inject PRP as well. There is some thought that PRP injections maybe helpful when you inject them into these joints that are developing osteochondritis in order to help heal that area where you’ve had damage.
Another similar injection is stem cells. We can take embryonic stem cells and inject them into the joint. Because stem cells basically can turn into any type of cell, the hope is that they will really speed healing these joints, but for this particular condition there aren’t any big studies that show that stem cell injections are full proof or that it’s even proven. But it’s still a treatment option that your doctors may offer to you. It’s just one of those sort of advance treatments still in the process of being studied. But it seems like there’s a lot of promise for both PRP injections and stem cell injections. We’re just waiting for more studies to actually show if it pans out.
The other thing of course a surgery. So if you don’t improve with simple treatments, it’s not hard to find a doctor who will recommend surgery because the joint looks terrible on X-ray. When you have an X-ray and the doctor is pointing out all of the bone spurring that happens around the joint and how the joints are damaged, it becomes pretty easy to become convinced that you might need surgery.
The most common surgery for osteochondritis is where we basically just to clean up the joint. We actually go in, remove the bones spurring that happens around the edges of the joint. We try to get some new cartilage to grow into those little damaged areas. But if the joints really destroyed we might try a joint replacement surgery or a cartilage transplant in order to put some new cartilage into that area. There are some synthetic joint implants that also can replace the joint. But if you’re a runner who likes to do lots of hills and lots of trails, those joint implants can fails. You have to make sure that you’re making the right procedure choice if you’re considering surgery.
The other thing to think about is when you talk to your doctor, what you really have to discuss is your activities. Doctors will most often have treatments that they like to use. It’s sort of the way that we’re just trained as doctors in the United States. We treat certain conditions in certain ways. S o when a doctor looks at your X-ray and it looks terrible, it’s very difficult for them to not think “Well, let’s just do surgery to fix this. Let’s just make it look better on the X-rays”. But you don’t really care about that, you care about activity.
So I really believe that when you’re a runner it’s actually more important to you than the average person that you choose the best treatment and surgically repairing the joint is not always the best choice if you want to keep running. But once you’ve made that choice to have surgery you can’t go back because the rules have changed, the anatomy’s different.
Above all else make sure that your doctor understands that you are a runner and you want to keep running! If you really want your doctor to understand where you’re coming from then try to explain to her in great detail the types of races you run, what sort of training you do, what surfaces you run on, what kind of training plan you’re currently on and what your goals are not just to make the pain go away but tell your doctor of your goal.
You have to get your doctor to work with you and focus on your activities and maintaining your activities as opposed to just thinking about what might be the best treatment in that doctor’s hand for that given condition. If you can do that, if you can make your doctor understand that you really want to keep running to take that into consideration then you both can work together and determine which treatment is going to be right for you.
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.
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